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Early intervention strategies Lea Hyvärinen, MD, PhD, FAAP Professor h.c, Rehabilitation Sciences, University of Dortmund, Germany Senior Lecturer, Developmental Neuropsychology, University of Helsinki, Finland www.lea-test.fi Pisa 2012, the 4th International Cerebral Palsy Conference. 1
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Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

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Page 1: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Early intervention strategies

Lea Hyvärinen, MD, PhD, FAAP

Professor h.c, Rehabilitation Sciences, University of Dortmund, Germany

Senior Lecturer, Developmental Neuropsychology, University of Helsinki, Finland

www.lea-test.fi

Pisa 2012, the 4th International Cerebral Palsy Conference.

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Page 2: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Usual findings

• Convergens, weak or lost

• Difficulties in eye contact and

• Early inteaction

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Page 3: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Birth trauma, 3rd nerve palsy> ptosis

Deformation of head

after suction cup

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Exotropia – Miosis lesions in 3rd nerve and Ehdinger-Westphal nucleus

Ptosis resolved after 2 weeks.

Loss of convergence, accommodation

and sluggish pupil reactions.

After strabismus operation the child looks

normal but is severely visually impaired.

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Page 5: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Symptoms of impaired vision at the age of 8 months

• outward squint operated, convergence still poor

• brought objects close to the eyes =

geometric magnification

• looked at the hair line, not at the eyes =

central scotoma

• explored carefully with hands and mouth

• recognised people at 18 months of age (voice?)

• moved freely and seemed to know where he is

Dg: Spasticity in all four limbs, especially hands, severely

impaired vision, forms and colours.

Vision was assessed with Teller Cards only > ”Normal”.

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Page 6: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Eye contact

and copying facial expressions

Possible at birth

Should be present at 6 weeks of age

Latest at 8th weeks of age

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Page 7: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Communication – at 8 weeks

Communication with both parents

Using both vision and vocalizing,

taking turns is important already at

this age.

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Page 8: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

12 weeks

Visual communication >> bonding

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Page 9: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Accommodation can be weak in otherwise normal looking infants

• 4 month old infant

• Dg: Infantile autism?

• ”Avoids eye contact”

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Page 10: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Strabismus >>Penalisation+bifocal near correction for the right eye = distance penalisation

Late development of accommodation may lead to esotropia

at the time when the infant starts to accommodate. Spectacle

corrections often supports development of binocularity.

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Page 11: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Penalisation+bifocal Amblyopia did not develop, binocular vision

During the first year In school age

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Page 12: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Infants at risk

Whenever there is a deviation from normal interaction /

communication

infant’s visual and auditory functions

need to be carefully assessed.

Eye contact, Eye movements, strabismus

Infants with motor problems, Syndromes

Health care nurses, therapists, paediatricians, ophthalmologists

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Clinical examination gives the foundation for the assessment of visual functioning

Photo: Miguel G. Alvares, MD Brazil Hiding Heidi test

Detection of gratings

Fixation to penlight, to picture, following, saccades,

accommodation, convergence, visual communication,

refraction, spectacles

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Page 14: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Fixation sticks

Fanz’ picture of smiling face (5 cm diameter) is fixated and follwed at 3 moths of age.

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Page 15: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Teller Acuity Cards

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Page 16: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

LEA GRATINGS symmetric presentation

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Page 17: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Contrast sensitivity Hiding Heidi test

If the infant responds with a social smile,

he must have seen the picture of smiling face,

at low contrast and moving – like the facial

expressions on the face.

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Page 18: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Figure-in-motion, Pepi-test possible often at the age of 4 months

Can be copied @

www.lea-test.fi

Near correction

Head support

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Page 19: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

PVL Delayed motor functions

Combined effect of visual and motor disorder delays the

development of an infant in all functional areas.

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Page 20: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Constricted visual field

Illuminated ball used by child’s own therapist.

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Page 21: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Fixation

Brief fixation on the middle

size picture of face

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Page 22: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Accommodation with dynamic retinoscopy difficult to measure when the infant does not look at

Mother’s face and voice

used as the target during

dynamic retinoscopy.

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Eye contact when reading lenses give a clear image on the retina

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Page 24: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Reaction during assessment of her brother noises and body language to shows disapproval

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Page 25: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Vision in motor training ten weeks later: improved visual and motor functions

RE: GrA less than in LE > training

as a part of physiotherapy

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Page 26: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Impaired vision affects

development of following areas of functioning:

- communication

- interaction

- motor development

- spatial concepts

- orientation in space

- object permanence

- language

Delay in any developmental area needs to be investigated.

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Page 27: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Support for poor visual information

Early interaction uses

smell, body contact, voice, Tadoma

facial expressions, eye contact

Vision for communication

Baby Tadoma technique

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Page 28: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Vision loss affects

development of following areas of functioning:

- communication

- interaction

- motor development

- spatial concepts

- orientation in space

- object permanence

- language

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Page 29: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Fragile baby

Gentle activation of a baby with hydrocephalus.

Notice the joy during the play therapy.

Comfortable support of posture on the knees of

the play therapist (not in a baby sitter).

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Page 30: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Low tonus and poor head control

Strong visual stimulus, LEA doll and illuminated

picture of face activate control of motor functions.

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Page 31: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Head control

Holding the infant

• on the shoulder

• across the thigh

• on small wedge

• Vertical lightbox

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Page 32: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Playmat and resonance board orientation in space, listening skills

Light coloured surfaces rough, dark surfaces

smooth> vision and touch coinside.

Plywood board on 2 inch frame functions

as a drum and makes the infant aware of

his movements. Echos from the washing

basin and the waste basket train listening.

Orientation in space supported.

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Page 33: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

”Little room” made of a brown paper box

Vision, touch, echos,

measuring space with his own body.

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Page 34: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

I moved! I moved again, the same thing happened!

Start stimulation without delay, coordination of vision and movement.

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Page 35: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Siblings and grandparents training

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Page 36: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Early Intervention requires

Early detection of the disorder

Early treatment of treatable conditions

Assessment of Functioning

Early intervention starts as soon as a visual impairment is detected

as an integral part of examinations and treatment,

at 0-3 years of age or later, if the damage occurs later.

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Page 37: Early intervention strategies - Lea test · 2012-10-08 · Early intervention strategies. Lea Hyvärinen, MD, PhD, ... Delay in any developmental area needs to be investigated. 26

Early intervention strategies

Lea Hyvärinen, MD, PhD, FAAP

Slides will be @ www.lea-test.fi

Pisa 2012, the 4th International Cerebral Palsy Conference.

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