INFANT MOTOR DEVELOPMENT AND THE HOME ENVIRONMENT

Andrea L Abbott School of ~ h ~ s i c Therapy al

Submitted in partial fulfilment

for the requirements for the degree of

Master of Science

Faculty of Graduate Studies The University of Western Ontario London, Ontario May 1999

@Andrea Abbott 1999

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ABSTRACT

Forty-seven mother-infant dyads were recruited to study the relationship between the home environment and infant motor development. When infants were 5 months old, each mother predicted her infant's motor development at 8 months, using the maternal version of the Alberta Infant Motor Scale. At 8 months of age, aspects of the home environment (measured by the HOME Inventory) and infant motor development (measured by the Alberta Infant Motor Scale) were assessed during a home visit. Although no statistically significant correlations were found between the specified relationships. the study mothers in the sample had high expectations of 8-month motor performance and both the mothers and the infants scored higher than normative samples on aspects of the home environment and infant motor development. These findings suggest that more supportive and stimulating home environments are associated with higher infant motor development scores.

Keywords: infant motor development, home environment, parental expectations

DEDICATION

I would like to dedicate this thesis to:

My parents. Wendy and John Abbott, for their ongoing support, genuine interest in this
project, and belief in my abilities. My husband and friend, Ian Tate. I could not have completed this project without his unwavering support and encouragement. My daughter, Zoe, for providing the joy in my life.
And my baby-to-be, "Sam".

ACKNOWLEDGEMENTS

i would like to thank the following people for their assistance with this project:

First and foremost, my advisor and mentor, Dr. Doreen Bartlett for her ongoing support. assistance, knowledge, expertise and friendship. She made this project a positive and rewarding experience.

My advisory committee. Dr. John Kramer and Jamie Fanning for their input.
The Public Health Nurses fiom the Middiesex Health Unit for welcoming me into their clinics to recruit families. The families that participated. I greatly enjoyed meeting such positive and welcoming mothers and babies. The Physiotherapy Foundation of Canada for their financial assistance provided from the
Ann Collins Whitmore Memorial Award.

The School of Physical Therapy, University of Western Ontario, for the financial assistance from the Special University Scholarship Fund.

TABLE OF CONTENTS

CERTIFICATE OF EXAMINATION ............................................................................. AE3STRACT................................................................................................................... DEDICATION ...............................................................................................................

11

..

111

.-.
iv v vi

ACKNO WLEGEMENTS ................................................................................................

TABLE OF CONTENTS ...............................................................................................

LIST OF TABLES .......................................................................................................
LIST OF ABBREVIATIONS .......................................................................................... CHAPTER 1. INTRODUCTION Introduction ....................................................................................................................... Related Research ............................................................................................................... Summary ............................................................................................................... Objectives ........................................................................................................................ Research Hypotheses.. ....... . . . . .....................................................................................

VIII

-..

LIST OF APPENDICES ................................................................................................ i x

x

1
2

Relationship Between the Environment and Development ..................................... 2

6
-7

CHAPTER 2. METHOD
Sample and Design.. .......................................................................................................... Data Collection: Measures ................................................................................................. Data Analysis ................................................................................................................
9
10

Data Collection: Procedures .............................................................................................. 13

14

CHAPTER 3 . RESULTS
Initial Sample Characteristics ............................................................................................ 16 Sample Characteristics at 5 Months ................................................................................... I 7 Sample Characteristics at 8 Months ................................................................................. Results from Objectives Primary 0bjectives ............................................................................................... -24 Secondary Objective ............................................................................................. -25
. .20

CHAPTER 4 . DISCUSSION
Discussion ........................................... Explanations for Negative Results ....... Clinical Significance ........................................................
. . . . ..................................... . -. ...- 2 9

Future Work ...................................................................................................................... Summary and Conclusions ................................................................................................

31

32

REFERENCES.................................................................................................................

-34

APPENDICES ..................................................................................................................

37

VITA................................................................................................................................

-72

vii

LIST OF TABLES

TABLE

PAGE

1. Maternal Characteristics at the Time of Recruitment ....... ........:. . . - . . . . - - ~ - ~ . - - - . . -17 -......

2. Summary of Mothers' Difficulty Completing the 5-Month

Fonns By Level of Education.. ......-.-- - -. - -- --. .- .-. -. -.. ..... . ... . 3 . Summary of Maternal Scoring of the Alberta Lnfant Motor

. ..

.,. .... - - . . ... ... 19

Scale Collected at 5-Months...................................................................... ....-.---..-20

4. Summary of 8-Month Alberta Infant Motor Scale Scores............................................- 22

5. Summary of Scores ?om the HOME Inventory

Subscales I, IV, and V .................................... ........................................................ 23

LIST OF APPENDICES

APPENDIX

PAGE

.. Initial Questionnaire ............................................................................................... 37

Item Examples from the HOME Inventory ............................................................. 41 Instructions and ltem Examples from the Maternal Version of the Alberta Infant Motor Scale .............................................................. Summary of Data from Reliability Testing for the HOME Inventory and the Alberta Infant Motor Scale ............................................. 48 Ethics Approval ...................................................................................................... Letter of Information .............................................................................................. Flyer ...................................................................................................................... Consent Form ......................................................................................................... 8-Month Questionnaire ........................................................................................... Extrapolated Normative Data Used to Convert 8-Month Alberta Infant Motor Scale Raw Data to Standardized 2-Scores .............................. 62 Summary of Data of Families Lost to Follow Up at the 5-Month Mail-out ....................................................................................... Summary Table for the Relationship Between Aspects of the Home Environment and Infant Motor Development ............................................... 68 Summary Table for the Relationship Between Parental Expectations and Infant Motor Development .................................................................... 70
64
-43

Item Examples from the Alberta Infant Motor Scale............................................... 46

50

52
54 56
58

Score Ranges of the HOME Inventory ................................................................... 66

LIST OF ABBREVIATIONS

AIMS.
IQ PDI
MAIMS

...............................................................

-Alberta Infant Motor Scale -..IntelligenceQuotient

.........................................................................

.............................

--.MaternalVersion of the Alberta Infant Motor ScaIe

........................................................

Psychomotor Developmental Index Socioeconomic Stztus

SES

........................................................................

CHAIPTER 1
INTRODUCTION

Introduction A clear relationship between the home environment and intellectual development has long been established (Bradley and Caldwell, 1976; b e y , Farren, and Campbell,
1979; Parker, Greer, and Zuckerman, 198 8); however, the relationship between the home

environment and infant motor development is less evident. This can be explained partially
by the belief that infant motor development evolves in the rate and sequence associated

with maturation of the central nervous system (McGraw, 1945). This neuromaturational perspective of infant motor development still forms the foundation for most therapeutic intervention programs for infants with motor dysfbnction. Recently, a new theoretical framework based on dynamic systems theory has proposed an alternate way of explaining development, thus setting the stage for the exploration of new views of infant motor development. The dynamic systems theory is a complex framework that has been used to explain the processes of change in many physical, environmental, and psychosocial phenomena (Gleick, 1987). When applied to development, this theory suggests that behavior is self-organizing and that new behaviors arise spontaneously fiom the interaction

of many changing subsystems based on the influential parameters in a task specific

context. This research was not designed to test the complex processes of the acquisition of new motor abilities, but to examine one of the principle tenets: the contribution of different subsystems to infant motor development. Specifically, dynamic systems theory suggests there are a host of subsystems within the child, and the physical and social environments that contribute to infant motor development (Thelen, Kelso, and Fogel,
1987). One of these subsystems might be the home environment and related influences

such as parental expectations. Knowledge of the home environment might help to accurately identify infants at environmental risk arid optimize treatment programs for

infants and young children with motor delays. The present study was designed to clarify the relationship between aspects of the home environment and infant motor development.

Related Research

As a result of the important shift in theoretical frameworks from the

neuromaturational perspective to one incorporating principles of dynamic systems theory,

a review of the motor development literature is warranted to answer the question "Does a
relationship between the home environment and infmt motor development exist?". Relationship Between the Environment and Development

The home environment is known to be associated with intellectual development. In a longitudinal study, Elardo and colleagues (1975) found a correlation of -54 between the

HOME Inventory environmental assessment at 6 months and the intelligence quotient (IQ)
at 36 months. Bradley and Caldwell(1977) also reported a significant correlation between 6-month HOME Inventory scores and IQ at 3 years of age. Specifically, categorisation of scores on the 6-month HOME Inventory resulted in correct identification of 71 % of the children from the low IQ group at 36 months of age and 62 % of the children from the average to superior IQ group at 36 months of age. Further evidence supporting the relationship between the home environment and intellectual development comes from a study examining samples of low- and middle-income families. Ramey and colleagues found that the qualities of the home environment were different in a low socio-economic status (SES) home than in a middle SES home (Ramey, Farren, and Campbell, 1979). The investigators reported that low SES mothers tended to be less verbal, interactive, and warm towards their children. Rarney and colleagues have reported that between 50 to 60
% of the variance in children's 36-month Standford-Binet Scores, which measures

intellectual abilities, could be accounted for by the mothers' attitudes, behaviour, and interactions with their children. When reviewing the literature examining the relationship between the home

environment and infant motor development, evidence is less clear. Early research concluded that no relationship existed between these constructs (McGraw, 1935; Dennis, 1938;Dennis and Dennis, 1940;Dennis and Najarian, 1957). In the early 193Os, infant motor development was explained by the neuromaturational theoretical framework. Psychologists widely accepted the view that motor development unfolded in a

9 8 8 ) . predetermined time and sequence and was unaffected by the environment wazel, 1
This fbndarnental assumption contributed to the climate permitting the deprivation studies of McGraw (McGraw, 1935) and Dennis (Dennis, 1938). In their studies, two sets of twins were deprived of stimulation in various ways. The premise was that these children would be normal in all aspects of development with a Limited amount and range of experiences. The investigators' findings were reported in this fashion and appeared to support their views. In another study, Dennis and Najarian (1957) examined the relationship between effects of deprivation and infant motor development on infants who were raised in a Lebanese institution. These infants were subjected to severe social and motor deprivation resulting fiom lack of caregivers and swaddling practices, respectively. The investigators reported that although infants demonstrated highly significant delays at two to twelve months of age, no long term developmental effects were observed at four and a half to six years of age. One example of an interpretation based on the neuromaturational model comes fiom a widely-reported historical study investigating the effect of infant cradling practices of the Hopi people on the timing of independent walking (Dennis and Dennis, 1940). The Dennises found no difference in the age of walking between Hopi infants who routinely used the cradle board in the first year and similar infants who did not. The investigators concluded that no relationship between the use of cradle boards and the time of onset of walking existed, supporting their idea that motor development is unaffected by the environment. However, a plausible explanation of these results is that the deprivation period for the restricted infants occurred before the critical threshold for Hopi infants was reached. On closer inspection of the description of cradle board use, it is clear that they were used extensively for the first 3 months of the infants' lives and less kequently thereafter. During this period, the infants had little or no opportunity for motor activity.

After three months, these infants might have had sufficient experience with gross motor activities because they were restricted for shorter periods of time. This alternate interpretation of the Dennises' findings contrasts with their proposed idea that motor development is unrelated to environmental influences. Early evidence in support of the relationship between the home environment and infant motor development comes fiom cultural studies. Cultural studies suggest that variability in the timing of motor development is present among infants growing up in different regions (Dennis and Dennis, 1940; Freedman, 1974; Super, 1976; Lester and Brazelton, 198 1; Cintas 1988; Hopkins and Westra, 1988; Cintas 1995).
An example of this is the intracultural study by Hopkins and Westra (1988)

investigating the environmental influences of matemal handling and parental expectations on infant motor development. The handling consisted of massage and a repertoire of active and passive stretches performed by West Indian mothers. This routine was started after the mother and infant returned home from the hospital. Mothers continued to provide passive stretches until the infant was too heavy to handle, which typically occurred around the time of independent sitting. At 6 months, the investigators found that the infants whose mothers elected to implement the handling routine were more advanced than the comparison group in the sitting descriptions of sits alone for a short time, can be left sitting on the floor, and sits well in a chair. A larger proportion of the formal handling regime infants stood when supported compared to the comparison group, however this difference only approached statistical sigdicance. Importantly, the mothers who did the formal handling routine had higher expectations for the skill of independent sitting and standing than the mothers in the comparison group. The group of mothers providing the formal handling routine also scored significantly higher on the subgroups of provision

with uppropriate [earning materials and maternal involvement of the HOME Inventory.
This intracultural study demonstrates that variability of infant motor development exists and suggests that environmental factors may influence motor development. Further evidence linking the environment and infant motor development is provided by Fetters and Tronick (1996). These investigators reported that two low socioeconomic status groups (infants exposed to cocaine in utero and controls) were more

similar than different. Both groups scored poorly on general motor performance. At 4 months of age, 91% of the exposed group and 78% of the control group scored poorly enough to be considered for early intervention referral. These findings support the proposition that the environmental influence of poverty is associated with, and possibly a strong predictor of, motor developmental outcome. Evidence against the sole influence ofneuromaturation is provided by Darrah and colleagues (1998) in an investigation of the intra-individual rate of gross motor development in full-term infants. The results suggest that the rate of motor development within individual infants is a non-stable process. A mean percentile change of 66.78 percentile points (SD = 13-47 percentiles) was found and 3 1 % of the infants scored less than the 10" percentile ranking on the Alberta M m t Motor Scale at least once during the monthly assessments fiom 2 weeks of age to the time of independent walking. No systematic pattern of variation among infants existed. These results question the assumption that infant motor development is consistent within infants, as suggested by the neuromaturational theoretical fiamework. Dynamic systems theory proposes that a variety of factors (including aspects of the environment) influence development and explain the variability of intra-individual rates of infant motor development. Further recent evidence supporting the influence of the environment is provided by Mulligan and colleagues (1998). This study examined the relationship between various physical characteristics of child-care centres, including levels of interaction with caregivers, access to a gross motor room, space per infant, and use of seats, swings and walkers, and aspects of infant motor development including psychomotor development, activity levels, and body composition of the infants. The investigators found that the level

of interaction between infant and caregiver for infants of 12 months of age were
associated with infant motor development. A higher level of interaction was associated with lower infant psychomotor developmental scores. This inverse relationship might be explained by the type of interactions that were occurring between the infant and caregiver in these centres. These centres tended to expose the infants to activities that encouraged the infants to be calm and quiet, such as reading books and participating in fingerplay songs. These results suggest that aspects of the hfknt's environment do influence infant

motor development, thus providing fbrther evidence that there are factors other than central nervous system maturation influencing infant motor development.

Summary

A detailed review of the English literature examining the relationship between the
home environment and infant motor development (Abbott and Bartlett, in press) yielded evidence supporting a possible relationship between these constructs. Early studies supported the view that the environment had no role in an infant's motor development. However, on re-examination of the data in the context of the theoretical framework at the time of publication, a different picture emerges. The idea that motor development is more variable and malleable than first thought comes fiom cultural studies. These studies demonstrate that parental expectations and cultural care-giving practices may have important iduences on motor development. Studies examining the environmental factor of poverty and the associated qualities of the home environment contribute to the idea that the environment may have an influential role in motor development. Finally, clarification of the non-stable rate of motor skill acquisition within individual infants suggests that there are more influences on infant motor development than central nervous system maturation alone. These sources of evidence support the dynamic systems theory in that multiple factors influence infant motor development. Aspects of the home environment might act as one subsystem of these influential factors. Further research is required to clarify the relationship between the home environment and infant motor development before clinical strategies can be developed and implemented. Specifically, aspects of the home environment and parental expectations of motor development need to be assessed and related to motor outcomes to determine if environmental influences have an impact on motor development.

Obiectives

The primary objectives of the present study were: 1. To determine the relationship between aspects of the home environment (HOME Inventory, Caldwell and Bradley, 1984) and infant motor development (Alberta Infant Motor Scale (AIMS),Piper and Darrah, 1994) at 8 months of age.

2. To determine the relationship between parental expectations (the maternal version of

the Alberta Infant Motor Scale (MAIMS), Bartlett, 1992) of subsequent infant motor development predicted by the mothers at 5 months and infant motor development (AIMS) assessed by a physical therapist at 8 months.

The secondary objective was: 1. To explore the relationship between three subscales of the HOME Inventory
(matenmi responsivity, provision of qproprzate learning materials, and maternal involvemenf) and the Alberta Infant Motor Scale prone and standing subscales at 8

months.

Research Hv~otheses

The primary hypotheses of the present study were:

1. There will b e a significant positive relationship between aspects of the home

environment (as measured by three of the HOME Inventory subscales: maternal

responsivity, provision of appropriate learning materials, and maternal involvement) and infant motor development (as measured by the AIMS) at 8 months of age.
2. There will be a significant positive relationship between parental expectations (as

measured by the MAIMS) at 5 months and infant motor development (as measured by the AIMS) at 8 months.

The secondary hypothesis was:

1. There will be a si@cant

positive relationship between the HOME Inventory

(specifically the three subscales of maternal responsivity, provision ofappropriate learning materials, and m u t e d involvement) and the Alberta Infant Motor Scale prone and standing subscales at 8 months.

CHAPTER 2

METHOD
Sample and Design

Sixty caregivers with infants aged 6 weeks to 5 months were targeted for recruitment fiom three main sources: the London Middlesex Health Unit mother-baby programs of Just Beginnings and the Well Baby Clinics; a program fbnded by Health Canada, Healthy Mothers-Healthy Babies; and London Bridges Childcare Services. Recruitment f?om these sources was planned to obtain representation across the spectrum of socioeconomic levels. A sample size of 60 primary caregiver-infant dyads was chosen to provide a power of .90 to detect a correlation greater than .40 (two-tailed alpha = -05) (Table 3.3.5; Cohen, 1988). A correlation of -40 was chosen because it is the lowest value in the range (-40 6 r 1 -69) considered to reflect a "modest" correlation (Weber and Lamb, 1970). This magnitude of correlation has been reported in the literature examining the relationship between the home environment and cognitive development (Carlson, 1985; Coll, 1986). Although these investigators reported non-significant findings for motor outcomes (see Appendix A), the current study used a tool with greater ability to measure variation in early motor performance. Using this detailed instrument, covariation between the home environment and motor development is easier to detect. Some exclusion criteria were relevant. Only English-speaking caregivers were recruited because part of the assessment process requires the caregiver to answer questions from the HOME Inventory (Caldwell and Bradley, 1984). Only those families who intended to care for their infant in the home for at least four days a week until the baby was eight months old were considered. This arbitrary selection of greater than half time was chosen in order for the home environment to have sufficient influence o n the infant. No infants with known sensory, motor, and/or congenital disabilities were recruited for this study.

A combination of a cross-sectional and a prospective correlationai research design

was used to examine the relationship between the home environment and infant motor development. From a cross-sectional perspective, assessments measuring aspects of the home environment (HOME Inventory) and the infant motor development (Alberta Infant Motor Scale, referred to as the AIMS) were administered at a single occasion when the infant was 8 months old. From a prospective correlational perspective, the maternal version of the AIMS (referred to as the MAIMS) was mailed to the families when the infant was 5 months old to determine the influence of parental expectations on infant motor development at the age of 8 months. Eight months of age was selected as the assessment age for the HOME Inventory and the AIMS because this has been reported to be the age at which the greatest amount of motor variability occurs. For example, at this age some infants are sitting while others are walking. At 8 months of age the standard deviation of a group of typically developing inFants is 7.8 points on a 58 point scale (Piper and Darrah, 1994). By using 8 months as the assessment age, motor variability is assured and the influence of chronological age on motor development is controlled. The independent variables in the present study were aspects of the home environment and parental expectations of infant motor development. The dependent variable was infant motor development.
Data Collection: Measures

Data collected from initial parental questionnaires (Appendix A) were used to describe the sample. These data included: infant gender, birth weight, gestational age, parity, delivery complications, parental age, level of parental education, and ethnic origin. Research conducted in London indicates that the level of maternal education is an appropriate proxy for socioeconomic status among adults (Turner, 1994). Furthermore, it
is an objective and reliably reported measurement.

The HOME Inventory (Caldwell and Bradley, 1984) was used (item examples are found in Appendix B) to measure the independent variable of aspects of the home

environment. This test consists of 45 items divided into 6 subscales of re~pomivity,

acceptance, organization, learning materials, involvement, and variety- For this study,
only three of the six subscales were used: maternal responsivity, provision of appropriate

learning materials, and maternal involvement. Previous research indicates that these three
subscales may be more influential on infant development than the subscales o f acceptance,

organization, and variety (Carlson et al., 1985; CoIl et al., 2986; Hopkins and Westra,
1988). Scoring for each item is on a pass-fail basis; one point is acquired per pass item.

Information needed for the test was obtained by interviewing the caregiver and observing the interaction between parent and infant. The infant had to be present, alert, and happy for the majority of the visit for this to be achieved. Ifthe infant was unwell or unhappy, the assessment was rescheduled for another time. The psychometric properties of the HOME Inventory have been investigated. Correlation coefficients reflecting internal consistency of the subscales are reported to be:
.72 (maternal responsivify), -77 @revision o f appropriate I e m i n g rnaterzalr), and -69

(maternal involvement) (Caldwell and Bradley, 1984). Interobserver reliability of 90 %

item agreement has been reported (Bradley and Caldwell, 1988). No test-retest reliability has been determined because re-asking the i n t e ~ e w questions a second time would create an artificial testing situation (Caldwell and Bradley, 1984). Face validity for the HOME Inventory exists; the questions developed for the assessment are based on a review of environmental characteristics related to favorable developmental outcomes (Caldwell,
1968). Over the last 15 years, the HOME Inventory has been revised and updated.

Construct validity based on the correlation of the home environment and maternal education has been determined. The correlation coefficients between maternal education

provision of appropriate learning materials, and the subscales of m a t e d re~ponsivify,

and maternal involvement are reported to be .22, -31, and .3 1, respectively at the age of 6 months (Caldwell and Bradley, 1984). These low correlations provide some evidence for construct validity and also suggest that more than matemal education needs to be considered in assessing the environment. To measure the independent variable of parental expectations, a spatially reorganized adaptation of the MAIMS (Bartlett, 1992) was used (instructions and item

examples are found in Appendix C). The MAIMS was developed to allow mothers to assess their own infant's motor development. This was achieved by changing the corresponding description of each developmental picture into lay-terms. Bartlett (1 992) reported the concurrent validity, in terms of intraclass correlation coefficients, between mothersy and physical therapists' assessment scores to be -99for fill-term infants. The MAIMS was spatially reorganized for the following reason. The original version had all four positions (lying on stomach, lying on back, sitting, and standing) on each of 5 pages spaced according to the sequence in which the activities typically emerge.
infmt in the four For example, at 6 months, the activities obtained by the ccaverage'y

positions fell in a relatively vertical h e . The items were spatially reorganized such that the four positions were on a separate page. This format provided no cues to the parent regarding the activities the baby might be doing in relation to the four positions. For example, the parent rated the activities the baby was doing while lying on stomach independently from the other three positions of lying on back, sitting, and standing. To measure the dependent variable of infant motor development at 8 months of age, the AIMS (Piper and Darrah, 1994) was used (item examples are found in Appendix D). This test is an observational, norm-referenced assessment designed to assess infants

from birth to independent wakingyup to the age of 18 months. The test is easily
administered; no handling of the infant by the examiner and no special equipment are required. Each item within the four subscales (prone, supine, sitting, and standing) is rated

as "observed " or "not observed". A total score is tallied by adding all observed items and
all items below that of the least mature observed item. A percentile ranking can then be determined from the normative data. Reliability for the AIMS has been reported to be high. Specifically, interrater reliability for a single testing occasion for the age range of 8 to 1 1 months is .98 and test-retest reliability is -99 (Piper and Darrah, 1994). High concurrent validity correlations were found when the A I M S was compared to the Peabody Developmental Motor Scales (Folio and Fewell, 1983) (r = -94) and the psychomotor index of The Bayley Scales of Infant Development (Bayley, 1969) (r = .85)for the 8 to 13 month age range (Piper and Darrah, 1994).

To achieve the secondary objective of exploring the relationship between three subscales of the HOME Inventory and the AIMS, two of the four subscales (prone and standing) were used. The rationale for this is that there is greater variability in these subscales than either supine or sitting at 8 months of age. Interrater reliability between the study investigator and advisor was conducted on the AIMS and the 3 subscales of the HOME Inventory on the first 6 families recruited to the project. The criterion of 90 % agreement on individual items for each subject was established and met. Reliability was checked mid-way through the 8-month home visits. Again, the objective of achieving 90% item agreement was achieved. The study advisor had previously established high reliability on the AIMS. A training videotape for the

HOME Inventory was acquired and reviewed prior to reliability testing. Data from
reliability testing is found in Appendix E.

Data Collection: Procedures

Ethics approval was obtained &om the University of Western Ontario (Appendix F). Subsequently, caregivers attending the Just Beginnings and Healthy Mothers, Healthy Babies programs and Well Baby Clinics were informed about the study (first by the employees of the various programs and clinics and then, if interested, by the investigator). Caregivers were provided with the letter of information (Appendix G) to consider whether or not they wished to participate in the study. Families using the London Bridges Childcare Services were informed about the study by means of a flyer (Appendix H) and letter of infomation. After consent had been obtained (Appendix I) an initial questionnaire was given to participants to collect descriptive data about the sample. When the infants were close to 5 months of age, the MAIMS was mailed to participants (Appendix C). Caregivers were asked to assess their infants' motor development at 5 months of age and then to predict their infants' motor development at 8 months of age. Caregivers were asked to assess their infants' motor development at 5 months to permit analysis of the contribution of 5-month motor status to the relationship between predicted and actual 8-month motor performance. At 8 months of age, a home visit was conducted.

During this visit, 3 subscales of the HOME Inventory (Caldwell and Bradley, 1984) and the A I M S (Piper and Dmah, 1994) were administered. Also at this time, some additional questions were asked to check the health status of the infant and to collect fbrther descriptive data about the sample (Appendix J ) . To control for the potential bias of order effect of the testing (HOME Inventory and AIMS), the order of the measures for each caregiver-infant dyad was determined prior to the home visit. This was done by assigning odd identification numbers to receive the

HOME Inventory first and the even identification numbers to receive the A I M S first.
Some flexibility in this plan was required. For example, ifthe X a n t was asleep on the investigator's arrival, the HOME Inventory was administered first because this was the interview portion of the home visit. The AIMS was then administered when the infant was awake and interested in his or her surroundings. Similarly, if the infant appeared to be tiring during the interview process, the interview was interrupted in order to administer the AIMS. The remaining HOME Inventory questions were then asked. Both the HOME Inventory and the AIMS can be administered with this degree of flexibility (Caldwell and Bradley, 1984; Piper and Darrah, 1994). At the end of the home visit, feedback was given to each caregiver regarding the infant's gross motor development by discussing the AIMS.

Data Analvsis
All information gathered ffom the initial and 8-month questionnaires was analysed to describe the sample. The primary and secondary objectives were analysed by calculating Pearson's r. The objectives were then analysed to take in account differences in chronological age because age and the effect of maturation is known to influence infant motor development (Piper and Darrah, 1994). This was done by converting raw AIMS scores to standardised z-scores using extrapolated normative data (Appendix K). The average change between 7 months and 8 months 3 weeks is 1.6 points on the AIMS (range 1-1-9). The raw scores were converted to z-scores to compare individual scores to the normal curve distribution represented by the normative sample of the AIMS. A raw score

is not always meaningfid by itself, however, knowing how a raw score compares in terms of standard deviations to a normative mean score is more meaningfid. For example, a raw

AIMS score of 52 at 8 months means little; however, a z-score of + 2 indicates that the
infant's motor score is two standard deviations above the mean for infants 8 months of age.

If normative data are available, z-scores can be calculated by dividing the deviation
of the raw score from the normative mean by the normative standard deviation using the following equation (Glass and Hopkins, 1984):

where x = raw score, u = normative mean, and c = normative standard deviation.

CWTER3

RESULTS
Initial Sample Characteristics

Forty-seven primary caregiver-infant dyads were recruited to participate in this project. More boys (n=28) than girls (n=19) were recruited. The average gestational age of the infants was 39.6 weeks (SD = IS), with a range of 35 to 42 weeks. Two of the infants were born prematurely, at 3 5 and 3 6 weeks' gestation. None of the caregivers reported any birth complications when considering their infant's wellbeing. At birth, the infants weighed on average 35 12 grams (SD = 5 19), with a range of 22 15 to 49 15 grams.

Only two of the infants weighed less than 2500 grams; these two infants were born at 35
and 3 7 weeks of gestational age.
All of the primary-caregivers of this sample identified themselves as the mother. The
4.9), with a range of 18 to 40 years. Only 2 of average maternal age was 30.4 years (SD=

the mothers were under 21 years of age. Ninety-eight percent of the mothers identified themselves as being Caucasian, with only one mother identifying herself as part Asian. At the time of recruitment, all mothers were caring for their infants in their homes hll-time, 7 days of the week. A large percentage of the total sample indicated that they had completed university (46.8 %), with only 6 mothers indicating that their highest level of education was partial or full high school completion. Sixty-three percent of the mothers were firsttime parents. A summary of the maternal characteristics related to education and parity is found in Table 1.

Table 1. Maternal Characteristics at the Time of Recruitment. Characteristic Education (n= 47) Some High School Completed High School Some College Completed College Some University Completed University Frequency Percentage ( % )

Additional Children at Home (n = 46) *

0

2 3

I * Data not available for one family.

Sample Characteristics at 5 Months At the time of the 5-month mailout, three families were lost to follow up. This occurred for a variety of reasons (e-g. away for holiday, moving house, or providing incomplete data). No systematic differences in infant birth weight, gestational age, number of other siblings, number of days cared for in the home by the mother and maternal education were noted between these three families lost to follow up and the remaining sample. A summary table of these data can be found in Appendix L. The average chronological age in months of the infants at the time the mothers completed the 5-month forms ranged from 4.7 to 5.5, with a mean of 5.0 (SD = 0.2). Upon examination of the returned assessments, inconsistencies in scoring were noted on 6 of the mothers' forms. Specifically, implausibly high scores were observed in two categories of explanation. First, some mothers assessed their infants as doing certain

motor activities that were implausibly high compared to the normative values of the Alberta Infant Motor Scale (AIMS). For example, 100% of the normative sample failed to demonstrate the prone item of reciprocal creeping at 5 months of age. If a mother assessed her infmt as doing this activity, credit was not given to that infant for this item. Second, those mothers giving their infant credit for doing an item, but not giving credit for a prerequisite item, made it implausible that the infant was doing the more advanced motor skill at 5 months of age. En this case, the infants were not given credit for the more advanced item. For example, if the mother gave credit for the prone item reaching

extended arm support but not forfotrrpoint kneeling, then it was implausible that the
infant was doing this item at 5 months of age. The specific items that caused the concern that these mothers had over estimated their infants' motor development included: propped
lying on side, reciprocal crawling.four-point kneeling to sitting or half-itting, and four-

point kneeling (2) from the prone sub-scale, sitting to lying from the sitting sub-scale (to
credit this item the infant needs to sit independently), and pulls to stand with support,

pulls to stm&stands with support, and supported stunding with rotation from the standing
sub-scale. The maternal assessment form did not specify that the infants need to attain standing independently to gain credit for the standing items. Some of the mothers specified on the forms that their infants were able to come to standing by pulling up on their forefingers. This description of 'pulls to stand' was not credited. Some statistically significant differences were found between the 6 mothers who had difficulties completing the maternal version of the AIMS (MAIMS) and the mothers who had no difficulty completing the MAIMS. First, a significant difference was found for maternal age ( ~ ( 4 3 ) = 2.09, p < .04). The group having dficulty was younger than the group not having difficulty, with mean ages of 26.7 (SD = 5.5) and 30.4 (SD = 4.9), respectively. Second, a statistically significant difference was found for maternal education, (Fisher's Exact Test, g< -02). Because there were so few entries in the various categories of educational levels, the categories were combined into two groups: some high school and completed high school became group 1, and the categories of some college through to completed university became group 2. Fifty percent of the mothers in group 1 had diEculty with the forms in contrast to only 8.6 % of those in group 2. Table 2

contains a summary o f the mothers who had difficulty or no ditticulty completing the forms.

- -

- - -

--

Table 2. Summary of Mothers' Difliculty Completing the 5-Month F o m s By Level of Education. Diff~cul ty No Difficulty Percentage
Group 1. Some/completed high school education (n = 6 ) .

50

Group 2. Greater than high school education (n = 38).

35

8.6

A summary of the raw data collected fiom the 5-month maternal assessment of infant
motor development and prediction of infant motor development at 8 months is contained
in Table 3.

Table 3. Summary of Maternal Scoring of the Alberta Infant Motor Scale Collected at 5 Months. Total (N = 44) Total (N = 44) Raw Predicted 8 Month MAIMS Scores

MAIMS Subscale Raw Actual 5 Month LMAIMS Scores Prone (mean, SD)

Supine (mean, SD)

Total (mean, SD) Note: MAIMS = spatially reorganized adaption of the maternal version of the Alberta Infant Motor Scale. SD = standard deviation.

Sample Characteristics at 8 Months

At the time of the 8-month home visit, one further family was lost to follow up.

The characteristics of this family include: infant birth weight of 3990 grams, gestational age of 40 weeks, maternal age of 33 years, male infant gender, one other sibling in the

home, and a maternal education level of 6 (completed university). In total, 43 home visits
were completed. The average chronological age of the infants at the time of the 8-month home visit ranged from 7 to 8-and-a- half months, with a mean o f 8.0 months

(SD = -3). Four infants fell outside of the targeted range of one week on either side of
eight months. Two of these infants were seven months and seven months and one week; this was due to corrections made for prematurity. Two of the infants assessed were 8-anda-halfmonths; this was due to difficulties scheduling a time for the home visit. At the time of the assessment, all of the mothers rated their infants' health to be generally good and they reported that their infants were receiving routine health care. None of the mothers had concerns about their infants' hearing or visual abilities. Six mothers mentioned that they were monitoring their infants for a pre-existing health condition or concern that they felt might influence their idants' overall development. These concerns included: size of head (n= 2), effects of prematurity, effects of a birth mark on the hand, low birth weight and low weight gain, and an ongoing bronchial condition. None of the mothers considered any of these concerns to be presently affecting their infants' development. When questioned about their infmts' general mood, aIl of the mothers considered their infants to be "usually cheefil and interested in what is going on around himher". At the time of the 8-month home visit, 40 mothers reported that they were at home with their infants for at least 4 out of 7 days a week. Seventy-four percent of the mothers were at home fbll-time with their infants. Three of the mothers had returned to hll-time work when their infants were six-and-a-half months old and were cared for out of the home for 5 days of the week. At the time of assessment, 41 of the 43 infants were rated by the primary investigator as "happy, content, and interested in their surroundings"; two infants were rated "somewhat unhappy, however, still interested in their surrounding^'^. All infants were able to complete the assessment to determine scores on the AIMS and the HOME Inventory. After assessing each infant's motor development, all infants were judged to be developing typically by the primary investigator. A summary of the raw data collected at the 8-month home visit of infant motor development and the three subscales of the HOME Inventory are surnmarised in Tables 4 and 5, respectively. To take dserences in chronological age into account, a l l 8-month AIMS scores were standardised using z-scores (see Appendix K for values to standardize each infant's score).

--

Table 4. Summary of Raw &Month Alberta Infant Motor Scale Scores.

AIMS Subscale

Total (N = 43)

Prone (mean, SD)

8.7 (0.7)

Supine (mean, SD) Sitting (mean, SD)

9.9 (1.4)

Standing (mean, SD) Total (mean, SD)

5.9 (2.6)

40.2 (7.8)

[ Note: SD = standard deviation.

Results from Obiectives

Primarv obiectives:

No statistically significant correlations (Pearson's r) were found between aspects of the home environment, as measured by the HOME Inventory, and infant motor development (using raw data and z-scores) for the following relationships: m a t e d responsivity and the total AIMS score (g = -. 13; g = -40 and r = -.14; g = -37, respectively); provision o f appropriate learning materials and the total A I M S score (_r -17; p = -27 and
=

r=-21; p = -17, respectively); maternal involvement and the total AIMS

score ( 1 = -.04; p = -8 1 and _r = -.08; g = .63, respectively). Scatter plots were constructed for each of the above relationships; no threshold or non-linear relationships were apparent. Because the sample scored in the middle and upper ranges of the HOME Inventory (see Appendix M), groups were recoded into 2 groups per subscale. All subscale scores from the middle range were coded as group I and scores from the upper range were coded as group 2. T-tests were then conducted to determine if

a difference in infant motor scores between the families that scored in the middle and
upper ranges of the HOME Inventory existed. Although not statistically significant, f appropriate learning materials had families scoring higher on the subscale ofprovision o infants with higher AIMS scores (g (41) = -1.96, p = -06). No difference in A I M S scores were noted for the subscales m a t e d requonsivity (g (4 1) involvement (1 (41) = - .30, p = -77). No statistically sigmficant relationship was found between parental expectations at
5 months and infant motor development at 8 months (using raw data and z-scores) as
-19; e = -23, determined by Pearson's correlation coefficient (1 = -19; p = -23 and r=
=

1.34, p = -19) and maternal

respectively). A scatter plot was constructed; no threshold or non-linear relationships were apparent. Due to the non-significant findings, the 5-month MAIMS data were not analysed firther.

Secondary Ob-iective:

No significant correlations (Pearson's r) were found between three subscales of the HOME Inventory and the raw scores for the prone and standing subscales of the AIMS
for the following relationships: m a t e d re~ponsivity and the prone subscale

(r = -.26; e = -09); m a t e r d respomzvity and the standing subscaie (1 = -06; p = -71 ) ;

provision o f appropriate learning materials and the prone subscde (K
= -21;p = - 18);

provision o f appropriate leaming materials and the standing subscale (r = - 18;Q = -25); maternal involvement and the prone subscale ( 1 = -.03; g = -85); and maternal involvement and the standing subscale (z = 4 2 ;
= -93).

Scatter plots were constructed

for each of the above relationships; no threshold or non-linear relationships were apparent.

CEAPTER 4 DISCUSSION
No statistically significant correlations were found for the following relationships: aspects of the home environment and infant motor development, parental expectations and infant motor development, and the three subscales of the HOME Inventory ( m u t e d

responsivity, provision of appropriate learning materials, and maternal involvement) and

the prone and standing subscales of the AIMS. Although the research hypotheses were not supported by the data, the study sample obtained high average scores for aspects of the home environment, parental expectations of subsequent motor behaviour, and infant motor development at 8 months. Plausible explanations for the negative findings include: homogeneity of the sample, lack of sensitivity of the HOME Inventory, questionable validity of the HOME Inventory t o support infant motor development, limitations associated with a univariate approach, and limitations associated with a cross-sectional design. Despite the lack of direct suppon of the research hypotheses, related evidence supports the association between aspects of the home environment and infant motor development. The study sample scored high for infant motor development, as measured by the AIMS, and for aspects of the home environment, as measured by the HOME Inventory. Specifically, the mean total A I M S score for this sample was 40.19 in comparison to the normative mean of 36-05, indicating that the study sample was a higher performing group than would be expected of a group of 8-month-old infants. Interestingly, the variability in both the study sample and the normative sample was virtually the same

(SD = 7.78 and SD = 7.77, respectively). Because the groups had equal variability, the
effect size between the two groups was determined. A medium effect size exists (d
= -5).

The value of -5 means that the upper half of the sample scored higher than 69.1% of the normative sample (Cohen, 1988). Another way to interpret the effect size is that 33 % of the combined areas of the study sample and the normative sample are not shared. Similarly, the study sample means for the subscales of maternal responsivity, provision o f

qpropriate learning materials, and maternal involvement were consistently higher than

those vaiues reported by the HOME Inventory (9.57 vs. 7.60; 7.91 vs, 5.04; 4.67 vs. 3.01, respectively). However, the variability of the study sample was consistently lower than that reported in the HOME Inventory (SD = 1.19 vs. 2.18; SD = 1.03 vs. 2.37; SD = 1.07 vs. 1.59, respectively) emphasizing the homogeneity of the sample mothers (Appendix N). Furthermore, related evidence supports the association between parental expectations and infant motor development. The study mothers had high expectations of subsequent motor development and their infants had high motor scores. This is evident when comparing the predicted 8-month mean scores and the actual 8-month AIMS mean scores for the individual subscales and total score: prone 20.0 vs. 15.7, supine 9.0 vs. 8.7, sitting 11.6 vs. 9.9, standing 9.4 vs. 5.9, and total 50.0 vs. 40.2, respectively. Little variability existed among the mothers' expectations relative to the actual 8-month AIMS scores: prone 1.8 vs. 4.2, supine 0 vs. -73, sitting 0.7 vs. 1-4, standing 3-0 vs. 2.6, and 4.1 vs. 7.8, respectively (Appendix 0). As stated in Chapter 1, this study was not designed to test dynamic systems theory as it has been applied to motor development; however, the results support the perspective that more than central nervous system maturation is associated with variations in the rate of acquisition of motor abilities in infancy.

Explanations for Nepative Results First, the study sample comprised a homogenous group of mothers. Specifically, little variability in ethnicity and maternal education existed among the families. Repeated attempts were made to recruit a heterogeneous group of families from a variety of cultural backgrounds and socioeconomic status (SES) levels. This was attempted by informing families about the study through a variety of sources. Families participating in programs targeted to lower SES groups were spec5cally approached. None-the-less, the sample represented a homogenous group of Caucasian mothers (98 %) mainly from the middle and upper SES levels as determined by maternal education. In general, the study families provided a stimulating and supportive home environment for their infants. No families scored in the lower quartile of the HOME Inventory for the subscales ofprovision o f qpropriate learning materials and maternal involvement, and only one family scored in

the lower quartile for the subscale of maternal responsivity. This sampling bias, coupled with a ceiling effect on the HOME Inventory scores, made it dEcult to detect relationships between aspects of the home environment and infant motor development and parental expectations and infant motor development. Second, the HOME Inventory provided little content to discriminate between middle and upper range of functioning families. The HOME Inventory was primarily designed to differentiate between inadequate and adequate home environments and not to distinguish between adequate and very supportive home environments (Bradley and CaIdweH, 1988). Because the sample mainly comprised adequate and very supportive home environments, the HOME Inventory lacked sensitivity to detect a relationship between aspects of the home environment and infant motor development. Third, the HOME Inventory was designed to measure the quality of the home environment to support cognitive, social, and emotional development (Bradley and Caldwell, 1988). Although the HOME Inventory has been used by a variety of health professionals interested in various aspects of development, the HOME Inventory has not been validated to support infant motor development. Presently, no such measure exists. Afler an extensive search, the HOME Inventory was considered the best available measure to evaluate aspects of the home environment. Subsequent experience using the HOME Inventory clarified that the items selected to support infant cognitive development might not be the same as the items needed to support infant motor development. For example,
the subscale ofprovision o f appropriate learning materials combines items relating to

equipment (i-e. strollers and high chairs) and toys that the infant plays with and has access to. Equipment, in general, might not be expected to enhance motor development. In contrast, toys might provide a motivating influence for infants to explore and learn about their environment, thus supporting early motor development. If the equipment and toy items were separated, a more appropriate grouping of items might exist. The subscale

f appropriate learning materials might then assist in clarifying the relationship provision o
between aspects of the home environment and infant motor development. Fourth, Limitations associated with a univariate approach exist. Aspects of the home environment measured may be necessary conditions supporting infant motor

development, but insufFent in absence of other interacting factors. This study was not designed investigate the multiple, interacting subsystems representing the entire physical and social home environment. Finally, limitations associated with a cross-sectional design exist. An assumption

i l l be stable over time was made when using a cross-sectional that the home environment w
design to measure aspects of the home environment and idant motor development. These
two constructs were simultaneously measured during the 8-month home visit. If the home

environment was measured prior to assessing infant motor development, statistically significant results supporting the relationship between aspects of the home environment and infant motor development might have been detected. Alternatively, the home environment could have been measured when the infmts were 8 months of age with follow up for motor development occuring when the infants were between 10 to 12 months of age. Although the targeted sample size of 60 mother-infant dyads was not achieved, sample size was not considered to be a limitation for this study because the 43 motherinfant dyads completing the study provide a power of -77to detect a correlation coefficient of -40 (Table 3.3.5; Cohen, 1988).

Ciinical Significance

Clarifying the relationship between aspects of the home environment and infant
motor development has important implications for therapists working in the early intervention field. Specifically, if this relationship is confirmed, support will be provided for early identification of infants at environmental risk, development of appropriate intervention strategies, consideration of the location for treatment, and decision-making about when to discharge infants Eom hrther follow-up and treatment. First, infants born with mild dyshnction who come from a disadvantaged background have been determined to be at greater risk than infants with more significant birth insults who come from supportive and stimulating home environments (Parker,

i s k need to be Greer, and Zuckerman, 1988). Therefore, infants at environmental r

identified early to plan intervention strategies. Therapists might need to provide specific screening services to determine which infants with motor dyshnction are at environmental
risk.

Second, the development of appropriate intervention strategies might provide infants at environmental risk with a stimuIating and supportive home environment. If required, further parenting education could be obtained by refemng the family to other health professionals such as social work, parenting cIasses, and social assistance. The early intervention therapist, famiIy support services, and the family could work together to provide an intervention program focusing on improving aspects of the home environment, thus supporting motor development. Third, if therapists are to be effective in using resources available to the infant and family, an understanding of the physical and social home environment is necessary. Treatment in the home, instead of a clinic, would provide an opportunity for the therapist to incorporate meaningfbl activities using resources already available in the home. It would also enable the therapist to determine what other resources the family might need to provide a supportive and stimulating home environment to enhance the infant's motor development. If inappropriate suggestions are made with respect to parental expectations and resources available to the family, there is Iittle chance the intentention will be effective. Fourth, before discharging an infant fiom therapy or follow-up, the home environment should be taken into account. The home environment of the infant who demonstrates borderline motor dyshnction shouid be considered when determining priorities for discharge. The infant identified at environmental risk may need prolonged treatment and monitoring to ensure that progress continues and no fhrther movement concerns anse.

Future Work

Before recommending implementation of the points suggested in the clinical significance section (above), the relationship between aspects of the home environment and infant motor development needs to be clarified fbrther in future investigations. Because this area of research is observational, causality will be difficult to determine. To strengthen the argument for a causal relationship between the home environment and infant motor development, variations in study designs could be implemented (Fletcher, Fletcher, and Wagner, 1996). These designs could include the elements o f temporality, strength of association., dose-response, reversibility, and consistency. For example, to establish temporality between aspects of the home environment and infant motor development, a prospective design could be implemented. The home environment could be assessed when the infant is between 3 and 5 months of age. Follow-up assessment of infant motor development could then occur when the infant is between 8 and 12 months of age. To improve the prospective aspect of the study examining the relationship between parental expectations of motor development and infant motor development, the time kame between predictions and actual assessment could be widened. For example, mothers could predict their infant's subsequent motor development before their infant is born. Follow-up assessment to measure actual 8-month motor development could occur when the infant is between 8 and 12 months of age. The strength of association between the home environment and infant motor development would be increased with implementation of the following suggestions into a study design. First, replication of this study could be done with a sample comprising a greater representation of the full spectrum of SES across families. This could be achieved by working more closely with health professionals that are involved with families from lower SES backgrounds. Second, a valid measure reflecting aspects of the home environment that support infant motor development needs to be created. A fist step could be identification of items within the HOME Inventory that reflect the relationship between the home environment and infant motor development. By increasing the variability of the sample and the sensitivity of the measure, detection of an association

between the home environment and infant motor development will be enhanced. Finally, the use of non-linear analyses needs to be considered to examine the relationship between the maternal subscales of the HOME Inventory (maternal responszvzty, and maternal involvement) and infant motor development. Although a non-linear relationship was not observed on visual inspection of scatter plots, such a relationship might exist in a sample with representation o f families fiom the full spectrum of SES levels. To determine i f a dose-response relationship exists, a heterogenous sample could be divided into the lower quartile and upper 2~~ percentile on HOME Inventory. The infant motor development scores could then be compared. If infants fiom a more supportive home environment had higher scores than infants fiom less supportive home environments, a dose-response relationship would be supported. Support for a causal relationship between the home environment and motor development might be obtained by incorporating the element of "reversibility". Intervention could be provided to vulnerable families through social support and parental education. If this element exists, infant motor scores would improve after intervention strategies have been implemented. Finally, consistency of results fiom different studies would strengthen the case for
a causal relationship between the home environment and infant motor development. For

example, recruitment fiom another homogenous group representing vulnerable families would provide further evidence if this sample comprised low scoring groups for aspects of the home environment, parental expectations, and infant motor development.

Summarv and Conclusions

This study aimed to clarify the relationship between the home environment and
infant motor development. Although no statistically significant correlations were found between aspects of the home environment and infant motor development and parental expectations and infant motor development, the study sample comprised high scoring groups for aspects of the home environment, parental expectations, and infant motor

development. These findings suggest that more supportive and stimulating home environments are associated with advanced infant motor development. The extent of this relationship needs fbrther investigation before therapeutic strategies for early identification
and intervention can be designed and implemented.

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Abbott 4 Bartlett D. The relationship between the home environment and infant motor development. Phys O c m p 7her Pediah: in press. Bartlett D. Vaiidih; ofMothersP Assessments of infant Motor Development. M. Sc. Thesis. Edmonton.
1992.

AB:University of Alberta, Department of Physical Therapy;

Bayley, N. Bqyley Scdes of lttfanz Development. New York, NY: The Psychological Corporation; 1969. Bradley R, Caldwell B. Early home environment and changes in mental test performance in children from 6 to 36 months. Dev Psyrhol 1976;l2:93-97. Bradley R, Caldwell B. Home observation for measurement of the environment: a

Def 1977; 8 11 41 7-420. validation study of screen efficiency. Am J Me~zt

Bradley R, Caldwell B. Using the home inventory to assess the family environment.

Pediatr Mrrs 1988; 14:97-102.

Caldwell B. On designing supplementary environments for early child development.

BAEYC Reports 1968; 10:1- 1 1.

Caldwell B, Bradley R. Home Observationfor Measurement of the Environment. Little Rock, AR: University of Arkansas; 1984. Carlson D, Labarba R Sclafiani J, Bowers C. Cognitive and motor development in infants o f adolescent mothers: a longitudinal analysis. Int J Behav Dev l98S;g: 113.

Cintas H. Cross-cultural variations in infant motor development. Phys Occzrp Ther

Pediatr l988;8(4): 1-20.

Cintas H. Cross-cultural similarities and differences in development and the impact of parental expectations on motor behaviour. Pediatr Phys 73er 1995;7:103- 1 1 1. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Edition 2 . Hillsdale

NY: ErIbaum; 1988.

Coll C. Vohr B, Hoffman J. Oh W. Maternal and environmental factors affecting development outcome of infants o f adolescent mothers. Dev and Behm Pediatr
1986;7: 230-236.

Darrah J, Redfern L, Maguire T, Beaulne P, Watt J. Intra-individual stability of rate of

gross motor development in full-term infants. Early Hzrm Drv 1998;52:169- 179. Dennis W. Infant development under conditions of restricted practice and of minimum social stimulation: a preliminary report. J Genet Psycho[ 1938;SS : 149- 158. Dennis W, Dennis M. The effect of cradling practices upon the onset of walking in

Hopi children. J Genet PJychol 194O;56:77-86.

Dennis W, Najarian P. Infant development under environmental handicap. P~)..chol

Morzogr 1957;7l: 1-13.

Elardo R, Bradley R, Caldwell. B. The relationship of infants' home environments to mental test performance from six to thirty -six months: a longitudinal analysis.

Child Dev 1975;46:71-76.

Fetters L. Tronick E. Neurornotor development of cocaine-exposed and control infants from birth through 15 months: poor and poorer performance. Pediatrics 1996;98:938-943. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology: The Essentials. Baltimore, MD: Williams and Wilkins; 1996. Folio Fewell RR. Peabody Developmental Motor Scales cnld Activity Cards.

Chicago, IL:Riverside Publishing; 1983. Freedman D. W a n Infmzcy: An Evolzrtionary Perspective. Hillsdale, N J : Lawrence Erlbaum; 1974. Glass G, Hopkins K. Statistical Methods irz Edzication and Psychology. Englewood Cliffs, NJ: Prentice-Hall; 1984. Gleick J. Chaos: MakrngaNcnv Science. New York, NY: Penguin; 1987. Hopkins B. Westra T. Maternal handling and motor development: an intracultural 1988;1 14377-408. study. Psychol Mo~logr Lester B, Brazelton T. Cross-cultural assessment of neonatal behaviour [Chapter 21 in Wagner D, Stevenson H (eds.), Czrltzrral Perspectives on Child develop men^. San Francisco, CA: W.H. Freeman and Company; l982,2O-S3. McGraw M. Growrh: A Stzrdy of Johnny and Jimmy. New York,NY: AppletonCentury; 1935.

McGraw M. The Nezcromzrsnilar Matzrration of the Htrman Infant. New York NY: Columbia University Press; 1945.

L,Ho M. Physical and environmental Mulligan L, Specker B, Buckley D, OYConner

factors affecting motor development, activity level, and body composition of infants in child care centers. Pediatr Phys Ther 1998;10: 156- 16 1. Parker S. Greer S, Zuckerman B. Double jeopardy: the impact of poverty on early child development. Pediatr C h North Am 1988;3 5 :1227- 1240. Piper M. Darrah J. Motor Assessment of the Developing Iltfmlt. Philadelphia, PA:

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Ramey C, Farren D.Campbell F. Predicting IQ fiom mother-infant interactions. Child

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Raze1 M. Call for a follow-up study of experiments on long-term deprivation of human infants. Percept M o m Skills 1988;67: 147-158. Super C. Environmental effects on motor development: the case of 'African infant precocity'. Dev Med Child Nezirol 1976; 18.56 1-567. Thelen E, Kelso J, Fogel A. Self-organizing systems and infant motor development.

Dev Rev 1987; 7:39-65.

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Appendix A

Initial Questionnaire

Infant Motor Development and the Home Environment: Initiaf Questionnaire

Andrea Abbon, Dr. Doreen Bartlett, and Dr. John Kramer, School of Physical Therapy, The University of Western Ontario
By filling out this form, you as the main caregiver of your baby, will help to determine how home influences might affect the activities that babies do. All information concerning you and your baby will be kept confidential. Your Name Your Address Postal Code Your Phone Number Today's Date

First. we would like to ask a few questions about your baby and your baby's delivery.
1. What is your baby's name?

(first)
2. What was your baby's birth date?

(last)

(day) (month) (year)

3. Is your baby a girl or a boy? (circle the number of your answer)

1 2

Boy Girl grams or Ib,

4. How much did your baby weigh when born?

- oz
weeks

5. How many weeks pregnant was the mother when your baby was born?
6. Were there any complications during the delivery?

If yes, please describe:

7. How many days, of a 7 day week, is your baby cared for in your home?

fb

days

Next, a few questions about you. as the main caregiver.

8. What is your relationship to your baby? (circle)

1 Mother 2 Father 3 Other, 9. What is your date of birth?

(day) (month) (year)

10. Do you have any other children?

r1
1 YES No
1

if so, what are their dates of birth?

11. What is the highest level of education that you have completed? (circle)

Some High School 2 Completed High School 3 Some College 4 Completed College 5 Some University 6 Completed University
12. Ethnic group can often influence the timing of when babies do different activities. Which of the following ethnic groups do you consider yourself a part of? [these responses are adapted from the Statistics Canada 1996 Census Survey]. (circle)

White (Caucasian) 2 Black (e.g. African, Haitian, Jamaican, Somali) 3 North American Indian or Metis 4 Asian (e-g. Chinese, Japanese, Korean, Cambodian, Indonesian, Laotian, Vietnamese, Filipino) 5 South Asian (e.g. Armenian, Egyptian, Iranian, Lebanese, Moroccan) 6 Other (piease describe)
I

We are planning to send out a summary of the study results after the study is finished. So that we are certain to be abIe to contact you over the nest few months. please provide us with the name. address. and phone number of a close friend or relative who will likely not move during this time.

Name: Address: Postal Code: Phone Number:

--

-- -

--

- -

Thank you for filling out this form. Please return it to us in the stamped envelope provided. We will mail you a form that looks at the activities that babies do on their back, stomach, sitting, and standing when your baby is close to 5 months old. If you have any questions, at any time, please call:
Andrea Abbott, Master of Science Candidate at 66 1-3360 Dr. Doreen Bartlett, Assistant Professor at 679-2 1 1 Z ext. 8953 Dr. John Kramer, Associate Professor at 66 1-3360

Appendix B

Item Examples from the HOME Inventory

Item Examples from the HOME Inventory by Caldwell and Bradley, 1984.

(InfantfToddler HOME)

Scoring instructions:

Place a plus (+) or minus (-) alongside each item if the behavior is observed during the visit or if the parent reports that the conditions or events are characteristic of the home

Item examples from each subscale:

Subscale I. RESPONSIVITY
2 . Parent responds verbally to child's vocalizations or verbalizations.

Subscale IV. LEARNING MATERIALS

29. Parent provides toys for child to play with during visit.

SubscaIe V. INVOLVEMENT
3 7. Parent consciously encourages developmental advance.

Appendix C

hstructions and Item Examples f?om the Maternal Version of the Alberta Infant Motor Scale

Infant Motor Development and the Home Environment

Andrea Abbott, Dr. Doreen Bartlett, and Dr. John Krarner, School Of Physical Therapy, The University of Western Ontario.
Thank you for filling out the first form. Would you, as your baby's main caregiver, please fill out the folIowing forms.
First, could you please write your name and today's date in the space below and answer the following questions:

Your Name: Today's Date:

I . What is your relationship to your baby?

2. How many days, of a 7 day week, is your baby cared for in your home?

days

Now we would like you to look at the attached form that looks a t what activities babies do while they are lying on their back, stomach, sitting, and standing. I . Look at each picture on the 5 month form and circle "Y" for YES my baby is doing this activity at 5 months of age or "N" for NO my baby is NOT doing this activity at 5 months of age. Do this for each of the four pages (lying on back, lying on stomach sitting, and standing). The descriptions below each picture should help answer any questions you may have.
2. Now look at the pictures on the 8 month form and begin with the activities that your baby was doing a t 5 months of age. On this form circle "Y' for YES I believe my baby will be doing this activity at 8 months of age or 'W" for NO I believe my baby will NOT be doing this activity at 8 months of age. Do this for each of the four pages (lying on back. lying on stomach, sitting, and standing).

Thank you for filling out these forms. Please return them to us in the stamped envelope provided. We will phone you when your baby is close to turning 8 months old to set up a time to come and visit you and your baby in your home for the final form. If you have any questions, at any time, please call: Andrea Abbott, Master of Science Candidate at 66 1-3 3 60 Dr. Doreen Bartlett, Assistant Professor at 679-21 1 1 ext. 8953 Dr. John Kramer, Associate Professor at 66 1-33 60

Item Examples from the Maternal Version of the Alberta Infant Motor Scale (MAIMS) by Bartlett, 1992.

Supine Subscale:
Hands to Feet

Sitting Subscale:

Reaches in Sitting

Prone Subscale:

Standing Subscale:

'Swimming'

Pulls to Standc Stands with Support

Appendix D

Item Examples fforn the Alberta Mant Motor Scale

Item Examples from the Alberta Infant Motor Scale (AIMS) by Piper and Darrah, 1994.

Supine Subscale:
Rolling Supine to Prone Without Rotation

Sitting Subscale:
We~ght Shift in Unsustained S i ? t i n g

.
r

. I

x-

Lateral head ngnnng funk moves as one u n ~ ?

Prone Subscale:

Standing Subscale:

Pivoting
-.

Supported Standing With Rotation

,-.
\-.-7 0 .
/ -

. . *. 3. . -;
Rvols Movement n O m ona legs Loterol trunk flexion

2otanon of Trunk o n a ~ehns

Appendix E

Summary of Data korn Reliability Testing for the HOME Inventory and the Alberta Infant Motor Scale

Summary of Data from Reliability Testing for the HOME Inventory and the Alberta Infant Motor Scale (AIMS) at 8-Months

ID #

HOME Inventory Item Agreement ( O h )

AKMS Item Agreement ( O h )

Initial Reliability Testing:

I
2 92.3
100

11

92.5

86

23

92.5

92.3

100

96.4

92

93

36

92

93

Follow-up Reliability Testing:

Appendix F

Ethics Approval

The UNnTERsITYof WESTERN ONTARIO

Vice-President (Research) Ethics Reuiew Board Derrtal Scicnces Building R E V E W BOARD FOR HEALTH SCIENCES RESEARCH WOLVTNG HUMAN SUBJECTS 1997-98 CERTlFICATION OF APPROVAL OF HUMAN RESEARCH
ALL HEALTH SCIENCES RESEARCH INVOLVING HUMAN SUBJECTS AT THE UNIVERSITY OF WESTERN ONTARIO IS CARRIED OUT IN COMPLIANCE WITH THE MEDICAL RESEARCH COUNCiL OF CANADA "GUIDELINES O N RESEARCH INVOLVING HUMAN SUBJECT." 1997-98 REVIEW BOARD MEMBERSHIP
1) Dr. B. Bomein. Assistant Dean-Research - Medicine (Chairman) (Anatomy/Ophthalmolog?~) 2) Ms. S. Hoddinott. Director of Research Senices (Epidemiology) 3) Dr. R Gagnon, St. Joseph's Health Centre Representative (Obstetrics & Gjnaecology) 4) Dr. R McManus, London Health Sciences Centre Victoria Campus Representative (Endocrinology & Metabolism) 5) Dr. D. Bocking, London Health Sciences Centre - University Campus Representative (Physician Internal Medicine) 6 ) Dr. L. Heller. Ofice of the President Representative (French) 7) M r s .E. loncs. Office of the President Representative (Community) 8) Ms. S. Fincher-Stoll, Office of the President Representatii-e(Legal) 9) Dr. D.Freeman, Faculty of Medicine & Dentis@ Representative (Clinical) 10) Dr. D. Sim. Faculty of Medicine & Dentistq Represenlative (Basic)(Epidemiolo~) 11) Dr. T.M. Underhill, School of Dentistry Representative (Oral Biology) 12) Dr. H. Laschinger, School of Nursing Representative (Nursing) 13) Dr. W.S. Yovetich.Facu1ty of Health Sciences Representative (Communicative Disorders) 14) Ms. M. Luvell. London Clinical Research Association Representati\.e 15) Research Institutes Representative 16) Mrs. R Yohnicki. Administrative Officer Alternates are appointed for each member.

THE REVIEW BOARD HAS EXAMINED THE RESEARCH PROJECT ENTITLED:

"Infant motor development and the home environment"
REVIEW NO:
E64SO

AS SUBMITTED BY:

Dr. J. Kramer - Physical Therapy, Elborn College

AND CONSIDERS I T TO BE ACCEPTABLE ON ETHICAL GROUNDS FOR RESEARCH INVOLWNG HUTi4AN SUBJECTS UNDER CONDITIONS OF THE UNIVERSITY'S POLICY ON RESEARCH MVOLVMG HUMAN SUBJECTS.
APPROVAL DATE:

April 23 1998 (UWOProtocol, Letter of Information & Consent)

AGENCY:
AGENCY TITLE:
c u
C.C.

Hospital Administration

Bessie Bonvein, Chairman

London. Ontario

Canada

N6A 5CI

Telephone: (519) 661-3036

Fax: (519)661-3875

Appendix G

Letter of Information

Information Kept by Families Title of the Project: Infant Motor Development and the Home Environment
The purpose of this project is to find out how aspects of the home may affect how babies move. The results of this project may improve the fixture care of babies who are having problems learning to move.
We are asking parents with babies in programs such as Just Beginnings and Healthy l i n i c s ,and parents who have Mothers-Healthy Babies, parents using the Well Baby C babies in one of London Bridges Child Care Services to take part in this project. We are looking for parents who are planning to care for their babies in the home for 4 out of 7 days a week until the baby is 8 months old. If you take part, we d ask you to fill out a short form with questions about you and your baby. When your baby is close to 5 months, we w i l l send you a form that looks at how your baby moves on his or her back stomach, sitting, and standing. We will also ask you to mark those activities you believe your baby will be doing at 8 months. This will take 30 to 40 minutes to do. We will include a stamped, addressed envelope to return these forms to us. Lastly, when your baby is close to 8 months, we will call you to set up a good time to meet with you and your baby at your home. During this time, we wili ask you some more questions about you and your baby. We will also watch how your baby moves while lying on the back, stomach, sitting, and standing. This visit will take about an hour.

This study will not harm you or your baby. At the end of the home visit, we will talk with you about how your baby moves and what you might expect your baby to do next. For your interest, we will send you a short summary of the results after all babies have finished the final visit. We will give a l l records a code number. We will not report any information idenafylng you or your baby. We will lock all of the information in a filing cabinet and shred it all 5 years after the study is finished. Taking part in this study is voluntary. You may refise to take part, refuse to answer any questions or withdraw from the study at any time with no effect to you or your baby. Please keep this letter for your information. If you have any questions, at any time, please call: h d r e a Abbott, Master of Science Candidate at 661-3360 Dr. Doreen Bartlett, Assistant Professor at 679-21 11 ext. 8953 Dr. John Kiamer, Associate Professor at 66 1-3 360 School of Physical Therapy The University of Western Ontario 1588 Elborn College London, Ontario, N6G 1Hl

Appendix H

Flyer

I S YOUR BABY
3 to 5 MONTHS OLD?
IF SO, WE INVITE YOU TO BE A PART OF A PROJECT LOOKING AT HOW BABIES MOVE. If you are interested in taking part in this project, please take a letter (below) and call:
Andrea Abbott, Master of Science Candidate 661-3360 Dr. Doreen Bartlett, Assistant Professor 679-2111 (8953) Dr. John Kramer, Associate Professor 661-3360

School of Physical Therapy Faculty of Health Sciences The University of Western Ontario

Appendix I

Consent Fonn

Consent Form Infant Motor Development and the Home Environment

I have read the accompanying letter of information, have had the nature of the study explained to me, and I agree to participate. All questions have been answered to my satisfaction.

Date

Signature

Appendix J

8-Month Questionnaire

Infant Motor Development and the Home Environment: 8 Month Borne Visit (to be filled out by investigator) Andrea Abbott, Dr. Doreen Bartlett, and Dr. John Kramer. School Of Physical Therapy. The University of Western Ontario. Name of caregiver: Name of baby: Date of assessment: First, I would like to ask a few questions about your baby.
1. Do you think your child hears well?

I NO 2 YES
2 Do you think your child sees well?
1 NO 2 YES

3 . Which of the following best describes your baby's health and how often he/she is sick? Also think about how ofien heishe needs to see anyone for health care. By "healthcare I mean: visiting a doctor, nurse, clitzic or hospitalfor illness. "Rozttinr health care means visitsfor shoe checkups, or occasiorral colds.
" "

1 My child is generally in good health and receives routine health care. 2 My child has slightly more than usual illnesses and visits for health care. 3 My child has frequent illnesses and needs frequent visits for health care. 4 My child is almost always ill, has very frequent visits for health care and/or frequent hospitilizations.
4. Are there any health conditions your child has that you think may affect hisher

development?

5. Which of the following best describes your baby's usual mood?

My baby is usually cheerhl and interested in what is going on around hidher. 2 My baby is often irritable. fretful or unhappy and often uninterested in what is going on around hirn/her. 3 My baby is almost always irritable, fretful o r unhappy and usually uninterested in what is gong on around himher.
1

Which of the following best describes how your baby practices new activities? For example. consider a new activity that your baby has recently tried to do, something like putting shapes into a container or trying to move forward to get a toy. (circle)
6.
1 2 3 4

My baby repeats a new activity until he/she can do it very well. My baby will try a new activity a few times and then do something eke. My baby gets frustrated easily when trying a new activity. My baby needs encouragement to try new activities.

7 . Different families use different pieces of equipment with their babies at home. What

equipment, if any. does your baby currently use in your home while they are awake? (circle all that apply)
I

What would be the average time per day, in minutes, that your baby would use the equipment? (circle time that matches equipment use)
0 0 0 0 0 0 0 0 1-10 1-10 1-10 1-10 1 10 1-10 10-20 10-20 10-20 10-20 10-20 10-20 1- 10 10-20 1-10 10-20

Jolly jumper Walker Exersaucer Playpen Highchair (other than for meals) Automatic swing Infant seat (e-g. bouncer seat) Other (please describe),

Does your baby enjoy playing on the floor by himselfierself?

1

NO YES

What is your relationship to your baby?

10. How many days, of a 7 day week, is your baby cared for in your home?

days

[Descriptive data of caregiver if the caregiver has changed from the initial questionnaire, if not proceed to question 141
1 1. What is your date of birth?

day

month

year

12. What is the highest level of education that you have cornpIeted? (circle)

1 2 3 4 5 6

Some High School Completed High School Some College Completed College Some University Completed University

13. Ethnic group can often influence the timing of when babies do different activities.

Which of the following ethnic groups do you consider yourself a part of? [these responses are adapted from the Statistics Canada 1996 Census Survey]. (circle)
1

2 3
4

5
6

White (Caucasian) Black (e.g. African, Haitian, Jamaican, Somali) North American Indian or Metis Asian ( e - g .Chinese, Japanese, Korean, Cambodian, Indonesian, Laotian, Vietnamese, Filipino) South Asian (e-g. Armenian, Egyptian, Iranian, Lebanese, Moroccan) Other (please describe)

14. Infant behavioral state at time of testing:

1

2 3

Appears happy, content, and interested in surroundings. Appears somewhat unhappy, still interested in surroundings. Appears unhappy to participate in motor activities.

Order of:

a. Home Inventory
b. Alberta Infant Motor Scale

[Review the infant's motor development with the caregiver before leaving.]

Appendix K

Extrapolated Normative Data Used to Convert 8-Month Alberta Infant Motor Scale Raw Total Scores to Standardized 2-Scores

Extrapolated Normative Data Used to Convert &Month Alberta Infant Motor Scale Raw Total Scores to Standardized %Scores.

Age Group (months)

Chronological Age (days)

Mean

Standard Deviation

Note: Bold = normative data fiom Alberta Infant Motor Scale from which extrapolated data were calculated. Assumption of linearity made to extrapolate the above data.

Appendix L

Summary of Data of Families Lost to Follow Up at the 5-Month Mail-out

Summary of Data of Families Lost to Follow Up at the 5-Month Mail-out

Characteristic

Description

Families Lost to Follow-

Infant Birth Weight (grams)

Gestational Age (weeks)

Maternal Age (years)

Gender of Infant (A4 = Male, F = Female)

'

M = 28 F = 19

Number of Other Siblings-

0 = 29 1 = 10 2 =6 3=1

0=2 1=1 2=0

3=0
Some High School = 1 Completed High School = 0 Some College = 0 CornpIeted College = 0 Some University = 0 Completed University = 2

Maternal Education'

Some High School = 2 Completed High School = 4 Some College = 7 Completed College = 9 Some University = 3 Completed University = 22
'

Note:

* Mean.

SD. " Range- Frequency.

Appendix M

Score Ranges of the HOME Inventory

Score Ranges of the HOME Inventory by Caldwell and Bradley, 1984.

(Infant/Toddler HOME)

Su bscale

Lowest Fourth Score

Middle Half Score

Upper Fourth Score

I. Responsivity

0-6

7-9

IV.

Learning Materials

0-4

5-7

Appendix N

Summary Table for the Relationship Between Aspects of the Home Environment and Infant Motor Development

ASPECTS OF THE HOME ENVIRONMENT AND INFANT MOTOR DEVELOPMENT

HOME INVENTORY SCORES:

Study Data: Mean (SDI Available Data: Mean (SD) 6 months

12 months

Provision of Appropriate Learning Materials: Maternal Involvement:

ALBERTA INFANT MOTOR TOTAL SCORES:

Study Data: Mean (SD)
40.2 (7.8)

Normative Data: Mean (SD)

36.1 (7.8)

Appendix 0

Summary Table for the Relationship Between Parental Expectations and Infant Motor Development

PARENTAL EXPECTATIONS AND INFANT MOTOR DEVELOPMENT

Alberta Infant Motor Subscales: Maternal Predicted 8 Month Scores:

Actual 8 Month Scores:

Prone (mean, SD)

20.0 (1-8)

Supine (mean, SD)

9.0 (0)

Sitting (mean, SD)

11.6 (0.7)

Standing (mean, SD)

9.4 (3 -0)