THE EFFECT OF DEVELOPMENTAL ACTIVITIES, EMBEDDED INTO PARENT?S ACTIVITIES OF DAILY LIVING, ON SUPINE SLEEPING INFANT MILESTONE DEVELOPMENT Beverley Hewson A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements of the Master of Science Degree in Occupational Therapy. Johannesburg, 2011 ii DECLARATION I declare that this dissertation is my own work. It is being submitted for the degree of Masters of Science in Occupational Therapy at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at this or any other University. Beverley Hewson __________________________, _______day of ______________________2011 iii ABSTRACT Therapeutic intervention should take humans? daily routines into account or it is unlikely to be assimilated into everyday practice. This is particularly true for the mothers of young children. The purpose of this study was to examine the effect of a prone postural control programme, by inserting infant stimulation activities in to the activities of daily living of mothers. 30 mother-infant dyads were randomly assigned at eight weeks postpartum, to an intervention or usual care group. Following a four month period in which the intervention group followed a prone activity programme developed by the researcher, the infants were reassessed. The Peabody Developmental Motor Scales (2nd Ed) were used to evaluate the programme?s efficacy and the results demonstrate a significant difference (p?0.00) in the total motor development between the two groups post intervention. Thus a ?prone playing? programme given to mitigate developmental delay associated with supine sleeping, was successful when embedded into the mother?s daily routine. iv ACKNOWLEDGEMENTS My sincere thanks and appreciation are directed toward a number of people, who have enabled this project: Denise Franzsen, my supervisor, for her tireless help and direction throughout this process. Professor Becker, statistician, for his welcome advice and assistance with data analysis. Gillian Shead, Kate Bailey, Wiekie Verhawe and Nicole Hillburn for their expert input. Kathy Seals for her time and infinite patience with the graphic designing process of the photo sheets. Thanks to all of the nursing sisters who helped with this research and were so willing to be involved. To all the mothers and their babies who were prepared give me a glimpse into their lives at a time of immense change and becoming. To the parents and infants involved in the photograph pages - for your time and patience with each picture. And most of all to David and Michael and my family, who have been an amazing source of strength, and my Heavenly Father who has sustained me throughout. v TABLE OF CONTENTS DECLARATION ............................................................................ ii ABSTRACT ................................................................................ iii ACKNOWLEDGEMENTS ............................................................... iv TABLE OF CONTENTS .................................................................. v LIST OF TABLES ....................................................................... viii LIST OF FIGURES ...................................................................... ix LIST OF APPENDICES .................................................................. x DEFINITIONS OF TERMS: ........................................................... xi ABBREVIATIONS: ..................................................................... xiii CHAPTER 1 INTRODUCTION ......................................................... 1 1.1 Background to the Study ..................................................... 2 1.2 Statement of the Problem .................................................... 5 1.3 Purpose of the Study ........................................................... 5 1.4 Justification for the Study .................................................... 6 1.5 Aims of the Study ............................................................... 7 1.6 Objectives of the Study ....................................................... 7 1.7 Null Hypothesis .................................................................. 8 CHAPTER 2 LITERATURE REVIEW ................................................. 9 2.1 The Occupation of Mothering .............................................. 10 2.2 Back to Sleep ................................................................... 16 2.3 Occupationally embedded exercise ...................................... 33 2.4 Programme Development .................................................. 36 CHAPTER 3 PROGRAMME DEVELOPMENT AND RESEARCH METHODOLOGY ........................................................................ 45 vi Part A: Programme Development .............................................. 47 3.1 Programme design ............................................................ 47 3.2 Postural Control Programme Validation ................................ 48 3.3 Photo sheets .................................................................... 50 Part B: Research Methodology ................................................... 56 3.4 Study design .................................................................... 56 3.5 Study Population and Sample Selection ............................... 57 3.6 Ethics .............................................................................. 61 3.7 Research Procedure .......................................................... 62 3.8 Outcome Measures ........................................................... 64 3.9 Method of Data Collection .................................................. 67 3.10 Data processing methods and Data analysis ....................... 70 CHAPTER 4 RESULTS ................................................................ 72 4.1 Population Sample ............................................................ 73 4.2 Sample Demographics ....................................................... 74 4.3 Assessment results ........................................................... 76 4.4 Analysis of diary pages ...................................................... 81 4.5 Null hypothesis ................................................................. 86 4.6 Summary of results........................................................... 86 CHAPTER 5 DISCUSSION ........................................................... 88 5.1 Demographics .................................................................. 89 5.2 Development of the IPCP ................................................... 91 5.3 Implementation of the IPCP ............................................... 94 5.4 The effectiveness of the IPCP ............................................. 95 vii 5.5 Assessing the success of embedding the IPCP into the mother?s Activities of Daily Living. ....................................................... 101 5.6 Summary ...................................................................... 102 CHAPTER 6 CONCLUSION ........................................................ 104 6.1 Recommendations .......................................................... 106 LIST OF REFERENCES: ............................................................ 108 APPENDICES .......................................................................... 124 viii LIST OF TABLES Table 4.1: Demographic Data for the Intervention & Usual care Groups .................................................................................... 74 Table 4.2: Positioning and parenting data regarding sleep behaviour and primary caregiver for Intervention and Usual care Groups ....... 75 Table 4.3: Comparison of mean values for the PDMS-2 at Baseline and Follow-up assessment results by group and within groups ....... 77 Table 4.4 Comparison of mean values for the PDMS-2 at Baseline and Follow-up assessment results by group and within groups ............. 78 Table 4.5: Annotation of the complete sets of diary pages returned for the Intervention and Usual care groups .................................. 81 ix LIST OF FIGURES Figure 3.1 Flow diagram indicating the process of the study, indicating Part A (green) and Part B (blue) .................................. 46 Figure 3.2 Pushing up on arms and reaching in natural play .......... 51 Figure 3.3 Snapshot of PDF file, Photo sheet page 1 ..................... 51 Figure 3.4 Initial facilitated sitting .............................................. 54 Figure 3.5 Corrected facilitated sitting ......................................... 54 Figure 3.6 Rejected Position ....................................................... 55 Figure 4.1 Comparative graph for the diary set 1 (9 ? 12 weeks) for infants in the usual care and intervention groups, expressed in hours. .............................................................................................. 83 Figure 4.2 Comparative graph for diary sets 2 and 3 (13 - 20 weeks) for the usual care and intervention groups, with times expressed in hours. ..................................................................................... 84 Figure 4.3 Activity profile for diary set 4 and 5 (21 - 28 weeks) for the intervention group. ............................................................. 85 x LIST OF APPENDICES A: Brainstormed activities and those modified in Pilot study 1 .... 125 B1: Photo-sheets for age band 2 ? 3 months, page 1 ................. 149 B2: Photo-sheets for age band 2 ? 3 months, page 2 ................. 150 C1: Photo-sheets for age band 3 ? 4 months, page 1 ................. 151 C2: Photo-sheets for age band 3 ? 4 months, page 2 ................. 152 D1: Photo-sheets for age band 4 ? 5 months, page 1 ................. 153 D2: Photo-sheets for age band 4 ? 5 months, page 2 ................. 154 E1: Photo-sheets for age band 5 ? 6 months, page 1 ................. 155 E2: Photo-sheets for age band 5 ? 6 months, page 2 ................. 156 F1: Photo-sheets for age band over 6 months, page 1 ............... 157 F2: Photo-sheets for age band over 6 months, page 2 ............... 158 G: Information page and consent form: Nursing sisters ............ 159 H: Information page and consent form: Usual care group ......... 162 I: Information page and consent form: Intervention group ...... 165 J: Plagiarism declaration and Ethical clearance certificate ......... 168 K: Biographical Questionnaire for all parents ........................... 170 L: Training manual for Nursing sisters (2 ? 3 months) .............. 172 M: Copyright agreement for Baby?s Day Diary? ........................ 177 N: Baby?s Day Diary? Day 1 (of 3): Intervention group ........... 178 O: Baby?s Day Diary? Day 1 (of 3): Usual care group .............. 179 P: Training instructions for the Baby?s Day Diary? ................... 180 Q: Data graphs of standard scores and quotients for PDMS-2 results, per infant .............................................. 182 xi DEFINITIONS OF TERMS: ? Activities of Daily Living ? ?are tasks of self-maintenance, mobility, communication, home management and community living that enable an individual to achieve personal independence.?1 p 463 For the purpose of this study, the activities of daily living pertaining to mothering include, but are not restricted to, baby care, home management and those work, leisure, social and personal management tasks which may have been applicable prior to the infant?s birth. ? Occupationally-embedded exercise ? are exercises that are inserted/incorporated in everyday tasks that are occupationally appropriate for the individual and provide meaning and motivation other than the achievement of exercise,2 such that the ?exercise occurs as a byproduct of pursuing task-specific goals.?3 p 27 ? Sleep position - The position in which parents place their infants to sleep during the day and night.4 This may include prone, supine or side-lying positions, or a combination thereof.5 ? Sudden Infant Death Syndrome ? ?The sudden death of an infant under one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene and review of the clinical history.?6 p 681 ? Programme development - ?Creating and evaluating an approach to service delivery for a defined client group.?7 p 491 ? Mechanism of change - ?Theoretically and empirically accounting for how a particular change occurs as a consequence of participating in an intervention.? 7 p 493 xii ? Tummy time ? is a conversational term, used to explain to parents the prone positioning of an infant when they are awake, but supervised, to encourage development of muscles of the head and neck and shoulders.8, 9 xiii ABBREVIATIONS: AAP: American Academy of Pediatrics ADL: Activities of Daily Living AIMS: Alberta Infant Motor Scale AP: Activity Profiles BTS: ?Back to Sleep? FMQ: Fine Motor Quotient GMQ: Gross Motor Quotient IPCP: Infant Postural Control Programme PDMS-2: Peabody Developmental Motor Scales ? 2nd Editions SIDS: Sudden Infant Death Syndrome TMQ: Total Motor Quotient