7/10/2013
Webinar Series: Qualitative
Determination of Delay
Gross and Fine Motor Domains
July 11, 2013
Agenda
For Gross and for Fine motor
 When to move on to a qualitative determination
 A look at the HELP Strands as compared to the BDI-2
 Completing the Eligibility Statement
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Learning Objective
Understand how and when to use
the identified HELP strands in the
Gross and Fine Motor domains in
order to determine eligibility based
on a Qualitative Determination of
Delay
Other Resources
•Help with the HELP
•Making It Work: Eligibility Determination
Parts 1 and 2
•Young Infant Series
•Qualitative Determination of Delay:
Overview and Background
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TAC §108.903 (c)
Evaluation must be conducted using a
standardized tool designated by DARS
ECI and each developmental area must
be evaluated as defined in 34 CFR
§303.321. When the interdisciplinary
team determines there is evidence that
the results of the standardized tool do
not accurately reflect the child's
development, the interdisciplinary team
must document evidence from a
supplemental protocol designated by
DARS ECI. The contractor must ensure
that evaluations are conducted by
qualified personnel.
TAC §108.903(d)
Evaluation must be
based on informed
clinical opinion and
include input from the
parent or other
significant people in the
child's life.
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Appropriate Teams
Expertise and Experience regarding concerns at
referral




Concerns expressed by referral source
Information in medical records
Good knowledge base re: therapist clinical opinion
Experience re: infant neuromuscular development
This usually is a therapist (PT/OT) but other
individuals may have the needed skills and knowledge
Inside HELP
• Always refer to Inside HELP when
administering the HELP Strands
• Information on:
– Talking to families
– Administration
– Procedures
– Definition of skills
– Scoring criteria
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Designated Help Strands
Gross Motor
Sub strand 3-1 Prone
Sub strand 3-2 Supine
Sub strand 3-4 Weight Bearing in Standing
The HELP Strands
What are we looking for on the HELP Strands that
may not be seen on the BDI-2 in the gross motor
domain





Muscle tone
Quality of movement responses
State organization
Postural control
Symmetry of limb use
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Factors to be aware of that can alert
you to move to QDD
 Gen Appearance (Chubby, stocky,
small, thin, frail – discrepancy in
size/proportion or shape in arms,
legs, head.
 Symmetry- does child use both sides
of the body equally, do left and right
side body parts look and move the
same, does child look symmetrical at
rest?
 Endurance – does child fatigue
quickly, respiration irregularities
during movement
Factors that can alert you to move to
QDD
Strength – does baby have brisk strong
kicking movements or slow and weak. Is
the grasp weak or strong when pulling to
sit.
Activity Level -Active/sedentary/lethargic
Precautions – Be aware of physiological
distress – change in skin color,
temperature, clamminess, shortness of
breath, rapid or arhythmical breathing.
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Move to QDD?
 Poor head control
 Flat spots on head
 Low energy
 Hands fail to open routinely
 Delayed visual exploration
 Mobility with substitute patterns
 Immature development of
righting reactions and/or
protective reflexes
 Delayed ability to cross midline
Move to QDD?
 What cant the baby do
that he/she should be
doing?
 How is this affecting
function
 Hypotonia
 Hypertonia
 Range of motion issues
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Case Study #1: QDD Gross Motor
Referral Concern: Developmental Delay
Age:13 months
BDI-2 Scores, HELP score, documenting Clinical Judgment and
writing the Eligibility Statement.
Case Study #1: QDD Gross Motor
• BDI-2 items scored
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Case Study #1: QDD Gross Motor
Subdomain Graph
Case Study #1: QDD Gross Motor
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Case Study #1: QDD Gross Motor
Case Study #1: QDD Gross Motor
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Case Study #1: QDD Gross Motor
Principals Of Motor Development
•
•
•
•
•
Cephalo-Caudal
Proximo-Distal
Mass to fine
Sequential and predictable
Earlier skills lay the foundation for
development of the next higher skills
• Motor development proceeds at various
rates within the same individual and
between different children
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Gross Motor Development - Prone
BDI-2
GM 3:
Lifts head and holds it up for 5
seconds when lying in prone.
GM 4:
Child lifts and turns head from
side to side while lying in prone
position.
HELP
3.05 Holds head to one side in prone
3.03 Lifts head in prone
3.04 Holds head up 45 degrees in
prone
3.09 Extends both legs
3.16 Rotates And extends head
3.15 Holds chest up in prone weight
on forearms
3.07 Holds head up 90 Degrees in
prone
3.26 Bears weight on hands in
prone
3.43 Bears weight on one hand in
prone
Scoring Options: Refer to “HELP with the
HELP” slides 16 to 39
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Gross Motor - Supine
Assessment in the supine position on the
BDI-2
• GM 7: Holds head parallel to body
when pulled from supine to seated
position.
Gross Motor Sub Strand 3-2 HELP
Supine
3.02 Turns head to both sides in supine
3.09 Extends both legs
3.11 Kicks reciprocally
3.14 Assumes withdrawal position
4.07 Brings hands to midline in supine
4.23 Looks with head in Midline
1.29 Brings feet to mouth
3.35 Raises hips pushing with feet in supine
3.42 Lifts head in supine
5.27 Struggles against supine position
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Scoring Options: Refer to “HELP with the HELP” slides 16 to 39
Weight Bearing in Standing
BDI-2
GM-14 Makes stepping movements when
held in upright position
GM-16 Pulls to stand while holding onto a
solid object without adult assistance
GM-18 Walks 3 or more steps with
assistance
GM-19 Stands in upright position without
support for 30 or more seconds
GM-21 Walks without support for 10 feet
without falling
GM-22 Moves from sitting to standing
without support
GM-23 Moves from supine to standing with
smooth coordinated movements without
support or assistance
HELP
3.23 Bears some
weight on legs
3.36 Bears almost all
weight on legs
3.45 Bears large
fraction of weight on
legs
3.46 Stand, holding on
3.60 Stands
momentarily
3.68 Stands a few
seconds
3.71 Stands alone well
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Scoring Options: Refer to “HELP with the
HELP” slides 16 to 39
Scoring Options
Refer to “HELP with the HELP” slides 16 to 39
•
•
•
•
+ = skill or behavior is present
+/- = skill appears to be emerging
- = skill is not present
A = skill or behavior is atypical or
dysfunctional
• N/A = item not applicable or
appropriate
• O = circle any score when environment
compromise child’s response
• A+ = hyper responsive / A- = hypo
responsive
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Eligibility Statement
Determine age equivalent (AE) for each
strand
Average the strand AEs and apply
clinical expertise to determine domain
AE
Calculate months of delay and % of
delay
Transfer % to page 1
Qualitative Determination of
Delay
Fine Motor
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Understanding Fine motor
Development
The ability to hold a spoon, turn a doorknob,
write the alphabet, count on fingertips, put a
puzzle together, type on a keyboard are all
fine motor skills. Fine motor skills involve the
small muscles of the hand creating precise
hand movements in coordination with vision.
Fine Motor Development
Hands: Unique
Core/Shoulder/Elbow
Forearm/ Wrist
Pronation/Supination
Ulnar/Radial Development and
Differentiation
Finger Thumb Opposition
Tripod/Pincer Grasp
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An Interesting fact about the hand
.
Designated Help Strands
Fine Motor

Sub strand 4-2 Grasp and Prehension

Sub strand 4-3 Reach/Approach

Sub strand 4-5 Bilateral and Midline Skills
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Case Study Qualitative
Determination of Delay Fine Motor
North Texas Rehabilitation Center
ECI Program
When to be Alerted to move to QDD
Criteria used to note atypical responses in all fine
motor strands:
•Increased muscle tone
•Low muscle tone
•Hands fisted when reaching for objects after 7
months
•Poor release of objects or clumsy control
•Exaggerated finger opening or splaying during
release – over 15 months
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Fine Motor – BDI-2 (0-3 years)
Grasp/Prehension; Reach/Approach; Bilateral and Midline Skills
FM-1 Holds hands in open loose fisted position when not grasping
an object
FM-2 Holds hands together in midline
FM-4 Holds object for 1 minute
FM-5 Holds hands in open position when not grasping an object
FM-6 Retrieves a small object by raking with fingers and pulling it
into the palm
FM-7 Transfers object from one hand to the other
FM-8 Partial finger Prehension
FM-9 Drops an object intentionally with demonstration
FM-10 Picks up raisin with neat pincer
FM-11 Extends toy and releases it from grasp
FM-12 Intentionally throws an object
FM-13 Removes forms from a form board
HELP Sub Strand FM 4-2 Grasp /Prehension
4.12
4.22
4.28
4.30
4.40
4.44
4.43
4.45
4.51
4.52
4.55
4.63
4.78
4.89
Indwelling thumb no longer present
Uses ulnar palmar grasp
Uses palmar grasp
Uses radial palmar grasp
Attempts to secure tiny objects
Rakes tiny object
Uses radial digital grasp
Uses inferior pincher grasp
Pokes with index finger
Uses neat pincer grasp
Grasps crayon adaptively
Points with index finger
Holds crayon with thumb and finger
Adult like grasp
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Grasp and Prehension
4.22
4.12
4.28
4.40
Looks at and tries to
pick up tiny object
unsuccessfully –
unless it sticks to
hand
4.30
4.44
Grasp and Prehension
Pokes with
index finger
4.45
4.43
4.52
4.51
4.55
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Fine Motor Sub Strand FM 4-2 Grasp/
Prehension
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Fine Motor Sub Strand 4-3 Reach/Approach
4.08
1.11
4.16
4.27
4.29
4.34
4.42
4.49
4.57
Activates arm on sight of toy
Inspects own hands
Reaches toward toy without grasping
Reaches for toy followed by momentary grasp
Reaches and grasps object
Recovers object
Reaches and grasps object with extended elbow
Extends wrist
Supinates fore arm
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Fine Motor Sub Strand 4-3 Reach/Approach
Fine Motor Sub Strand 4-5 Bilateral and
Midline Skills
4.02
4.06
4.21
4.23
4.26
6.16
4.34
4.37
4.38
4.46
1.61
4.54
4.68
Moves arms symmetrically
Brings hands to midline in supine
Clasps hands
Looks with head in midline
Reaches for object bilaterally
Places both hands on bottle
Retains small objects in both hands
Reaches for object unilaterally
Transfers object
Bangs two cubes held in hands
Unwraps a toy
Uses both hands freely; may show preference for one
Uses both hands in midline-one holds other manipulates.
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Bilateral and Midline
Fine Motor Sub Strands 4-5 Bilateral and Midline
Skills
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Eligibility Statement
Determine age equivalent (AE) for each
strand
Average the three strand AEs and apply
clinical expertise to determine domain AE
Calculate months of delay and % of delay
Transfer % to page 1
Scoring : Refer to HELP with the HELP
slides 16 to 39)
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In Conclusion
Questions
[email protected]
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