BSID III FOR ASSESSING DEVELOPMENT OF INFANTS IN NICU FOLLOW-UP CLINIC

Infants who have been hospitalized in a neonatal intensive care unit (NICU) may present with a multitude of challenges that put them at risk for delayed development. Early Intervention and specialized NICU follow up clinics are in place to help identify NICU graduates’ need for therapy services. Well-established, standardized assessments, such as the Bayley Scales of Infant and Toddler Development (BSID-III) are utilized by occupational and physical therapists when making recommendations for therapy. The purpose of this retrospective chart review (N=104) was to identify the extent to which BSID-III motor scores were predictive of a referral for further developmental therapy in infants who were seen in NICU follow-up and to examine how therapist clinical judgment related to BSID-III scores. Independent sample t-tests conducted to compare motor performance to recommendations for motor therapy found there was a significant difference in the gross motor scores for those who were and were not recommended for motor therapy. Quality, quantity, and variability of motor skills emerged as recurring themes in therapist’s clinical judgment for initiating motor therapy, despite BSID-III scores that were within normal limits. Findings from this study indicate that the factors that influence follow-up recommendations are complex and that test scores alone were not indicative of whether or not a referral was given. Information gathered from this study may help increase understanding of how BSID-III scores and clinical judgment relate for therapists recommending motor therapy for NICU graduates. BSID III FOR ASSESSING DEVELOPMENT OF INFANTS IN NICU FOLLOW-UP CLINIC 4 Use of the Bayley Scales of Infant Development-III by therapists for assessing development and recommending treatment for infants in a NICU follow-up clinic Infants born extremely prematurely or with neonatal illnesses have a greater chance of surviving with the advanced technology, medical treatments, and specialized care that are now available. Neonatal intensive care units (NICUs) provide specialized care for infants who are critically ill or premature. In the past NICUs were often given a classification of level I through III based upon the sophistication of care available although more recently level IV has been proposed for use (Committee on Fetus and Newborn, 2012). There is not currently a standard classification system used by all hospitals or all states (Committee on Fetus and Newborn, 2012). A level III or IV NICU, depending on classification system used, offers the highest level of care according to this classification system and is able to provide the specialized level of care needed for infants at highest risk (Committee on Fetus and Newborn, 2012). A 2012 retrospective cohort study of 1,328,132 infants born prematurely found that mortality rates for infants born in highlevel NICUs were significantly lower than those born in other lower-level delivery hospitals (Lorch, Biacci, Ahlberg, & Small, 2012). A 100 to 300 percent improvement in risk-adjusted mortality rates was seen for high-level NICUs meaning that hospitals without a high-level NICU had increased infant mortality rates (Lorch et al., 2012). The Centers for Disease Control and Prevention found that in 2006, 77.3% of infants born with a very low birth weight were admitted into a NICU (CDC, 2010). This has led to an increase in the number of infants in need of extended specialized NICU care. These fragile infants can present with a multitude of challenges that put them at risk for delayed development (Tanta & Youngblood Langton, 2010a). Multidisciplinary teams of professionals with expertise in neonatal care work with infants and their families to develop a plan of care for high-risk BSID III FOR ASSESSING DEVELOPMENT OF INFANTS IN NICU FOLLOW-UP CLINIC 5 newborns to promote survival. A NICU stay and neonatal complications put many infants at risk for delays in motor development, necessitating regular developmental screening through a neonatal follow-up program. Occupational therapists and physical therapists who have substantial experience in pediatrics, advanced knowledge of development, of the medical conditions frequently seen in neonatal care, and of how to provide specialized interventions using advanced clinical reasoning, are part of the team of professionals who provide specialty care in the NICU and in follow-up settings (American Occupational Therapy Association [AOTA], 2006). Occupational therapists in the NICU setting provide feeding and neuromuscular interventions, as well as serve as a primary source for parent training and education. The AOTA (2006) declared the appropriateness of OT working in this specialty area: Occupational therapy’s domain of concern encompassing the interaction among the biological, developmental, and socialemotional aspects of human function as expressed in daily activities and occupations makes it particularly suited to address the needs of the developing infant and family (AOTA, 2002). The occupational therapy method of activity analysis and adaptation to achieve a functional outcome is valuable in promoting “goodness of fit”, as there is often a mismatch between the NICU environment, parental expectations, and the infant’s capabilities (pp. 659-660). There is much that remains unknown about the long-term developmental outcomes of infants who receive treatment in the NICU, but there is a consensus that many of these infants require continuing specialized treatment after being discharged (McGrath, Sullivan, Lester, & Oh, 2000). Much of the previous research on infants in a NICU has focused primarily on premature and very low birth weight infants, with fewer studies on those born full-term (Claas et al., 2011; Hack & Fanaroff, 1998; Huang et al., 2012; Shiariti et al., 2008). A meta-analysis of forty-one published English language studies on infants born prematurely found that there were BSID III FOR ASSESSING DEVELOPMENT OF INFANTS IN NICU FOLLOW-UP CLINIC 6 lasting motor impairments later in childhood (Kieviet, Piek, Aarnoudse-Moens, & Oosterlaan, 2009). Additional studies have reported sensory, cognitive, and psychosocial impairments as well (Claas et al., 2011; Hack & Fanaroff, 1999; Halsey, Collin, & Anderson, 1993; Huang et al., 2012; Kieviet et al., 2009; Stanton, McGee, & Silva, 1991; Sun, Mohay, & O’Callaghan, 2009). Studies of normal birth weight infants who were cared for in a NICU for reasons other than prematurity, have found that they too have ongoing health concerns (Marino et al., 2012, Shiariti, et al., 2008; Swanson & Dicianno, 2010). Infants admitted to a NICU may have complications resulting from congenital or genetic conditions (e.g., Down syndrome, congenital heart disease, spina bifida), from a difficult labor or delivery resulting in injury, or from illness after birth. Despite the greater proportion of infants who need NICU care surviving there are increased risks for morbidity and poorer developmental outcomes compared with infants who do not require hospitalization following birth (McGrath et al., 2000). With screening and early recognition of developmental delay in premature infants, early interventions are possible (Rydz, Shevell, Majnemer, & Oskoui, 2005). Neonatal follow-up programs provide important services for infants who are at high risk for developmental problems after they progress home from the NICU. A survey of 170 NICU’s in the U.S. found that the Bayley Scales of Infant and Toddler Development III (BSID-III) was one of the assessments used most often in follow-up programs (Kuppala, Tabangin, Haberman, Steichen, & Yolton, 2012). In addition to its clinical use the BSID-III has been widely used in research. Gross motor development is an area where early observable delay in infants can be recognized (Spittle, Orton, Doyle, & Boyd, 2009). Gross motor skill involves control of large muscle groups that are involved in such tasks as sitting upright, walking, or moving from one BSID III FOR ASSESSING DEVELOPMENT OF INFANTS IN NICU FOLLOW-UP CLINIC 7 position to another. As motor delays are early and visible signs of developmental concerns in infants, assessments that are able to reliably aid in identifying motor difficulties are essential for professionals who are responsible for follow-up of infants at increased risk for developmental delays. The BSID-III includes a motor scale, which measures both fine and gross motor skills. The BSID-III is complex in its administration and interpretation thus training and experience is needed with both administration and interpretation of the assessment. A training DVD is included with the BSID-III kit and training workshops are available although not required for test administration. A competent examiner needs to possess the skills to follow standardized protocol for administration, have knowledge of statistics to understand the psychometric properties of the assessment, and be able to score and interpret the assessment (Bayley, 2006a). Occupational therapists are among the professionals who can be trained to administer this assessment, and take into account the results during clinical reasoning over follow-up treatment recommendations.