DOCUMENT RESUME

ED 391 280 EC 304 529

AUTHOR Bennett, Forrest C.; Hedlund, Rodd E.

TITLE The NICU follow-Through Project. Final Report.

INSTITUTION Washington Univ., Seattle. Center on Human

Development and W.sability.

SPONS AGENCY Special Educatior. Programs (ED/OSERS), Washington,

DC.

PUB DATE . [953

CONTRACT H024D20045

NOTE 59p.

PUB TYPE Reports Descriptive (141)

EDRS PRICE MF01/PC03 Plus Postage.

DESCRIPTORS Agency Cooperation; At Risk Persons; Birth Weight;

*Early Intervention; Hospitalized Children;

*Inservice Education; *Medical Services; *Neonates;

Neuropsychology; Parent Education; *Premature

Infants; Professional Development; *Severe

Disabilities; Technical Assistance

IDENTIFIERS *Intensive Care Units

ABSTRACT

This final report describes activities and

accomplishments of the NICU Follow-Through Project, a 3-year project

designed to help hospital neonatal intensive care units (NICUs) and

community developmental centers serving infants with disabilities or

very low birth weights (VLBW) replicate the project's innovative and

successful training components. The model provided training to

medical and early intervention professionals in 18 outreach

communities within 10 states. Program accomplishments included: (1)

assisted medical and early intervention professionals to train and

facilitate parents in supporting their VLBW infants with severe

disalilities while engaging them in caregiving activities and social

interactions; (2) assisted medical and intervention professionals to

interpret the neurobehavioral cues expressed by these infants and to

respond in an appropriate contingent manner during caregiving,

assessment, or intervention sessions; (3) assisted medical and early

intervention professionals to implement a comprehensive interagency

coordinated service plan for VLBW/severely disabled infants and their

families; and (4) trained medical/educational professionals to become

trainers of a neurobehavioral assessment. Individual sections of this

report describe the project's goal and objectives, outreach training

communities, implementation of objectives, evaluation of training

programs, and products. Eight appendices provide additional

information and materials such as training materials for team

building, naturalistic observation of newborn behavior, infant

behavioral assessment, and examples of action plans. (Contains 73

references.) (DB) ***********************************************************************

Reproductions supplied by EDRS are the best that can be made

from the original document. ***********************************************************************
The NICU Follow-Through Project

FINAL REPORT

Early Education Program for Children With Disabilities

U.S. Department of Education

Pr/Award Number: H024D20045

CFDA: 84.024D

Forrest C. Bennett, M.D.

Principal Investigator

Rodd E. Hedlund, M. Ed.

Project Director

Clinical Training Unit

Center on Human Development and Disability

University of Washington

Seattle, Washington 98195

(206) 685-1242

Fax: (206) 543-5771

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CENTER (ERIC)

ri This document has been reproduced as

received from the person or organization

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Points of view or opinions stated in this docu ment do not necessarily represent official OER1 position or policy
ABSTRACT

NICU FOLLOW-THROUGH PROJECT

Early Education Program for Children with Disabilities

Forrest C. Bennett, M.D. Rodd E. Hedlund, M.Ed.

Principal Investigator Project Director

The NICU Follow-Through Project will help hospital neonatal intensive care units (NICUs) and

community developmental centers replicate the model's innovative and successful training components.

The NICU Follow-Through Project includes the following four components and associated objectives:

A. Provide neurobehavioral training to hospital NICU and developmental center staff focused on

supporting the neurophysiological organizational capacity of the very low birthweight/disabled

infant population.

I. Train NICU staff to assess infants' behavioral cues utilizing the Naturalistic

Observation of Newborn Behavior (NONB), and provide appropriate

neurobehavioral caregiving.

2. Train Developmental center staff to assess infants' behavioral cues utilizing

the Infant Behavioral Assessment (IBA), and provide appropriate neurobehavioral

intervention.

B. Help staff at hospital NICUs and community developmental centers develop and implement a

comprehensive transition and intervention plan for very low birthweight/disabled infants and their

families.

1. Assist hospital NICU and developmental center staff to develop and implement a

Transition Action Plan to better serve very low birthweight/disabled infants and their

families.

2. Assist hospital NICU and developmental center staff to develop and implement a

Neurobehavioral Action Plan for caregiving and intervention.

C. Train a professional, previously certified in the administration of the IBA, to become an IBA

instructor.

D. Evaluate trainee attainment of competence, providing technical assistance as necessary.

The result will be a comprehensive hospital-to-home transition plan for a continuum of services for

the family and infant during this most critical transition phase. Parents will benefit from more informed

participation in the transition process as well as learning to respect and support the neurophysiological integrity

of their infant. The very low birthweight/disabled infant population will benefit indirectly from improved

services through increased agency cooperation and neurobehavioral training received by both hospital NICU

and developmental center staff in the neurobehavioral components of this model. The hospital NICU and

developmental center staff will benefit from the development and/or refinement of interagency cooperation

thus ensuring possibilities for future agency collaborations, as well as learning to provide appropriate

neurobehavioral support to these fragile infants during a caregiving or intervention session.

1
NICU Follow-Through Project

CFDA: 84.024D

Final Report

TABLE OF CONTENTS

Page

Abstract 1

I. Theoretical and Conceptual Framework 2

The NICU Follow-Through Project 5

Project Goal and Objectives 7

Table 1: Project Objectives, Activities, and Timelines 8a-8j

IV. Outreach Training Communities: Years: 1-3 9

Figure 1: Outreach Sites Year 1 9a

Figure 2: Outreach Sites Year 2 9b

Figure 3: Outreach Sites Year 3 9c

V. Implementation of Project Objectives 10

Table 2: NICU Follow-Through Project Workshop #1 10a

Table 3: NICU Follow-Through Project Workshop #2 10b

Table 4: NICU Follow-Through Project IBA Trainer Workshop 10c

Table 5: IBA Trainer Workshop: Visits #1 & #2 10d

Table 6: Timeline for Objective Implementation 10e-h

VI. Evaluation of Training Components 11

Table 7-10: Site Training Evaluations 1 1 a-11d

Figure 4: Inter-observer Agreement By Subsystems 14a

VII. Project Products 15

VIII. Assurance Statement of Dissemination of Final Report 18

IX. References Cited in This Report 19

Appendices

Appendix A: Team Building for Transition Training Materials

Appendix B: Naturalistic Observation of Newborn Behavior (NONB) Training

Materials
Appendix C:

Appendix D:

Appendix E:

Appendix F:

Appendix G:

Appendix H:

Infant Behavioral Assessment (IBA) Training Materials

IBA Trainer Training Materials

An Example of: The Team Building for Transition Action Plan

Examples of IBA/NONB Neurobehavioral Action Plans

Informed Consent: Cocaine, Pregnancy, Use and Offspring Development

IBA Scoring Protocol

5
I. THEORETICAL AND CONCEPTUAL FRAMEWORK

Low Birthweight: Incidence and Sequelae--Research Findings

Advances in neorrital intensive care technology permit many more infants born with very low

birthweight or severe disabi ities to survive and return home with their parents than ever before. In the United

States, about 7% of all infavts are born weighing less than 2,500 grams each year. In 1988, 247,668 infants

were born weighing less than 2,500 grams, and 43,161 weighed less than 1,500 grams (Hack, Horbar, Mallooy,

Tyson, Wright, & Wright, 1)91). Since 1985, further refinements in obstetric and neonatal care have

dramatically reduced mortality for very low birthweight infants (VLBW) (1001-1500 grams). These infants

are reported to have an 80-90% chance of survival (Office of Technology, 1987). Current survival rates of

infants born at extremely low birthweight (501-1000 grams) are described to be 49-52% (Bennett, 1988; Hack,

et. al., 1991).

The decrease in mortality rates, however, are associated with an increased prevalence of children with

poor long-term neuro-developmental outcomes related to low birthweight (Bennett, 1984; Collin, Halsey, &

Anderson, 1991; Grunau, 1986). Serious disabilities associated with this population are: cerebral palsy, mental

retardation, sensorineural hearing loss, and visual impairment, often in combination. Bennett (1987a)

estimates that approximately 20% of preterm VLBW (1,000-1,500 grams) infants suffer one or more of these

major handicapping conditions. For infants under 1,000 grams the incidence increases to approximately

30--40% (Bennett, 1987a; Klein, Hack, Gallagher, & Fanaroff, 1985; Knobloch, Malone, et al., 1982). As

with serious disabilities, the prevalence of mild disabilities (e.g., borderline intelligence [IQ 70-84], gross/fine

motor milestone delays, communication disorders, temperament difficulties) increases with decreasing birth

weight and gestational age. Current estimates of mild handicaps in VLBW infants vary between 15% and 25%

(Bennett, 1987b). The incidence of major and minor handicapping conditions existing in the VLBW infant

population totals 35--45%, demonstrating a residual, neuro-developmental problem that compromises their age

expected function (Saigal et al., 1982). Longitudinal studies of premature very low birthweight infants,

1,,iicate that this population has an increased risk of school dysfunction (Marlow, D'Souza, & Chiswick, 1987;

Szatmari. Rosenbaum, Campbell, & King, 1990); the risk for VLBW is estimated at nearly 50%

(Bennett, 1987a). Approximately 65% of infants under 1,000 grarns experience school problems, with

particular difficulties in reading comprehension, mathematics, perceptual skills, and fine motor balance and

coordination (Nickel, Bennett, & Lamson, 1982; Sell, 1986).

Hunt, Cooper and Tooley (1988) found that 50% of children born with VLBW had mild disabilities

at 8 and 11 years of age and almost 11% had moderate to severe problems. The incidence increases for infants

with significant neonatal illness who come from homes of low parent education and poor social milieu. Hunt

et al. (1988) reported that 81% of these children had some mild problem and approximately 55% had some

moderate to severe problem. Escalona (1984) labeled these children as being at "double hazard" for poor

developmental outcome, as a result of both biological and environmental interference. However, even in

homes with high parent education, a significant neonatal illness takes a major long-term toll, with 81% of

infants showing at least mild problems and almost 10% showing moderate to severe problems (Escalona,

1984).

More recently, in a school-age follow-up study, Hack, Taylor, Klien, Eiben, Schatschneider, and

Merucuri-Minich (1994) found that infants born with birthweights under 750 grams were at high risk for

neurobehavioral dysfunction and poor school performance. These children were significantly impaired with

respect to cognitive ability, psychomotor skills, and academic achievement. They had poorer social skills and

adaptive behavior and more behavioral and attention problems.

2
Infant Characteristics

Many VLBW infants or infants born with severe disabilities are difficult babies during the neonatal

period and for months after arriving home. Once discharged from the hospital neonatal intensive care unit

(NICU), these infants continue to lack a well organized central nervous system which results in less control

of sleep, arousal, alerting, attention, fussing, and feeding. Consequently, these infants behave in unexpected

and often frustrating patterns for the first three to six months after homecoming (Gorski, 1984). These infants

exhibit less attentiveness (Field, 1977; Goldberg, Brachfeld, & DiVitto, 1980), less game playing (Field,

1979a), less smiling and positive affect (Field, 1979b), greater fussiness and irritability (DiVitto & Goldberg,

1979; Elmer & Gregg, 1967), and are verbally inactive and avert their gaze during early social interactions

(Brown et al., 1980; Brown & Bakeman, 1979; Goldberg et al., 1980; Hedlund & Tatarka, 1991b). Because

many of the VLBW infants diagnosed with severe disabilities or at-risk lack the physiological control to

respond to stimuli appropriately or predictably, they are unable to provide the internal feedback that normally

reinforces the infant to progress to higher developmental tasks ( Beckwith & Cohen, 1980; Beckwith et al.,

1976). These infants also fail to provide predictable, clear behavioral cues that assist parents to respond in a

manner that will produce organized and contingent responses in their baby. When the infant is born with very

low birthweight or a severe disability, parents face the difficulty of caring for a child with frequent feeding and

sleeping difficulties (Campbell, 1989; Schaffer, 1984), of interpreting confusing signals or lack of signals,

and of overcoming their own grief and lack of confidence to care for a fragile infant. As these children often

cannot give their parents clear behavioral cues that are easy to interpret and respond to, the lack of clear cues

may in turn have a deleterious effect upon their caregivers (Als, 1992; Hedlund, 1989a).

The long-term implication of infant behavioral characteristics has been demonstrated in longitudinal

studies that show the persistence of neurobehavioral disorganization in infants who are VLBW beyond early

childhood (Als,1988, 1994; Barnard et al., 1984; Field, 1983, 1984). Jones (1977) observed similar continuities in behavior with prelinguistic children with Down syndrome. In observations of infants with

disabilities, Kogan (1980) found aberrant parent-child interactions persisting into preschool age. Crawley and

Spiker (1983) found correlctions between cognition and infants' social responsiveness, social initiative, and

play maturity at 2 years of age.

Parental Response to the Infant

Parents need help in learning how to cope with their VLBW/severely disabled infant's disorganized

behaviors and lack of clear signals. While caregivers are naturally imbued with a desire for reciprocal,

contingent interaction and seem to be biologically programmed for normal newborn behavior (Als et al., 1992),

these infants pose many problems. A substantial body of research suggests that parents of these infants show

continuing anxiety and low confidence in their caregiving competence, at least during the first year of their

infants' lives. These parental concerns are thought to be related to specific interaction patterns that have been

observed between these infants and their caregivers. Infants born with very low birthweight or severe

disabilities have problems with information processing and are therefore easily disorganized in their overall

behavior (Als, 1992). Parents of these infants may be frustrated or feel tremendous guilt in response to the

infant's disorganized behavior (Gorski, Davison, & Braze 1ton, 1979), may be frightened by the great sensitivity

of the infant (Als et al., 1988), may be hesitant to interact with their fragile infant (Minde, White law, Brown,

& Fitzhardinge, 1983), or may often experience emotional , physical, and financial stresses which place the

infants at high risk for child abuse and neglect (Egeland & Sroufe, 1981; Frodi, Lamb, Leavitt, Donovan, Neff,

& Sherry, 1978; Stern & Hildebrandt, 1984). Field (1983) observed that parents may need to work harder to

generate smiles, attention and contented vocalizations. However, the parents' efforts were often

counterproductive and frequently elicited stress in their infants. Parents must learn to sublimate the natural

3
tendency to "try harder" when the infant demonstrates a hypoactive or inappropriate response to their

stimulation (Barnard & Kelley, 1990). An infant's poor responsiveness, difficult temperament and diminished

I I k.--1 1.11 SI 55 I. 111" I as; I II II IS

& Bauer 1987). even more so than an alteltd rate of development (Beckman. Thiele Pokorni &

Balzer-Martin. 1986),

The impact of the infant's behaviors upon the parent, as well as the parent's sensitivity to reading the

infant's cues, has received increased attention in the literature. Research in the 1970s and 1980s on

infant-parent interaction and its relation to infant development revealed the central role of parents'

responsiveness to infant signals in mediating infant cognitive and linguistic development, as well as infant

sociability (Ainsworth & Bell, 1974; Ainsworth, Bell, & Stayton, 1974; Bretherton & Walters, 1986; Cohen

& Parmelee, 1983; Greenburg & Cmic, 1988; Heinicke, Beckwith, & Thompson 1988; Holdgrapher & Dunst,

1986; Piaget & Inhelder, 1969; Simeonsson, Bailey, Huntington, & Comfort, 1986; Tronick & Gianino,

1986b). The formation of an enduring attachment relationship (Bowlby, 1969) between parent and infant

appears to be directly affected by the mutual social regulation between the partners in the dyad (Beebe, Alson,

Jaffe, Feldstein & Crown, 1988). The infant's sense of security may result from adequate homeostatic

regulation within the caregiving relationship, with the earliest form of "security of attachment" encoded

physiologically in the experience of nondisruptive and need-satisfying regulation of neurobehavioral

organization (Pipp & Harmon, 1987).

With the recognition of the critical role social interactions play in the development of the child as well

as the impact the infants' characteristics have on the caregiver, a new approach in supporting mutually

satisfying parent-infant interactions, is most desperately warranted. Parents of infants born with VLBW or

severe disabilities need help and support from medical/early intervention professionals in: 1) observing their

infant and trusting their own observations (Als, 1992), 2) recognizing and interpreting the often unpredictable

behavioral cues expressed by their baby (Yoos, 1989), 3) providing the neurobehavioral support to the infant.

that is suggested by the expression of these cues (Kraus, 1990; Vandell & Wilson, 1987), and 4) experiencing

pride and joy in their infant and trusting their own importance and effectiveness in parenting their baby (Als.

1992).

4
II. THE NICU FOLLOW-THROUGH PROJECT

Infants who are born with very low birth weight (VLBW), with severe disabilities, or at-risk for

failures in developmental outcome require an array of intensive services throughout their first two years of life.

There has been an explosion in the creation of "infant stimulation" programs offered via schools and private,

community-based intervention programs (Als, 1992; Barrera, Rosenbaum, & Cunningham, 1986; Vanden Berg,

1985). "The past two decades have seen an increase in both the number of clinicians involved and the number

of programs aimed at optimizing developmental recovery during and following neonatal hospitalization and

at preventing or ameliorating associated neurodevelopmental morbidities. Professional support has extended

to the home environment, where family and community provide much of the support for survivors of

high-technology care" (Bennett, 1990, p. 34).

Infant sti=lation programs, in hospital and developmental centers continue to take a

stimulus/environmental deprivation approach to intervention, helping the child to "catch up" by introducing

him or her to various modes of sensory stimulation and instruction in age-appropriate developmental skills

(Bennett, 1987a; Guralnick & Bricker, 1987). This form of intervention is inappropriate or even harmful for

these VLBW/severely disabled infants, as they are not stabilized at the neurophysiological level that would

allow them to effectively process the sensory input offered (Als, 1992, 1994; Barnard & Kelly, 1990; Gorski,

1984; Nurcombe, Howell, Rauh, Teti, Ruoff, & Brennan, 1984). "Stimulation that is too complex or intense

or inappropriately timed in terms of infant state threshold maturity or physiologic status can be as harmful as

lack of stimulation" (Blackburn, 1983, p. 78). Efforts to stimulate these infants to compensate for

developmental deficits or sensorially impoverished environments may, in fact, cause overstimulation (Als,

1992; Barnard & Kelly, 1990) and force them into coping at the expense of their physiologic function and

stability (McCollum & Stayton, 1985). VLBW infants and infants with severe disabilities should be provided

opportunities to engage in social and environmental interactions when they are contingent upon the behavioral

cues expressed by the infant (Als et al., 1988; Braze lton, 1984b; Hedlund, 1989a). Unfortunately, very few

models now exist that help both parents as well as medical and early intervention professionals to recognize

and support the neurobehavioral stability of these fragile infants.

As VLBW infants and infants with severe disabilities are discharged from hospital neonatal intensive

care units, parents are confronting the long-term implications of their child's Epecial needs. "Support and

neurobehavioral intervention cannot end when the infant is discharged from the NICU, but must systematically

link families and infants to sound models of community-based supports that build on the neurobehavioral care

and intervention provided in the NICU" (Als, 1992). The research literature has clearly demonstrated a need

for the development of a continuum of intervention services, beginning at the hospital NICU and spanning the

transition to home and community service providers. Intervention offered these infants and their families must

capitalize on family strengths and resources to empower parents to make informed decisions, create

opportunities for parent-to-parent contact, develop a range of services to make informed decisions, focus

intervention goals on parent-identified needs, and facilitate and support the development of mutually satisfying

parent-infant interactions. To date, very few model exist that specifically address this state-of-the-art

intervention need.

In response to the needs described above, the NICU Follow-Through Project has provided training

to medical and early intervention professionals in 18 outreach communities within 10 states. This innovative

approach:

1. assisted medical and early intervention professionals to train and facilitate parents in

5
supporting their VLBW/severely disabled infant while engaging them in caregiving activities

and social interactions;

2. assisted medical and intervention professionals to interpret the neurobehavioral cues

expressed by these infants and to respond in an appropriate contingent manner during a

caregiving, assessment, or intervention session;

3. assisted medical and early intervention professionals to implement a comprehensive

interagency coordinated service plan for very low birthweight/severely disabled infants and

their families; and

4. trained medical/educational professionals to become trainers of a neurobehavioral assessment.

The NICU Follow-Through Project's goal, objectives, and activities; a description of the implementation of

the objectives; evaluations of the training components; and a description of the project products, is presented

in the following report.

6
III. PROJECT GOALS AND OBJECTIVES

The NICU Follow-Through Project objectives and corresponding sub-objectives are listed below.

GOAL: TO PROVIDE AND/OR IMPROVE EDUCATIONAL SERVICES TO VLBW/

DISABLED INFANTS DISCHARGED FROM LOCAL NICUs, AND THEIR

FAMILIES BY HELPING AT LEAST 56 NEW OUTREACH SITES (YEARS 1- 3)

TO ADOPT THE NICU FOLLOW-THROUGH PROJECT allt,CGH

REPLICATION OF ITS MAJOR COMPONENTS.

OBJECTIVE 1: Assist hospital NICU staff to develop a comprehensive Transition and Neuro-behavioral

Action Plan for VLBW/disabled infants and their families

Objective 1.1: Assist the NICU staff to develop and implement a Transition Action Plan with the

developmental center staff via instruction in the Team Building for Transiiion training

component.

Objective 1.2: Assist the NICU staff to develop and implement a Neurobehavioral Action Plan for

caregiving in the NICU.

Objective 1.3: Assess progress made in the implementation of the Transition Action Plan. Determine a

new transition objective for NICU/developmental center staff to collaboratively implement.

Objective 1.4: Assess progress made in the implementation of the Neurobehavioral Action Plan.

Determine a new neurobehavioral objective for the NICU staff to implement.

OBJECTIVE 2: Assist community developmental centers to develop and implement a comprehensive

Transition and Neurobehalbioral Action Plan for VLBW/disabled infants and their families,

Objective 2.1: Assist the developmental center staff to develop and implement a Transition Action Plan

with the NICU staff via instruction in the Team Building for Transition training component.

Objective 2.2: Assist the developmental center staff to develop and implement a Neurobehavioral Action

Plan for therapeutic/education intervention in the developmental center.

Objective 2.3: Assess progress made in the implementation of the Trarisition Action Plan. Determine new

transition objective for NICU/developmental center staff to collaboratively implement.

Objective 2.4: Assess progress made in the implementation of the Neurobehavioral Action Plan.

Determine a new neurobehavioral objective for the developmental center staff to

implement.

OBJECTIVE 3: Train NICU/developmental center staff at each of the outreach sites to assess infants'

behavioral cues utilizing the Naturalistic Observation of Newborn Behavior (NONB) and

the Infant Behavioral Assessment (IBM and provide appropriate neuro-behavioral

caregiving/developmental intervention,

7

.
Objective 3.1: Instruct 6 NICU trainees and 8 developmental center trainees in the Synactive Model of

Newborn Behavioral Organization and Development.

Objective 3.2: Instruct the 6 NICU trainees in the administration of the NONB and the implementation of

appropriate neurobehavioral caregiving.

Objecti ve 3.3 Instruct the 8 developmental center trainees in the administration of the IBA and assist them

to apply the IBA results to provide sensitive infant educational/ therapeutic intervention.

Objective 3.4: Conduct reliability checks and certification in the NONB and IBA with the 6 NICli trainees

and 8 developmental center trainees.

OBJECTIVE 4: Train a professional previously certified in the administration of the LBA. to become an IBA

instructor.

Objective 4.1: Conduct reliability and competency checks with the prospective trainer utilizing the IBA

and intervention strategies.

Objective 4.2: Assist the prospective trainer to learn and present the didactic lecture on the Synactive

Model of Newborn Behavioral Organization and Development.

Objective 4.3: Provide instruction to the prospective trainer in the IBA training format, manual, and

instructional materials.

Objective 4.4: The prospective trainer will observe the NICU Follow-Through Project instructors conduct

an IBA training workshop.

Objective 4.5: NICU Follow-Through Project instructor will observe the prospective trainer conduct an

IBA training workshop in his/her own outreach community.

Objective 4.6: NICU Follow-Through Project instructor will observe the prospective trainer conduct an

IBA certification session.

OBJECTIVE 5: Evaluate trainee attainment of competence. providing technical assistance as necessary.

For each of these major objectives/sub-objectives, specific activities have been identified in order to

evaluate the quality of implementation and the timeliness of the completion of tasks and activities. The

objectives, activities, and timelines that were followed during the 3 years of the implementation of this project

are presented in Table I.

8

BEST COPY AVAILABL1
Table 1

Project Objective, Activities, and Timelines

Pro ect Mana ement

OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

Project Management a. Notify sites of funding. Principle Investigator

Project Director

Month 1

b. Hold planning meeting with sites/telephone

conferences.

Project Director Months 2-7

c Refine instructional format/procedurcs for

training Prospective IBA Trainers.

Project Director

Pediatric Physical Therapist

Months 1-5

d. Refine evaluative NICU Follow-Through

Project Questionnaires.

Project Director

Pediatric Physical Therapist

Pediatric Nurse

Months 1-3

e. Gather/duplicate niaterials. Project Director

Pediatric Physical Therapist

Pediatric Nurse

Months 1-3

f Monitor budget. Principle Investigator

Project Director

Months 1-12

g. Prepare and send reperts to OSERS. Principle Investigator

Project Director

Months 7-8

Objective 1.0: Assist hospital NICLL staff to develop a comprehensive Transition and Neurobehavioral

Action Plan for VLBW/disabled infants and their families,

OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

1.1: Assist the NICU staff to develop and implement a

transition Action Plan with the developmental

center staff via instruction in the Team Building

for Transition training component. a. Instruct trainees in Team Dynamics. Project Director

Pediatric Physical Therapist

Months 5-10

b. Instruct trainees in the utilization of the Action

Plan via case study.

Project Director

Pediatric Physical Therapist

Months 5-10

c. Trainees will demonstrate effective use of Action

Plan with case study.

Pediatric Physical Therapist Months 5-10

8a

Li
OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

d. Assist trainees to determine specific transition

objective(s) that they would like to collaborate on

with community developmental centers.

Project Director

Pediatric Physical Therapist

Months 5-10

e. Develop implementation and monitoring plan for

determined transition objective(s) utilizing the

Action Plan Worksheet.

Project Director

Pediatric Physical Therapist

Months 5-10

1.2: Assist the NICU staff to develop and implement a

Neurobehavioral Action Plan for caregiving in the

NICU. a. Assist the NICU staff to utilize the Action Plan

Worksheet to identify and implement a

neurobehavioral objective for their NICU.

Project Director

Pediatric Physical Therapist

Months 5-10

b. Assist the NICU staff to develop an inservice

workshop on the Synactive Model, the NONB

and related intervention strategies, for those

NICU professionals who were unable to

participate in the NONB training.

Project Director Months 5-10

1.3: Assess progress made in the implementation ofthe

Transition Action Plan. Determine new transition

objective NICU/developmental center staff to

collaboratively implement.

a. Review progress made in the implementation of

Transition Action Plan during initial site visit.

Project Director

Pediatric Nurse

Months 7-12

b. Make modifications/refinements in plan where

warranted.

Project Director

Pediatric Nurse

Months 7-12

c. Assist NICU/developmental center staff to

identify a second transition objective.

Project Director

Pediatric Nurse

Months 7-12

d. Develop an implementation/monitoring plan for

determined transition objective utilizing Action

Plan.

Project Director

Pediatric Nurse

Months 7-12

1.4: Assess progress made in the implementation of the

Neurobehavioral Action Plan. Determine a new

neurobehavioral objective for the NICU staff to

implement. a. Review progress made in the implementation of

the Neurobehavioral Action Plan during initial

site visit.

Pediatric Nurse Months 7-12

b. Make modifications/refinements in plan where

warranted.

Pediatric Nurse Months 7-12

8b

.14
OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

c. Assist NICU staff to identify a second

neurobehavioral objective.

Pediatric Nurse Months 7-12

d. Develop an Implementation/Monit( Ting plan for

determined transition objective utilizing Action

Plan Worksheet.

Pediatric Nurse Months 7-12

Objective 2.0: Assist community development centers to develop and implement a comprehensive

Transition and Neurobehavioral Action Plan for VLBW/disabled infants and their

families.

OBJECTIVES AND ACTIVITIES PERSON(S) RESPONSIBLE TIMELINE

2:1: Assist the developmental center staff to develop

and implement aTransition Action Plan with the

NICU staff via instruction in the Team Building

for Transition training component. a. Instruct trainees in Team Dynamics. Project Director

Pediatric Physical Therapist

Months 5-10

b. Instruct trainees in the utilization of the Action

Plan via case study.

Project Director

Pediatric Physical Therapist

Months 5-10

c. Trainees will demonstrate effective use of

Action Plan with case study.

Project Director

Pediatric Physical Therapist

Months 5-10

d. Assist trainees to determine specific transition

objective(s) that they would like to collaborate

on with hospital NICU.

Project Director

Pediatric Physical Therapist

Months 5-10

e. Develop implementation and monitoring plan

for determined transition objective(s) utilizing

Action Plan Worksheet.

Project Director

Pediatric Physical Therapist

Months 5-10

2.2: Assist the developmental center staff to develop

and implement a Neurobehavioral Action Plan

for therapeutic/educational intervention in the

developmental center. a. Assist the developmental staff to utilize the

Action Plan Worksheet to identify and

implement a neurobehavioral objective for their

developmental center.

Pediatric Physical Therapist Months 5-10

8c
OBJECTIVES AND ACTIVITIES PERSON(S) RESPONSIBLE TIMELINE

b. Assist the developmental center staff to develop

an inservice workshop on the Synactive Model,

the IBA and related intervention strategies, for

those developmental center professionals who

were unable to participate in the IBA training.

Pediatric Physical Therapist Months 5-10

2.3: Assess progress made in the implementation of

the Transition Action Plan. Determine a new

transition objective for NICU/developmental

center staff to collaboratively implement. a. Review progress made in the implementation of

Action Plan during initial site visit.

Project Director

Pediatric Nurse

Months 7-12

b. Make modifications/refinements in plan where

warranted.

Project Director

Pediatric Nurse

-, Months 7-12

c. Assist NICU/developmental center staff to

identify a second transition objective.

Project Director

Pediatric Nurse

Months 7-12

d. Develop an implementation/monitoring plan for

determined transition objective utlizing the

Action Plan.

Project Director

Pediatric Nurse

, Months 7-12

2.4: Assess progress made in the implementation of

the Neurobehavioral Action Plan. Determine a

new neurobehavioral objective for

developmental center staff to implement. a. Review progress made in the implementation of

the Neurobehavioral Action Plan during the

initial site visit Workshop #1.

Project Director Months 7-12

b. Make modifications/refinements in plan where

warranted.

Project Director Months 7-12

c. Assist developmental center staff to identify a

second neurobehavioral objective.

Project Director Months 7-12

d. Develop an implementation/monitoring plan for

determined neurobehaviora: objective utilizing

the Action Plan.

Project Director Months 7-12
Objective 3.0: Train NICU/developmental center staff at each of the outreach sites to assess infants'

behavioral cues utilizing the Naturalistic Observation of Newborn_Behavioral (NONB)

and the Infant Behavioral Assessment (IBM and provide appropriate neurobehavioral

caregiving/developmental intervention,

OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

3.1: Instruct 6 NICU trainees and 8 developmental

center trainees in the Synactive Model of Newborn

Behavioral Organization and Development.

a. Instruct developmental center staff in the

significance of the 4 subsystems of

communication.

Project Director

, Months 5-10

b. Provide training in approach, stress, and selfregulatory behaviors expressed by infants.

Project Director Months 5-10

c. Instruct trainees in the integration of the 4

subsystems of communication.

Project Director Months 5-10

d. present studies (Als, 1986, 1988) which support

the utilization of neurobehavioral caregiving and

intervention.

Project Director Months 5-10

e. Provide instruction in caregiving/developmental

strategies that support the neurobehavioral

organizational capacity of the infant.

Project Director Months 5-10

3.2 Instruct the 6 NICU trainees in the administration

of the NONB and the implementation of

appropriate neurobehavioral caregiving.

a. Discuss NONB Observation Sheet to guide the

assessment of observed behaviors.

Project Director Months 5-10

b. Define infant behaviors via NONB videotapes

and item-by-item review of Observation Scan

Sheet.

Project Director Months 5-10

c. Review NONB Observation Protocol. Project Director Months 5-10

d. Assist trainees to adapt their caregiving

techniques to more closely support the

neurophysiological organization of the infant.

Project Director Months 5-10

e. Sensitize trainees to NICU environmental stimuli,

positioning/handling techniques and their impact

on the infant's neurobehavioral organization.

Project Director Months 5-10

f. Observe a specific infant before, during, and after

a caregiving intervention by the infant's nurse.

Project Director Months 5-10

8e
OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

g. Summarize observation and discuss implications

for care.

Project Director Months 5-10

h. Develop an individual care plan for the infant that

was observed.

Project Director Months 5-10

i. Review trainees "homework" for the follo;,ing

months and schedule date for assessment of skills

learned and certification in the NONB.

Project Director Months 5-10

3.3 Instruct the 8 development center trainees in the

administration of the IBA and assist them to apply

the IBA results to provide sensitive infant

educational/therapeutic intervention.

a. Provide item-by-item review of IBA. Pediatric Physical Therapist Months 5-10

b. Review professional videotape/slide presentation

of behaviors identified by IBA.

Pediatric Physical Therapist Months 5-10

c. Administer and score IBA utilizing videotape

examples of interventionist/caregiver-infant

interaction.

Pediatric Physical Therapist

1 Months 5-10

d. Summarize observation and discuss implications

for intervention.

Pediatric Physical Therapist Months 5-10

e. Assist trainees to adapt their intervention

techniques and strategies to more closely support

the neurophysiological organization of the child.

Pediatric Physical Therapist Months 5-10

f. Provide intervention strategies that will optimize

an intervention session with an infant attaining

the "best performance" from the child.

Pediatric Physical Therapist Months 5-10

g. Sensitize trainees to environmental stimuli,

positioning/handling techniques, and their impact

on the infant's neurobehavioral organization.

Pediatric Physical Therapist Months 5-10

h. Sensitize trainees to their own interactional style

during intervention episode via "live" observation

of interventionist-infant interaction and review of

past videotapes made prior to site visit by

development center staff.

Pediatric Physical Therapist Months 5-10

I. Highlight the interactional strategies/modalities

that interventionist may utilize and how this

effects the infant.

Pediatric Physical Therapist Months 5-10

8f

-, .1 o
OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

j. Teach trainees to utilize professional videotape to

assist parents to "tune in" to the behavioral cues

of their infant.

Pediatric Physical Therapist Months 5-10

k. Provide instruction in the use of parent

handouts/materials.

Pediatric Physical Therapist

. Months 5-10

I. Review trainees' "homework" for the following

months and schedule date for assessment of skills

learned and certification in the IBA.

Pediatric Physical Therapist Months 5-10

3.4: Conduct reliability checks and certification in the

NONB and IBA with the 6 NICU trainees and 8

developmental cepter trainees. a. NONB Reliability Phase Pediatric Nurse Months 7-12

1) Observe infant in the NICU before, during,

and after a caregiving episode.

2.) Make independent written

observation/recommendations for

modification of care.

3) Compare and discuss respective

observations/recommendations.

4) A second observation is conducted as

deemed necessary by the trainer.

Pediatric Nurse

.

.

Months 7-12

b. IBA Reliability Phase Project Director Months 7-12

1) Observe infant during a caregiving,

social/intervention activity.

2) Make independent written

observations/recommendations.

3) Compare and discuss respective

observations/recommendations.

4) A second observation is conducted as

deemed necessary by the trainer.

5) Review trainees' post-training videotape.

6) Check 10 reliabilities.

7) Administer IBA post-test.

Project Director Months 7-12

8g
Objective 4.0: Train a professional. previously certified in the administration of the IBA. to become an

113Ainainsaa.

OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE

TIMELINE

4.1: Conduct reliability and competency check with the

prospective trainer utilizing the IBA and intervention

strategies.

-

a. Review prospective trainer's videotapes. Project Director

Pediatric Physical Therapist

Month 6

b. Review and evaluate the IBA Trainer's Competency

Checklist.

Project Director

Pediatric Physical Therapist

Month 6

c. Presentation of case studies developed by

prospective trainer in their work with families and

professionals while utilizing the 1E13A and

supplemental training materials.

Project Director

Pediatric Physical Therapist

Month 6

d. Two "real time" observations of two infants,

conducted at NFTP site, in which a minimum of

85% agreement is attained with the prospective

trainer.

Project Director

Pediatric Physical Therapist

Month 6

e The prospective trainer presents independent written

observations and recommendations based on the two

"real time" observations utilizing the IBA and

neurobehavioral intervention strategies. . 4.2: Assist the prospective trainer to learn and present the

didactic lecture on the Synactive Model of Newborn

Behavioral Organization and Development. a. Review slide and video presentation of the Synactive

Model of Neurobehavioral Organization and

Development with the accompanying presentation

outline and text describing:

Project Director Month 6

1) Low Birthweight: Incidence and Sequelae

2) Behavioral/Temperament Characteristics of

Selected Infant Populations.

3) CNS Development

4) Neuro-Social/Behavioral Development

5) The Synactive Model

6) Research Findings

7) Historical Overview of Infant Interventions

8) Interventions Strategies

Project Director Month 6

4.3: Provide instruction to the prospective trainer in the

IBA training format, manual, and instructional

materials.

8h
OBJECTIVES AND ACTIVITIES PERSON(S)

RESPONSIBLE . TIMELINE

a. Review IBA Syllabus and instructional format. Pediatric Physical Therapist Month 6

b. Review IBA Training manual and provide

instructional procedures for its utilization during the

training session.

Pediatric Physical Therapist Month 6

c. Review and describe procedures for use of IBA

slides and videotapes.

Pediatric Physical Therapist

, Month 6

d. Instruct prospective trainer in the utilization of IBA

infant video segments.

Pediatric Physical Therapist Month 6

e. Instruct prospective trainer in the neurobehavioral

intervention techniques/strategies taught in the

workshop.

Pediatric Physical Therapist Month 6 _

f. Review an provide instruction in the use of all

training materials/handouts. _

Pediatric Physical Therapist Month 6

4.4: Prospective trainer will observe the NICU FollowThrough Project instructors conduct an IBA training

workshop. a. The prospective trainer observes the IBA instructors

train 8 professionals in the administration of the IBA

and the utilization of neurobehavioral intervention

strategies.

Project IThirector

Pediatric Physical Therapist

Month 6

4.5: NICU Follow-Through instructor will observe the

prospective trainer conduct an IBA training

workshop in his/her own outreach community. a. The prospective trainer conducts the 3-day IBA

workshop with 8 professionals in their own outreach

community.

Project Director Month 9

b. Prospective trainer is critiqued by IBA instructor.

Training feedback is provide to the prospective

trainer at the conclusion of the workshop.

Project Director Month 9

4.6: NICU Follow-Through Project instructor will

observe the prospective trainer conduct an IBA

certification session. a. The prospective trainer conducts certification session

with the 8 professionals that initially received

instruction during the IBA workshop from the

prospective trainer

Project Director Month 11

b. Certification as an IBA trainer is granted upon

successful completion of all requirements.

Project Director Month 11

81
Objective 5.0:

Please see:

Evaluate trainee attainment of coraNtQnce. providinz technical assistance as

liecessary,

VI. Evaluation of Project Training Components

8j
IV. OUTREACH TRAINING COMMUNITIES: YEARS 1-3

In the first year, the NICU Follow-Through Project trained over 400 medical and educational

professionals at 19 sites (6 Hospital NICUs, 13 Developmental Service Agencies) located in 6 outreach

communities within 4 states: Missouri, New Hampshire, Utah, and Washington. (please see Figure I ).

In the second year, the project trained approximately 450 medical and educational professionals at 20

sites (7 Hospital NICUs, 13 Developmental Service Agencies) located in 6 outreach communities within .5

states: Idaho, Massachusetts, Missouri, South Dakota, and Washington (please see Figure 2).

In the third year, the NICU Follow-Through Project trained approximately 450 medical and

educational professionals at 17 sites (6 Hospital NICUs, 11 Developmental Service Agencies) located in 6

outreach communities within 5 states: California, Florida, Massachusetts, Ohio, and Washington (please see

Figure 3). The demand for training in Massachusetts was so great, that we actually provided additional

training to a second group of trainees in the administration of the Infant Behavioral Assessment and the

Newborn Individualized Developmental Care and Assessment Program.

9
Tacoma

WASHINGTON

Figure 1

NICU Follow-Through Project

6 Outreach Sites: Year 1

6 Outreach Communities: 6 Hospital.NICUs

13 Developmental Service Agencies

WASHINGTON

Tacoma

1. Tacoma General Hospital

Tacomo. Learning Center

Valley Learning Center

2. Mary Bridge Children's Hospital

Mary Bridge Therapy Center

Visiting Nurses Association

Kansas City

St. Louis

Missount

MISSOURI

Kansas City

4. Kansas City Children's Mercy Hospital

Children's Home Care

Visiting Nurses Association

St. Louis

5. St. Lodis Children's Hospital

Hospital Home Health Department

Nurses for Newborns

9a

UTAH

Provo

UTAH

Provo

3. Utah Valley Regional Medical Center

Provo Early Education Program

Kids on the Move

City-County Health Department of Utah

County

NEW HAMPSHIRE

Lebanon

6. Dartmouth-Hitchcock Medical Center

United Development Services

Milestones, Inc.
Figure 2

NICU Follow-Through Project

6 Outreach Sites: Year 2

6 Outreach Communities: 7 Hospital NICUs

13 Developmental Service Agencies

MISSOURI

Kansas City

; . Children's Mercy Hospital

NICU Follow-Up Clinic

Children's Home Care

KansasCity

MISSOURI

Spokane

; Seattle

WASHINGTON

WASHINGTON

Seattle

2. Children'sHospital and Medical Center

Merrywood School

Northwest Center

Spokane

4. Sacred Heart Medical Center

Deaconess Medical Center

Children's Guild School

Visiting Nurses Association

Pb

SOUTH DAKOTA

Sioux Falls

5-

SOUTH DAKOTA

Sioux Falls

2. Souix Valley Hospital

Sioux Falls Public Schools:

Early Childhood Program

City-County Health Department

MASSACHUSETTS,-,"\

Winchester

MASSACHUSETTS

Winchester

5. Winchester Hospital

Winchester Early Intervention Program

Tri-City Early Intervention Program

IDAHO

Boise

6. St. Luke's Regional Medical Center

St. Luke's High Risk Clinic

St. Luke's Home Care

Adult & Child Development Center
WASHINGTON

Everett

I. Providence General Medical Center

Providence High Risk Center

Providence Children's Center

Seattle

2. Center on Human Development & Disability

High Risk Clinic

Experimental Education Unit: Infant

Program

Figure 3

NICU Follow-Through Project

Outreach Sites: Year 3

6 Outreach Communities: 6 Hospital NICUs

11 Developmental Service Agencies

Everett

\ Seattle

WASHINGTON

Miami

FLORIDA

Miami

4. University of Miami/Jackson Memorial Hospital

Mailman Center: Department of Pediatrics

Mailman Center: The Early Intervention Program

OHIO

Toledo

3. The Toledo Hospital

Children's Hospital: NICU Follow-Up Clinic

Lucas County Board of Mental Retardation and

Developmental Disabilities Early Intervention

Program

Toledo

MASSACHUSETTS

oraf\ster

MASSACHUSETI

Worcester

4. The Medical Center of

Central Masschusetts

Worcester Early Intervention Program

Marlboro Early Intervention Program

CALIFORNIA

San Diego

4. Mary Birch Hospital

for Women at Sharp Memorial

High Risk Clinic

1

9c

San Diego
V. IMPLEMENTATION OF PROJECT OBJECTIVES

Objectives 1.1-3.4: Workshops #1 and #2

To accomplish these objectives, each outreach community was visited twice. Objectives 1.1-1.2,

2.1-2.2, and 3.1-3.3 were accomplished during Workshop #1 (please see Table 2). A second visit, Workshop

#2, was scheduled approximately two months later, to complete objectives 1.3-1.4, 2.3-2.4, and 3.4 (please

see Table 3). Table 6: Timeline for Objective Implementation, provides a schematic of the training schedule

that was utilized to ensure the timely implementation of each objective for each outreach training site during

Years 1-3.

Objective 4.1-4.4: The IBA Trainer Workshop

We have trained three individuals to become IBA Trainers. These include: Mary Quinn-Hurst, a

pediatric occupational therapist at Sacred Heart Medical Center in Spokane, Washington; Murry Ralston, a

pediatric occupational therapist at St. Lukes Regional Medical Center in Boise, Idaho; and Laurie Mouradian,

a pediatric occupational therapist at the Winchester Early Intervention Program in Winchester, Massachusetts.

We had originally projected to train more individuals as IBA Trainers but found that each individual

prospective trainer needed additional time and technical assistance to integrate the information and master the

presentation of the IBA training workshops. Our energies and time were thus directed to assisting each of the

3 prospective trainers to individually master the LBA training materials for the presentation and guidance of

their own trainees. Table 4 provides a schematic of the trainirg which accomplished Objectives 4.1-4.4.

Objective 4.5-4.6: IBA Trainer Site Visits #1 and #2

To implement Objective 4.5 the NICU Follow-Through project director visited the site of the

prospective trainer to observe the candidate conduct an IBA training session with 8 professionals from her own

community (Site Visit # 1: Table 5). The NICU Follow-Through project director then returned to the site of

the prospective trainer, Objective 4.6 (Site Visit #2: Table 5) to observe the prospective trainer certify the 8

professionals that she originally Mined. Table 6: Timeline for Objective Implementation, provides a

schematic of the training schedule that was utilized to ensure the implementation of objectives 4.1-4.6. In

order to meet the training needs of each of the prospective trainers, additional site visits were scheduled to

assist them to further refine their instructional techniques.

Objective 5.0: Evaluate trainee attainment of competence, providing technical

assistance as necessary.

Please see: VI. Evaluation of Project Training Components

10
Table 2 NICIU Follow-Through Project Workshop NI Objectives: 1.1-1.2, 2.1-2.2, 3.1-3.3 Day NI Thursday Day 02 Friday Day N3 Saturday Day N4 Sunday Day NS Monday Targeted Staff: Morning Session: 8:00-12:00 Full Day Session: 8:00-5:00 Morning Session: 8:00-12:00 Full Day Session: 8:00-5:00 Full Day SC33i011: 8:0015:00 6 NICIJ Trainees 8 Early Intervention Trainees Invited Community Professionals Ailernoon Session: 1:00-5:00 4 NICU Trainees: Bedside Observation: 2 Trainees in thc morning 2 Trainees in thc afternoon Full Day Session: 8:00-5:00 2 NICU Trainees Bedside Obsrvation A ft sosion: I:004m "6 6 NICU Trainees I Early Intervention Trainees 6 NICU Trainees 8 Early Intervention Trainees NICU Trainees NIDCAP Interview Full Day Session: 8:00-5.00 6 NICU Trainees 8 Early intervention Trainees 8 Early intervention Trainees I Early Intervention Trainees Objectives: Morning Session Full Day Session Full Day Session Full Day Session Morning Session instruct 6 N1CU Trainees, 8 Early Intervention Trainees, and invited outreach community professionals in the Synactivc Model of Neonatal Behavioral Organization a nd Development. Anernoon Session Continuation of instruction in thc administration of the NONB with NICU Trainees. Begin instruction of 8 Early Intervention Trainees in the ailministration of thc Infant Behavioral Assessment (DM) and assist them to apply (he IBA results to provide sensitive infant educational/therapeutic intervention. Continuation of instruction in the administration of the NOM with NICU Trainees Continuation of instruction in the administration of thc IBA with Early Intervention Trainees. Begin instruction in Team Building for Transition Continuation of Tcam Building for Transition: Develop Transition Action Plan. 152mnsvnktfion The NICU and Early Intervention Trainees meet separately to develop their Neurobehavioral Action Plan for carcgiving and therapeutic/cducsiion intervention. Begin instruction of the 6 NICU Trainees in the administration of thc Naturalistic Observation of Newborn Behavior (NONI)) and the implementation of appropriate neurobehavioral carcgiving. Amount of Time Spedfled: 8 liours 8 Hours 8 Hours 8 !lours 8 limas Outreach Trainers Responsible: Rodd liediund, M.Ed. Mary Tatarka, M.S., P.T. Rodd I ledlund, M.Ed. Mary Tatruka, M.S., l'.T. Rodd I Iedlund, M.E.4j. Mary Tatarka, M.S., P.T. Rodd liediund, M.Ed. Mary Tatarka, M.S., P.T. Rodd Hedlund, M.Ed. Mary Tatarka, M.S., P.T. 8 10a BEST COPY AVAILABLE
Table 3 NICU Follow-Through Project Workshop #2 Objectives: 1.3-1.4, 2.3-2.4, 3.4 Day NI Friday Day /12 Saturday . Day N3 Sunday Targeted Staff: Morning Session: 8:00-12:00 Ivtorning Session: 8:00-12:00 Morning Session: 8:00-12:00 2 N1CU Trainees 3 Early Intervention Trainees Afternoon Session: I:00-5:00 2 NICU Trainccs 2 Early Intervention Trainees Afternoon Session: 1:00-5:00 PM 6 N1CU Trainees 8 Early Intervention Trainees 2 NICU Trainees 3 Early Intervention Trainees 6 N1CU Trainees 8 Early intervention Trainees Objectives: Morning/Afternoon Session Morning Session Morning Session Conduct reliability checks and certification in the NOM and IDA. Conduct reliability chccks and certification in thc NOND and IBA. Afternoon Sessicn Review/Problem Solving: Assess progress made in the implementation of the Transition Action Plan. Determine new transition objective for the team to collaboratively implement. Review/Problem Solving: Assess progress madc in thc implementation of the Neurobehavioral Action Plan with cach group. Determine a new neurobehavioral objective that each group will implement. Amount of Time Specified: Two 4 Hour Sessions Two 4 Hour Sessions 4 Hours Outreach Trainers Responsible: Rodd Hedlund, M.Ed. grctchcn Lawhon, Ph.C. Rodd Hedlund, M.Ed. gretchen Lawhon, Ph.C. Rodd Hedlund, M.Ed. gretchen Lawhon, Ph.C. 3i 1 Oh
Table 4 NICU FoIlow-Through Project Trainer Workshop Training the Prospective IBA Trainer: Objective 4.1-4.4 This workshop is conducted at the University of Washington Prospective Trainer's Arrival:. Thursday Evening Prospective Trainer's Departure: Wednesday Evening Friday Saturday Sunday Monday Tuesday Wednesday Targeted Staff: 1 Prospective IBA Trainer I Prospective IBA Trainer 1 Prospective IBA Traincr I Prospective IBA Trainer I Prospective IBA Trainer I Prospective IBA Trainer Objectives: 4.1: Conduct reliability and compctcncy check with prospective trainer utilizing IBA and intervention strategics. 4.2: Assist trainee to learn and prcscnt thc didactic on the Synactive Model of Neonatal Behavioral Organization and Development, 4.3: Provide instruction to the prospective trainer in the IBA training format, manual, and instructional materials. 4.4: Prospective trainer observe N1CU Follow- Through Project instructor conducting IBA training scssions, 4.4: Prospective trainer observe NICU Follow- Through Project instructor conducting IBA training sessions, Summation of IBA trainer workshop. Review the training session conducted by NICU Follow- Through Projcct instructor with prospective trainer. Amount of Time Specified: 8 Hours 8 Hours 8 Hours 8 Hours 8 Hours 8 Hours Outreach Trainer Responsible: Projcct Dircctor Pediatric Physical Therapist Project Director Pediatric Physical Therapist Projcct Dircctor Pcdiatric Physical Thcrapist Project Director Pediatric Physical Therapist Project Director Pediatric Physical Therapist Project Director Pediatric Physical 'Therapist 3 10c
Table 5 Training the IBA Trainer IBA Trainer Site Visits NI and 2: Objective 4.5-4.6 The N1CU Follow-Through Project Director visits the prospective trainer at her own outrcach site during Visits N I and #2. OBJECTIVE 4.5: NICU Follow-Through Project Director observes the prospective trainer conduct an IBA training workshop in hcr own outreach community. SITE VISIT N 1 Day NI: Thursday Day #2: Friday Day #3: Saturday Targeted Staff: Prospective IBA Miner Prospective IBA Trainer , Prospective IBA Trainer Objective: 4.5: NICU Follow-Through Project instructor observes prospective trainer conduct IBA training scssion with 8 professionals within his/her own outreach community. 4.5: Continuation of NICU Follow- Through Project instructor's observation of prospective IBA trainer conducting IBA training session. 4.5: NICU Follow-Though Project instructor critiques the observed IBA training session with the prospective IBA trainer. Amount of Time Specified: 8 Hours 8 Hours 5 Hours Outreach Trainer Responsible: Project Director Project Director Projcct Director _. OBJECTIVE 4.6: N1CU Follow-Through Projcct instructor observes thc prospective trainer conduct an IBA certification scssion. SITE VISIT #2 Day N1 : Friday Day #2: Saturday Targeted Staff: Prospective IBA Trainer Prospective IBA Trainer Objective: 4.6: N1CU Follow-Through Project instructor observes prospective traincr certify thc 8 professionals who were originally trained by the prospective traincr in site Visit #1. 4.6: NICU Follow-Through Project instructor critiques the observed IBA 'certification process with the prospective trainer. Certification as an IBA trainer is granted upon successful completion of all requirements. Amount or Time Specified: 8 Hours 8 Hours Outreach Trainer Responsible: Project Director Project Director I Od
Table 6

Timeline for Objective Implementation

Major Activities Performed By Oct Nov DCC Jan Feb Mar Apr May Jun Jul Aug Sep

Project Management

X

X X

Notify sites of funding Bennett

Hedlund

Hold planning meetings %ith Hedlund

sites/Telephone Conference

Refine instructional Hedlund

format/procedures for NFTP Tatarka

training Lawbon

Gather/duplicate materials Hedlund

Tatarka

Lawbon

Monitor budget Bennett

Hedlund

Prepare/send reports to OSERS Bennett

Hedlund

X X

, X

X

X

>

10e
. - 1.0: i h ital NI t. dev . itn lem nt a 'I/ Iran 't.i.n .n Neur

Major ActivKies

Plan for VLBW/handicapped infants and their families,

Performed By Oct Nov Dec I

Training Objectives

1.1 Assist NICU staff to develop Hedlund

and implement an Action Plan Tatarka

for transition with the

developmental center via

instruction in the Team

Building for Transition

training component

1.2 Assist the NICU staff to Hedlund

develop and implement a

Neurobthavioral Action Plan

for caregiving in the NICU.

1.3 Assess progress made in the Hedlund

implementation of the Lawhon

Transition Action Plan.

Determine new transition

objective for NICU/

developmental center staff to

collaboratively work on.

1.4 Assess progress made in the Lawhon

implementation of the

Neurobehavioral Action Plan.

Determine a new transition

objective for NICU staff to

implement.

B. A. ective 2.0:

ham. Acti

NICU Follow-Through Project Workshop #1

Sites: 1 2 I 3 4 5 6

ii communi evelo men cente ev

1 2 3 4 5 6

NICU Follow-Through Project Workshop #2

II .

Sites:

Sites

d im 1 ment

1

1

2 3 4 5 6

2 3 4 5 6

. In rehe *v Transition and

Major Activities

Neurobehavioral Action Plan for VLBW/handicamed infants and their families.

Performed By Oct Nov I Dec I Jan I Feb Mar Apr I May I Jun I Jul I Aug I Sep

2.1 Assist developmental center Hedlund

staff to develop and implement Tatarka

an Action Plan for transition

with the NICU staff via

instruction in the Team

Building for Transition

training component

2.2 Assist the developmental Tatarka

center staff to develop and

implement a Neurobehavioral

Action Plan for therapeutic/

education intervention in the

developmental center.

Sites

FOlow-Throurdi Project Workshop #1

: 1 2 3 4 5 6

1 2 3 4 5 6

NICU Follow-Through Project Workshop #2

101

3
Major Activities Performed By Oct Nov Dec Jan Feb Mar Apr May I Jun Jul Aug Sep

2.3 Assess progress made in the Hedlund

implementation of the Lawhon

Transition Action Plan.

Determine new transition

objective for NICU/

developmental center staff to

collaboratively work on.

2.4 Assess progress made in the Hedlund

implementation of the

Neurobehavioral Action Plan.

Determine a new

neurobehavioral objective for

the developmental center staff

to implement

Sites: 1

1

2

2

3

3

4

4

5

.

5

6

6

C. Objective 3.0: Train NICU/develoomental center staff at eackof the outreach sites to assess infants' behavioral cues ufilizing the

Naturaligic Observation of Newborn Behavior (NOM and the Infant_Behavioral Asmstnent (MAI and provide

goorooriate neurobehavioral =tidying/developmental intervention.

Major Activities Performed By Oct Nov Dec Jan I Feb I_ Mar Apr [ May Jun I Jul I Aug 1 Sep

NICU Follow-Through Proiecj Workshop #2

3.1 Instruct 6 NICU trainees and 8 Hedlund Sites: 1 2 3 4 5 6

developmental center trainees

in the Sr:active Model of

Neonatal Behavioral

Organization and

Development.

3.2 Instruct the 6 NICU trainees Hedlund

in the administration of the

NONB and the

implementation of

appropriate neurobehavioral

caregiving.

3.3 Instruct the 8 developmental Tatarka

center trainees in the

administration of the IBA and

assist them to apply the IBA

results to provide sensitive

infant educational/therapeutic

intervention.

3.4 Conduct reliability checks and Hedlund

certification in the NONB and Lawbon

IBA with the 6 NICU trainees

and 8 developmental center

trainees.

Sites

1 2 3 4 5 6

et I w-Tl . . . -_a W. .. 2 3 4 5 6

.;

1 Og ;, 0

5 6
D. Objective 4.0: Train professionals previously certified in Lhe adminimation of the IBA to become IBA Trainers.

Major Activities Performed By Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

4.1 Conduct reliability and Hedlund

competency check with Tatarka

prospective trainers utilizing

IBA and intervention

strategies.

4.2 Assist trainees to learn and Hedlund

present the didactic on the IBA

Synactive Model of Neonatal workshop

Behavioral Organization and

Development.

conducted

in

4.3 Provide instruction to the Hedlund

prospective trainer in the IBA Tatarka

training format, manual, and

instructional materials.

Seattle

X

4.4 Prospective trainer observes Hedlund

NICU Follow-Through Project Tatarka

instructors conducting IBA

training session.

visrr

4.5 NICU Follow-Through Project Hedlund

instructor observes the

prospective trainer conduct an

Prospective Trainer

X

IBA training workshop in her

own outreach community.

VISIT #2

4.6 NICU Follow-Through Project Hedlund

instructor observes the

prospective trainer conduct an

Prospective Trainer

X

IBA certification session.

S. ective 5.0: Evaluat nee a I en f m ten- rot,' n technical as n wt. Major Activities Performed By Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Collect, analyze, and report

results of: 1) NF1? Training

Evaluative Questionnaires, 2)

Effectiveness of Transitiop

and Neurobehavioral Action

Plans, and 3) IBA, NONB

certification results.

Hedlund

Lawhon

Tatarka

Sep

ame,naelau..
VI. EVALUATION OF PROJECT TRAINING COMPONENTS

The NICU Follow-Through Project has offered outreach training to medical and early intervention

staff located in 18 outreach communities within 10 states. These outreach communities have represented a

wide range of service providers including staff at: Hospital neonatal intensive care units, hospital NICU

follow-up clinics, developmental centers, school districts, ant: public health agencies. The medical/early

intervention staff at these sites provide services to well over 15,000 infants born with very low birth weight

or severe disabilities and their families per year (please see Tables 1-3).

Data collected from these outreach communities demonstrate that the NICU Follow-Through Project

has been very well received by all participants. This model has been effectively applied as a training model

for NICU/developmental center staff that work with very low birth weight/severely disabled infants and their

families. Specific evaluation results of this training are reported below:

1. Evaluations of the NICU Follow-Through Project's Training Components: a. Didactic: The Synactive Model of Neonatal Behavioral Organization. Approximately 1300

NICU/developmental center staff have attended the didactic on the theoretical construct of

the Synactive Model and corresponding intervention/caregiving strategies. The didactic is

offered to all NICU/developmental center staff as well as other community professionals.

Professionals who may not be receiving training in the administration of these instruments are

thus given the opportunity to learn more about the theory and its application. On all fourteen

evaluation questions, between 85%-96% of the participants mted the training "excellent"

(please see Table 7).

b. Naturalistic Observation of Newborn Behavior (NONB). One hundred- three NICU nurses,

physical therapist, and respiratory therapist have now been trained and certified in the

administration of the NONB. On thirteen of the fourteen evaluation questions, between

83%-91% of the trainees rated the training as "excellent" (please see Table 8).

c. Infant Behavioral Assessment (IBA). One hundred-seventy developmental service providers

(e.g., public health nurses, occupation/physical therapists, special educators) have been

trained and certified in the administration of the 113A. On thirteen of the fourteen evaluation

questions, between 88%-96% of the trainees rated the training as excellent (please see Table

9).

d. Team Building for Transition. Approximately 360 hospital NICU and developmental center

staff have received instruction in Team Building for Transition. On thirteen cf the fourteen

evaluation questions, between 81%-93% of the trainees rated the training as "excellent"

(please see Table 10).

e. All IBA and NONB trainees (N = 273) fulfilled the specified training requirements and were

granted certification in the administration of these neurobehavioral instruments.

11
Table 7

TRAINING EVALUATION

DIDACTIC: SYNACTIVE MODEL OF NEWBORN BEHAVIORAL ORGANIZATION

N = 1300

The numerals below indicate the number and approximate percentage of trainee responses in

each of the rating categories below.

Poor Fair Good Very Good Excellent

Instructor Evaluation

Indicate your assessment of the preceptor in terms of

the following:

1. Clarity and organization of presentations: 167(13%) 1133 (87%)

2 Usefulness of presentations in understanding

course content: 178 (14%) 1122 (86%)

. Skill in use of instructional resources

(overheads, slides, etc.): 36 (3%) 155 (12%) 1109 (85%)

. Enthusiasm and stimulation of participant

interest: 20 (2%) 87 (7%) 1193 (92%)

5. Over all teaching effectiveness: 31 (2%) (63) 5% 1206 (93%)

6. As a whole, the organization of the presentation

was: 35 (3%) 42 (3%) 1223 (94%)

. The appropriatemess of presentation content to

the current level of trainee knowledge: 86 (7%) 1214 (93%)

. The amount I learned in this presentation was: 17 (1%) 52 (4%) 1231 (95%)

9. Clarity of content was: 30 (3%) 63 (5%) 1207 (92%)

Overall

10. Rating for the lecture as a whole: 15 (1%) 42 (3%) 1243 (96%)

11. The overall contribution of this lecture to my

understanding of the Synactive Model and its

application to developmental assessment,

intervention, and caregiving was: 19 (1%) 48 (4%) 1233 (95%)

I la

1
Table 8

TRAINING EVALUATION

NATURALISTIC OBSERVATION OF NEWBORN BEHAVIOR (NONB)

N = 103

The numerals below indicate the number and approximate percentage of trainee responses in

each of the rating categories below.

Poor Fair Good Very Good Excellent

Instructor Evaluation

Indicate your assessment of the preceptor in terms of the

following:

1. Clarity and organization of presentations: 12 (12%) 99 (88%)

2. Usefulness of presentations in understanding course

content: 15 (15%) 88 (85%)

3. Skill in use of instructional resources (overheads,

slides, etc.): 12 (12%) 91 (88%)

4. Enthusiasm and stimulation of participant interest:

10 (10%) 93 (90%)

5. Over all teaching effectiveness: 14(14%) 89 (86%)

Lecture Evaluation: Content and Organization

6. As a whole, the organization of the presentation was:

. 3 (4%) 14 (13%) 86 (83%)

7. Overall clarity of participant responsibilities: 2 (2%) 17 (16%) 84 (82%)

8. Definition of reading assignments, and small group

tasks:

. 7 (6%) 15 (15%) 83 (81%)

9. The appropriateness of workshop content to the current 86 (83%)

level of trainee knowledge 2 (2%) 9 (9%)

Overall

10. The amount I learned in this workshop was: 6 (5%) 12 (12%) 94 (91%)

11. Overall, the reasonableness of the amount of assigned

readings was: 6 (5%) 12 (12%) 85 (83%)

12. Clarity of content was: 6 (5%) 13 (13%) 84 (82%)

13. Rating for the lecture as a whole: 4 (4%) 8 (8%) 91 (88%)

14. The overall contribution of this lecture to my

understanding of the Synactive Model and its

application to developmental assessment, intervention,

and caregiving was: 10 (10%) 93 (90%)

I lb
. Table 9

TRAINING EVALUATION

INFANT BEHAVIORAL ASSESSMENT (IBA)

N = 170

The numerals below indicate the number and approximate percentage of trainee responses in

each of the rating categories below.

Poor Fair Good Very Good Excellent

Instructor Evaluation

Indicate your assessment of the preceptor in terms of the

following:

1. Clarity and organization of presentations: 14 (8%) 156 (92%)

2. Usefulness of presentations in understanding course

content: 9 (5%) 161 (95%)

3. Skill in use of instructional resources (overheads,

slides, etc.): 16 (9%) 154 (91%)

4. Enthusiasm and stimulation of participant interest:

11 (6%) 159 (94%)

5. Over all teaching effectiveness: 5 (3%) 13 (8%) 152 (89%)

Lecture Evaluation: Content and Organizathll

6. As a whole, the organization of the presentation was:

, 7 (4%) 163 (96%)

7. Overall clarity of participant responsibilities: 8 (5%) 11 (6%) 151 (89%)

8. Definition of reading assignments, and small group

tasks: 8 (5%) 13 (8%) 149 (88%)

9. The appropriateness of workshop content to the current

level of trainee knowledge 1 (1%) 14 (8%) 155 (91%)

Overall

10. The amount I learned in this workshop was: 6 (4%) 164 (96%)

11. Overall, the reasonableness of the amount of assigned

readings was: 11 (6%) 6 (4%) 153 (90%)

12. Clarity of content was: 3 (1%) 8 (5%) 159 (94%)

13. Rating for the lecture as a whole: 8 (5%) 162 (95%)

14. The overall contribution of this lecture to my

understanding of the Synactive Model and its

application to developmental assessment, intervention,

and caregiving was: 6 (4%) 164 (96%)
Table 10

TRAINING EVALUATION

TEAM_BUILDING FOR TRANSITION

N 360

The numerals below indicate the number and approximate percentage of trainee responses in

each of the rating categories below.

Poor Fair Good Very Good Excellent

Instructor Evaluation

Indicate your assessment of the preceptor in terms of the

following:

1. Clarity and organization of presentations: 12 (3%) 35 (10) 313 (87%)

2. Usefulness of presentations in understanding course

content: 3 (1%) 33 (9%) 324 (90%)

3. Skill in use of instructional resources (overheads,

slides, etc.): 23 (6%) 32 (9%) 305 (85%)

4. Enthusiasm and stimulation of participant interest:

22 (6%) 42 (13%) 292 (81%)

5. Over all teaching effectiveness: 7 (2%) 35 (10%) 318 (88%)

Lecture Evaluation: Content and Organization

6. As a whole, the organization of the presentation was: 12 (3%) 19 (5%) 329 (89%)

7. Overall clarity of participant responsibilities: 9 (3%) 36 (10%) 315 (86%)

8. Definition of reading assignments, and small group

tasks: 22 (6%) 42 (12%) 296 (82%)

9. The appropriateness of workshop content to the current

level of trainee knowledge 9 (3%) 39 (11%) 312 (87%)

Overall

10. The amount I learned in this workshop was: 4 (1%) 38 (11%) 318 (88%)

11. Overall, the reasonableness of the amount of assigned

readings was: 19 (5%) 47 (13%) 294 (82%)

12. Clarity of content was: 9 (3%) 50 (14%) 301 (84%)

13. Rating for the lecture as a whole: 33 (9%) 327 (91%)

14. The overall contribution of this lecture to my

understanding of the Synactive Model and its

application to developmental assessment, intervention,

and caregiving was: 25 (7%) 335 (93%)

l I d

14
2. The establishment of a Newborn Individualized Developmental Care and Assessment (NIDCAP) National

Training Center

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been

established to provide education and specific training in developmental observation and assessment for health

care professionals who have responsibility for the long- and short-term care of high-risk newborns and preterm

infants and their families, and for staff members who are involved in the implementation of their care on a

day-to-day basis. NIDCAP consists of the following training components: a.

b.

c.

Level I: Developmental Care Education and Observational Training for

Individual Professionals;

Level II: Nursery Integration of Developmental Care; and

Level III: Establishing a NIDCAP Training Center

The NICU Follow-Through Project provided training to NICU staff in the administration of the

Naturalistic Observation of Newborn Behavior (NONB), Level I training offered by NIDCAP. Through our

initial training at St. Lukes Regional Medical Center in Boise, Idaho, their NICU staff decided to work

towards the development of a NIDCAP Training Center. With continued technical assistance from our project

staff (G. Lawhon & R. Hedlund), the dedicated work of their staff, and the work and guidance provided by

Dr. Heidelise Als, we are most happy to report the establishment of a National NIDCAP Training Center at

St. Lukes Regional Medical Center. St. Lukes Training Center is one of 9 National Training Centers situated

across the country, and the only one within the northwest region of the country. As a National Training Center,

St. Lukes will now train other hospital NICU staff in Level I training of NIDCAP and thus continue the

neurobehavioral training that was initially implemented by thL. NICU Follow-Through Project.

3. Response to Interagency Team Building

Brewer (1994), with the support of the NICU Follow-Through Project staff, conducted a study to compare

and contrast team approaches employed by the hospital NICU, NICU follow-up clinics, and early intervention

staff who participated in the NICU Follow-Through project's "Team Building for Transition" training

component. A survey with open ended questions was sent to 55 staff members from 3 sites that had

participated in the Team Building workshop. Descriptive and qualitative analyses were used in this study.

Common themes, comparisons, and contrasts among the three sites were described.

Of the 19 respondents the majority (78%) indicated that relationships had been affected positively as a

result of the Team Building training. Increased communication and rapport were cited most frequently as

examples of how relationships had been affected. Respondents from all sites reported that identifying a

common goal was an effective strategy in achieving positive outcomes for transition of infants from

hospital-to-home or to-community early intervention programs. Respondents from all three sites also reported

that an increase in coordination of follow-up services for NICU graduates was an outcome that probably would

not have occurred without the training. A common theme throughout the responses was the impact that the

training had upon the participant's awareness of community resources.

In summary, based upon this small sample, many positive outcomes for the transition of infants were cited

as having occurred as a result of the NICU Follow-Through Project.

12
4. Team Building for Transition Action Plans

Approximately 360 hospital medical/early intervention staff, representing the 18 outreach communities

have developed an interagency plan for collaboration. This Team Building Action Plan has been successfully

implemented in all the outreach communities to facilitate interagency service delivery for infants born with

very low birthweight or severe disabilities and their families. An example of one of these Action Plans that

has been developed by one of our outreach communities may be found in Appendix E.

5. Neurobehavioral Action Plans

Over the course of the last 3 years 103 NICU staff received training in the Naturalistic Obeservation of the

Newborn Behavior (NONB) and 170 developmental service providers received training in the Infant

Behavioral Assessment (IBA). Neurobehavioral Action Plans were developed by each of these two training

groups within their respective out reach community. This assisted the trainees to fulfill the certification

requirements and implement appropriate neurobehavioral intervention strategies. Please see Appendix F for

examples of the IBA/NONB Neurobehavioral Action Plans that were created by each of these groups.

6. Validation of the Infant Behavioral Assessment

The NICU Follow-Through Project staff has been continuing with the test development of the Infant

Behavioral Assessment (IBA). Co-authors of the IBA (R. Hedlund & M. Tatarka) were involved in an

ongoing study that will allow us to examine the IBA's reliability, construct validity (by the test's ability to

differentiate among groups of infants), concurrent validity (correlations with neonatal behavioral measures and

with an infant motor assessment [i.e., Movement Assessment of Infants]) and predictive validity (correlations

with later standardized developmental tests).

The primary purpose of the study was to evaluate the effects of cocaine exposure in utero on the

neurobehavioral competence of infants at four months of age. Our sample of drug-exposed infants (n = 190)

was a subset of a larger group of infants from a major NIDA-funded study entitled, "Cocaine: Pregnancy Use

and Offspring Development," Ann Streissguth, Principal Investigator. The NIDA study involves the

longitudinal assessment of a cohort cc 500 infants (during the newborn period and then at 4, 6, 12, and 26

months of age). With the support of the NIDA group, the IBA was added to the 4-month protocol to further

sensitize that evaluation to the subtle differences in motor organization, attention, and interaction observed in

these infants.

The subjects were drawn from four groups of mothers with varying prenatal drug use: 1) Cocaine plus

high levels of marijuana, alcohol, and cigarettes (MAC); 2) cocaine plus low levels of MAC; 3) no cocaine

plus high MAC levels; and 4) no cocaine plus low MAC levels. Infants were divided approximately equally

among the four groups. All subjects had provided informed consent in accordance with human subjects'

guidelines at the University of Washington (see Appendix G for Human Subjects' application).

The IBA was scored twice for each infant during the course of the 4-month motor assessment. The first

IBA administration served as a baseline measure, and the second occurred after the infant had been "stressed"

by the handling required during the motor examination. A method of collapsing the data to obtain a single

change score between the first and second observations has been devised to derive a composite measure of

each infant's attention/organization (Appendix H : IBA Scoring Protocol).

Data from the NIDA study are being analyzed through a grant from the Association for Retarded Citizens

of Washington (Tatarka, Hedlund, & Schwartz, 1994). We will obtain the descriptive statistics of our smaller

13
sample from the Streissguth data. We will obtain the following statistics:

1. Inter-rater reliability on a subset of the MA's;

2. comparisons of the MA behaviors and composite

(change) scores and behavioral clusters for each infant group; and

3. comparisons of neurobehavioral characteristics with dose

measures and maternal variables.

7. Training Efficacy and Inter-observer Agreement of the IBA

Tatarka & Hedlund (1994) examined the inter-observer agreement of the MA to evaluate the efficacy of

the training and accuracy of the current form of the assessment. Sixty pairs of raters were selected from among

medical/early intervention professionals who had received training during the implementation of the NICU

Follow-Through Project. Two different forms of the TBA were used by the IBA trainees. Thirty pairs of raters

independently scored the 1990 version of the assessment and thirty different pairs of raters scored the 1991

(current) version. IBA assessments were chosen from among the 10 required from each trainee for

certification. The corresponding infants for each of the two forms included two groups; half of the infants

(n = 15 for each form) were typically developing and half (n = 15 for each form) were identified by the raters

as having, or being at risk for, a developmental disability.

Figure 4 depicts the average agreement of the two groups of raters by MA category. In all but one

category there were improvements in the inter-observer agreement from the old version to the new version of

the assessment. Item-by-item percent agreement on the old version ranged from 76% (hand movements) to

99% (visceral signals). On the current version, item-by-item agreement ranged from 90% (oral behaviors) to

100% (neurological indicators).

Two possible explanations may account for the nearly universal improvement in inter-observer

agreement: 1. Changes in the training format may account for the differences, or 2. changes in the

operational definitions of the individual items may have improved rater consistency. In all likelihood, it is

some combination of these two factors that contributed to the improvement in instrument reliability.

In summary, the Infant Behavioral Assessment as well as the associated training continue to undergo

revisions. The aforementioned study confirms our success with both the quality of training and the

development of the assessment.

14
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VII. PROJECT PRODUCTS

The following products have been developed/revised as part of our past/current neurobehavioral work

(Hedlund, 1986, 1989, 1992). The NICU Follow-Through Project has disseminated these products to its 18

outreach sites.

Infant Behavioral Assessment ( Appendix C ): The Infant Behavioral Assessment (MA) (Hedlund &

Tatarka, 1988) sensitizes educational and medical professionals to the neurophysiological state and

organi.mtional system of the infant while assisting them to adjust their intervention style to more closely match

the neurobehavioral and developmental needs of the infant. Drawing upon the work of Drs. Heidelise Als

(1984, 1985, 1986), T. Berry Brazelton (1984a, 1984b). Kathryn Barnard (1978), Hedlund and Tatarka (1988)

developed the IBA. This assessment focuses upon the behavioral repertoire of the infant, pinpointing specific

stress, approach; and self-regulatory behaviors that the child utilizes during social interactions as a means of

communicating his/her needs and wants. The IBA is used to assess the infant's behavioral repertoire, the

self-regulatory capacity of the infant, and specific behavioral antecedents that may be responsible for the

expression of these behaviors.

The identification of the infant's unique behavioral repertoire as it develops over time assists the

professional to: 1) help parents to "tune into" the ever changing behavioral cues of their child and adjust their

interactional style to more closely mesh with that of their infant's, and 2) monitor the behavioral cues expressed

by the child during an assessment, educational, or therapeutic intervention session. The medical or educational

professional can then adopt specific intervention strategies that are sensitive to the neurophysiological

capabilities and sensory threshold of the infant and prescribe home activities that ensure parental success when

they interact with their baby.

Infant Behavioral Assessment Training Manual (Appendix C ): The Infant Behavioral Assessment

Training Manual (Hedlund & Tatarka, 1991b) was developed as an instructional aid to be utilized by trainees

during their course of study in the administration of the MA. Specific areas addressed in the manual include:

1) the rationale and demonstrated need for a neurobehavioral assessment, 2) an overview of the literature with

regard to neurobehavioral organization as reflected in selected infant populations, 3) the theoretical construct

of the IBA, and 4) specified procedures with regard to the actual administration of this instrument.

Infant Behavioral Assessment Slide and Video Presentation: A slide and video training program has been

developed as part of the IBA instructional format. The slide presentation provides examples of each of the

infant behaviors identified on the MA. These are utilized during the item-by-item review of the IBA

behavioral definitions. The video presentation consists of video segments of infants during caregiving and

intervention sessions. These videotapes are utilized to assist the IBA trainees to attain inter-rater reliability

with this instrument. Copies of these IBA slides and videos have been made available to the prospective IBA

trainers to assist them in their training presentations.

Synactive Model Slide and Video Presentation: Slides and videos have been developed to assist the

prospective MA trainers in presenting the four hour didactic on the Synactive Model of Newborn Behavioral

Organization. The slide presentation provides supplemental material with regard to:

The incidence and sequelae of the very low birthweight infant population

Behavioral/temperament characteristics of this population

15
CNS development

CNS vulnerability

Neuro-social/behavioral development

The Synactive Model of Newborn Behavioral Organization

A historical overview of infant intervention

Neurobehavioral intervention strategies

The video presentation consists of video examples of neurobehavioral strategies for supporting the

neurophysiological organizational capacity of the infant during an assessment, intervention, or caregiving

procedure. Copies of both the slide and video presentation have been made available to the prospective IBA

trainers to assist them in their training presentations.

The IBA Trainers Training Materials (Appendix D ): The training materials provide the format and

organization for the instruction of each prospective trainer. These include an outline and description of

prospective trainer's responsibilities, instructions for the development of the prospective trainer's videotape and

case study requirements, and the course syllabus of the first training workshop that is held in Seattle.

Parent Training Materials (Appendix C): We have developed several parent training materials to assist

the medical and educational professionals to help parents read and respond to the behavioral cues of their

infant and engage in appropriate activities that meet the neurophysiological needs of their child. These

include:

1. "Getting to Know Your Baby and Keeping Track of Those Important First Years". Parents

utilize this baby scrapbook as a means of keeping track of medical appointments, medications,

intervention recommendations. It serves as a resource for the parents, and the medical and

early intervention professionals that may be visiting the home. Parents record their child's

neurobehavioral/developmental progress and anecdotal data as their child matures.

2. "Your Baby's Responsiveness, States: The Sleep/Wake Rhythms of Newborns". This parent

hand-out identifies the state organizational system of the newborn and describes in

non-technical terms the six levels of consciousness (i.e., deep sleep, light sleep, drowsy, alert,

active alert, cry). Each state is illustrated with a photograph that accompanies the description

of each state. Parents are thus assisted to recognize these states and adjust their home

environment and interactional style to match the needs of their baby's state organizational

system.

3. "Getting to know Your Baby: Interactional Cues". This hand-out helps parents to appreciate

infant behaviors as truly meaningful. Approach, stress, and self-regulatory behaviors are

discussed and examples of each behavior are provided. Parents are encouraged to identify

the unique behavioral cues of their own infant, interpreting and responding to them in a

manner which supports the neurobehavioral organizational capacity of their infant. Specific

ways to assist parents console their child as well as ways to assist the child to self-regulate on

his/her own are suggested.

Video Training Tape: Infant Behaviors: A Communication System. Video is a valuable medium for

capturing the often fleeting and subtle behavioral cues that infants who are born with very low birthweight or

severe disabilities express in everyday social/caregiving interactions with their parents and interventionists

alike. Infant Behaviors: A Communication System (Hedlund & Tatarka, 1991a) is a 25 minute videotape that

16

5i
introduces both parents and professionals to the special "body language" that infants use while interacting with

others. Based upon Dr. Heidelise Als' extensive research with premature infants, this videotape provides both

parents and interventionist with an overview of the self-regulatory, stress and approach behaviors that infant

utilize to express their needs and wants. This videotape enables us to:

Educate parents about the significance of their baby's body language by providing video

examples which clearly define the range of infant behaviors that may be expressed by their

child.

Help parents "tune in" to their own interactional style and how that affect their child. Once

parents become sensitive to their baby's behavioral repertoire, they begin to reflect upon how

their own interactional style effects their baby.

3. Help parents, through guided practice and encouragement, to adapt their interactional styles

as their infant develops. The ways that parents and their babies interact and play together

change as the baby grows and develops, requiring parents to continually adjust their responses

and interactional style. When parents notice and understand the variations in their child's

interactional style, they can maximize their opportunities to successfully interpret and respond

to their child's ever changing communication behaviors.

Training professionals to "tune in" and respond in an appropriate manner to the communication behaviors

of the infant will enhance the quality of care and intervention that they offer to families and their very young

fragile babies. This videotape assists medical and educational professionals to:

1. Monitor the infant's behaviors during assessment, educational, therapeutic or caregiving

sessions and thus provide intervention that is sensitive to the neurophysiological capabilities

and sensory threshold of each infant.

Set goals for both child and family that are based on the child's true capabilities. Information

from an infant's developmental assessment is often used to develop a therapeutic/educational

program and to set goals for the infant's family. This videotape helps professionals conduct

assessments that facilitate the best performance from the infant, through the utilization of

neurobehavioral supportive strategies, and thus yield appropriate goals and objectives for

child and family alike.

3. Develop individualized educational and therapeutic care plans that are within the limits of the

child's capabilities, and prescribe home activities that ensure parental success when they

interact with their child. This videotape sensitizes professionals to individual parents' abilities

to effectively read and appropriately respond to their child's behavioral cues. The

medical/educational professional then uses this knowledge to select and adapt specific home

activities that will promote a positive parent-infant relationship.

17

f-;
VIII. Assurance of Statement of Dissemination of Final Report

The final report for the NICU Follow-Through Project has been sent to ERIC Clearinghouse on

Handicapped and Gifted Children. Copies of the title page and abstract have been sent to:

1. NEC*TAS

2. National Clearinghouse for Professions in Special Education

3. National Information Center for Children and Youth with Disabilities (NICHY)

4. Technical Assistance for Parent Programs Project (TAPP)

5. National Diffusion Network

6. Child and Adolescent Service System Program (CASSP)

7. Northeast Regional Resource Center

8. Mid South Regional Resource Center

9. South Atlantic Regional Resource Center

10. Great Lakes Area Regional Resource Center

11. Mountain Plains Regional Resource Center

12. Western Regional Resource Center

13. Federal Regional Resource Center

18 , _

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