PERSPECTIVE

published: 24 January 2022

doi: 10.3389/fped.2021.787196

Starting at Birth: An Integrative,

State-of-the-Science Framework for
Optimizing Infant Neuromotor Health
Colleen Peyton 1,2,3*† , Theresa Sukal Moulton 1,2,3† , Allison J. Carroll 2,4† , Erica Anderson 2 ,
Alexandra Brozek 2,5 , Matthew M. Davis 2,3,5,6 , Jessica Horowitz 2,5 , Arun Jayaraman 7 ,
Megan O’Brien 7 , Cheryl Patrick 8 , Nicole Pouppirt 2,3 , Juan Villamar 2,5 , Shuai Xu 9 ,
Richard L. Lieber 7,10,11‡ , Lauren S. Wakschlag 2,4,5‡ and Sheila Krogh-Jespersen 2,5‡
1
Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine,
Chicago, IL, United States, 2 Institute for Innovations in Developmental Sciences, Northwestern University, Chicago, IL,
United States, 3 Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States,
Edited by:
4
Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL,
Dora Il’yasova,
United States, 5 Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL,
Duke University, United States
United States, 6 Ann and Robert H. Lurie Children’s Hospital, Stanley Manne Children’s Research Institute, Chicago, IL,
Reviewed by: United States, 7 Shirley Ryan AbilityLab, Chicago, IL, United States, 8 Division of Rehabilitative Services, Ann & Robert H.
Sam Pierce, Lurie Children’s Hospital of Chicago, Chicago, IL, United States, 9 Department of Dermatology, Northwestern University
Children’s Hospital of Philadelphia, Feinberg School of Medicine, Chicago, IL, United States, 10 Department of Physiology, Northwestern University Feinberg
United States School of Medicine, Chicago, IL, United States, 11 Department of Physical Medicine and Rehabilitation, Northwestern
Chantal Lau, University Feinberg School of Medicine, Chicago, IL, United States
Baylor College of Medicine,
United States

*Correspondence:
Numerous conditions and circumstances place infants at risk for poor neuromotor health,
Colleen Peyton yet many are unable to receive treatment until a definitive diagnosis is made, sometimes
Colleen.peyton1@[Link]
several years later. In this integrative perspective, we describe an extensive team science
† These authors share first authorship effort to develop a transdiagnostic approach to neuromotor health interventions designed
‡ These authors share
to leverage the heightened neuroplasticity of the first year of life. We undertook the
senior authorship
following processes: (1) conducted a review of the literature to extract common principles
Specialty section: and strategies underlying effective neuromotor health interventions; (2) hosted a series
This article was submitted to
of expert scientific exchange panels to discuss common principles, as well as practical
Children and Health,
a section of the journal considerations and/or lessons learned from application in the field; and (3) gathered
Frontiers in Pediatrics feedback and input from diverse stakeholders including infant caregivers and healthcare
Received: 30 September 2021 providers. The resultant framework was a pragmatic, evidence-based, transdiagnostic
Accepted: 17 December 2021
Published: 24 January 2022
approach to optimize neuromotor health for high-risk infants based on four principles:
Citation:
(a) active learning, (b) environmental enrichment, (c) caregiver engagement, and (d)
Peyton C, Sukal Moulton T, Carroll AJ, strength-based approaches. In this perspective paper, we delineate these principles and
Anderson E, Brozek A, Davis MM, their potential applications. Innovations include: engagement of multiple caregivers as
Horowitz J, Jayaraman A, O’Brien M,
Patrick C, Pouppirt N, Villamar J, critical drivers of the intervention; promoting neuromotor health in the vulnerability phase,
Xu S, Lieber RL, Wakschlag LS and rather than waiting to treat neuromotor disease; integrating best practices from adjacent
Krogh-Jespersen S (2022) Starting at
Birth: An Integrative,
fields; and employing a strengths-based approach. This framework holds promise for
State-of-the-Science Framework for implementation as it is scalable, pragmatic, and holistically addresses both the needs of
Optimizing Infant Neuromotor Health. the infant and their family.
Front. Pediatr. 9:787196.
doi: 10.3389/fped.2021.787196 Keywords: neuromotor health, infants, physical therapy, transdiagnostic, early intervention

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Peyton et al. CARES Framework for Neuromotor Health

INTRODUCTION in infants at increased risk of poor neuromotor health.

To extract these principles and strategies, we used the
Neuromotor health is a critical substrate of infants’ development sequenced approach of conducting a literature review, convening
and learning. Early development is a period of great change, expert panels, and encouraging stakeholder engagement. (For
vulnerability, and opportunity, making early identification and detailed methods on how this process was conducted, see
amelioration of neuromotor risk of the utmost importance. Supplementary Material A).
More than 17% of children will have a diagnosed developmental
disability (1, 2), many of whom will also have motor challenges. Literature Review
Myriad environmental, genetic, and medical circumstances Our literature review initially focused on studies examining
influence infants’ motor development across multiple domains. developmental populations with neuromotor conditions (e.g.,
Given the interdependent nature of these developing abilities, cerebral palsy, born preterm, born full-term with brain injury)
a multi-modal, holistic approach is needed beginning before from traditional fields of rehabilitation science and motor
formal diagnosis. learning. Due to the aforementioned gaps in this literature, we
Early intervention is effective at preventing or mitigating then felt it was critical to include evidence from adjacent fields
pediatric neuromotor conditions (3). However, many established of developmental psychology, clinical psychology, infant mental
rehabilitation interventions are limited in that: (1) early health, and prevention-implementation science. This review
transdiagnostic (i.e., those that target multiple conditions, identified common strategies, constraints and future directions.
multiple risk mechanisms or vulnerability to risk) approaches
lack consensus guidelines (4–6) and (2) they are not tailored Expert Panels
to the infant’s and/or family’s ecology (i.e., unique contexts, We invited distinguished researchers and clinicians to discuss
values, and needs), contributing to disparities in service access, “lessons learned” from their early intervention studies and
engagement, and neuromotor outcomes. These limitations have experiences with our group. We convened 12 scientific exchange
impeded many interventions from actualizing their promise to panels, organized thematically (Supplementary Material B). The
improve neuromotor outcomes for all infants. panels comprised 25 individuals from 18 institutions in four
Recent strides have been made in early intervention evidence countries. Panelists included researchers, physical therapists,
for infants with motor challenges, including the importance physicians, psychologists, and nurses with research and clinical
of education and support of caregivers (7, 8), understanding expertise in the domains of neuromotor development, parenting
family ecology when setting therapeutic goals (9), infant- and family-based interventions, implementation science, infant
initiated movements (9–12), and supporting the transition mental health, and neonatal care. The cross-fertilization
from hospital to home (9, 13). Building on this foundation, from these panels provided invaluable insights including
our goal was to reach further into adjacent disciplines of pragmatic, real-world considerations that were fundamental
developmental psychology, infant mental health and prevention, to formulation of CARES common principles and strategies.
and implementation science (14–17) to create a neuromotor Importantly, intervention scientists provided insight regarding
intervention framework that incorporates considerations of pragmatic approaches and scalability for transdiagnostic
holistic development, family engagement, implementation, interventions (19, 20).
and scalability.
This perspective paper synthesizes diverse literatures, expert Stakeholder Engagement
panels, and stakeholder feedback as the foundation for a Caregivers
novel framework: the Caregiver engagement, Active leaRning, We recruited caregivers with diverse caregiving roles and
Environmental enrichment, and Strengths-based framework socioeconomic backgrounds to participate in a panel through
(CARES). CARES promotes optimized infant neuromotor health, Northwestern University’s Center for Community Health.
relational health, and family wellbeing during the first year of life. Panelists were caregivers of young children with neuromotor risk
In keeping with the Healthier, Earlier vision we have previously or diagnosis who shared their perspectives about neuromotor
articulated (18), the CARES framework promotes beginning development and intervention services to inform approaches
intervention at the earliest stage of the risk sequence before to physical therapy with infants at-risk. Caregivers highlighted
conditions are typically diagnosed, promoting neuromotor the following themes as critical for consideration: (1)
health via early detection or attenuation of neuromotor delays. Desire for more information and early education about
neuromotor development; (2) Value of strengths-based positive,
METHODS knowledgeable, and effective therapists; and (3) Hope and
optimism for future developments in research and interventions
Process to Identify and Refine Common to promote neuromotor health.
Intervention Principles
Our goal was to synthesize commonalities in: (1) principles, Healthcare Providers
defined as broadly applicable theoretical concepts that form Neonatologists and nursing staff provided perspectives on
the foundation of interventions and (2) discrete clinical medical and therapeutic care of high-risk infants. Infant mental
strategies (i.e., actions, skills, or methods utilized by the health specialists discussed early caregiver-infant relationships
therapist and caregivers) that underlie successful intervention and caregiver well-being as factors in infant developmental

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Peyton et al. CARES Framework for Neuromotor Health

outcomes and caregiver adherence to intervention efforts. exploration (e.g., caregivers, siblings), and (3) environmental
Finally, physical therapists identified potential barriers and exploration (e.g., sand, grass, slippery surface). The specific
facilitators of integrating new principles into practice. type of exploration can be used as a strategy to incorporate
treatment into daily routines, centered around caregiver goals
and priorities.
RESULTS
Intervention Principles Underlying CARES: Cares Principle 2: Environmental
An Integrative Framework for Optimizing Enrichment (Therapeutic Context)
Infant Neuromotor Health Environmental enrichment is defined in the CARES framework
As shown in Figure 1, the CARES principles are connected as the creation of a space or activity within the infant’s natural
through a lens of therapeutic action (active learning; mechanism environment, which is designed to pair the level of difficulty of a
that drives change), therapeutic context (environmental task with the infant’s ability to complete the task. Socio-cultural
enrichment; environment in which therapy is delivered), influences, and variations in the physical environment influence
therapeutic delivery (caregiver engagement; the way in which and shape motor responses and learning in human infants
the therapeutic dose is provided), and therapeutic frame (36). Targeted environmental enrichment strategies can improve
(strengths-based; the construct that informs treatment). motor outcomes in infants with neuromotor risk (37). Everything
Each of the principles and their respective strategies are around an infant that they may see, hear, or interact with defines
defined and discussed in detail in the following sections and their environment. As such, caregivers and therapists alike may
outlined in Table 1. not be aware that their presence impacts the environment of the
infant as well as their actions, and the design of intervention.
Cares Principle 1: Active Learning The key strategy of environmental enrichment is targeted
selection of objects or toys, settings, body positions, and caregiver
(Therapeutic Action) interactions that facilitate achieving the infant’s and/or family’s
Active learning is defined as infant-directed actions, occurring
goals. The selection of objects and settings can enhance active
when an infant moves to explore their environment, including
learning if they are easily accessible within the infant’s everyday
the people and objects around them. Infant motor development
routine, generating numerous opportunities to explore. In
results from maturing physiologic systems that are shaped
contrast, other models of therapy that include specific therapeutic
by task-specific experiences and environmental demands (21).
equipment available only in a specialized therapeutic care setting
Learning and neuroplasticity are maximized when an activity is
may narrow the opportunity for repetition.
salient (22), the movement is initiated by the infant (23–25), and
The specific choice of everyday objects can be used to meet
the task is repeated with variable strategies and errors (21). This
family goals. For instance, if caregivers would like the infant
current view contrasts directly with established approaches in
to be able to reach with both hands, the environment can be
physical therapy intervention in which therapist-handling of the
enriched by considering the properties of the toys in the infant’s
infant aims to inhibit movement patterns deemed “abnormal”
world; a toy that is larger or more fluid is more likely to be
and/or to facilitate movement patterns defined as “normal,”
played with using both hands (38). Objects or supports in the
creating a passive partnership in which the infant is the recipient
environment can also help an infant gain access to a skill that
of a therapist-led handling treatment (26). Passive activities may
would otherwise be too difficult. For instance, the use of a
engage aspects of the sensory system (27), but are less likely
reclined seat may provide an infant with the opportunity to
to create new motor connections in the infant’s brain. Passive
reach for and manipulate an object by reducing the postural
activities are also less likely to result in the cognitive and social
demands on an infant who is not yet able to independently
growth associated with infant-driven learning (28–30).
support themselves in an upright position (39). Another strategy
The adoption of current neuroscience-oriented motor
that can be used to enrich an infant’s environment is to provide
learning theory in physical therapy has led to newer approaches
a “just-right challenge” (40), tailoring the level of difficulty of a
that promote infant active exploration. This active learning is
task to the infant’s ability level to create a targeted context for
critical in early development for establishing motor, cognitive,
an infant to explore and learn. When an infant engages in a
and social competences (29–32).
just-right challenge, they are often active and playful, resulting
To maximize an infant’s active learning, the infant must be
in higher amounts of problem-solving, repetition, and practice.
given time to act. If this is not successful or the infant does not
By enriching the infant’s natural environment, new opportunities
make any attempts, a therapist may model the behavior for them
for learning and problem-solving are afforded to the infant in a
to see before offering help to complete a task (i.e., “Wait-Model-
therapeutic context and the broader family ecology.
Support-Stop scaffolding”). Modeling actions relies on cognitive
mechanisms, such as imitation (33) that support the process of
active learning. Finally, learning is limited in stressful situations Cares Principle 3: Caregiver Engagement
(34, 35), so if an infant becomes upset the activities should be (Therapeutic Delivery)
stopped or modified. Caregiver engagement is defined as a collaborative coaching
Active learning can be observed in three types of exploration: model in which therapists and caregivers are equal partners, and
(1) object exploration (e.g., toys, food, utensils), (2) social families are fully engaged as decision-makers and participants

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Peyton et al. CARES Framework for Neuromotor Health

FIGURE 1 | CARES Framework. Active learning is the therapeutic action or mechanism (dark purple), environmental enrichment is the therapeutic context, creating
opportunities for action to occur (light purple), caregiver engagement is therapeutic delivery of intervention (green), and strength-based approach is the therapeutic
frame (red) influencing each level.

in the infant’s intervention. Whereas many therapy models (41) instead of on them (48, 49). Motivational interviewing involves
view the therapist as the “expert” and caregivers as “recipients” non-judgmental collaboration, techniques to elicit caregivers’
of the intervention, this caregiver-led approach builds on ideas and solutions, and respect of caregivers’ autonomy for
families’ capacity to successfully and confidently implement the decision-making (48, 49). Many studies show that motivational
intervention and enhance their infants’ development. Caregiver interviewing increases treatment engagement and retention,
engagement is a collaborative process whereby the family and which in turn leads to better health outcomes (50–52). Therapists
therapist work together to set goals for therapeutic activities use this skill to identify potential challenges to engagement by
based on the caregivers’ priorities for their infant and family (42), approaching caregivers with the assumption that intervention
the unique resources available to and challenges faced by the will be most effective when it is tailored to the demands and
family, and the therapist’s experience and knowledge. Capacity- environments of each family, and when priorities identified
building also means welcoming the infant’s entire “circle of by caregivers receive central focus. As such, caregivers feel
care” into the intervention—that is, engaging as many caregivers understood and build greater rapport with the therapist. The
as the family deems appropriate. This reduces burden on the therapeutic delivery is one of empathy and reflection, exploring
primary caregiver [often the mother (43–45)] by distributing what works and what does not, and supporting caregivers’
responsibilities and, importantly, increasing dosage. Caregiver autonomy and self-determination. Fundamentally, this approach
engagement includes the following strategies: caregiver coaching, helps caregivers identify their own capacity to engage in the
motivational interviewing, and attentiveness to relational health. intervention activities with their infant.
Caregiver coaching centers the caregiver as the interventionist Relational health refers to the quality of the infant’s earliest
and promotes capacity-building by encompassing collaborative relationships and is foundational for optimal growth and
goal-setting with and coaching of the caregiver to implement development (53–56). The relational health emphasis in
the intervention. Caregiver-led and caregiver-implemented early intervention recognizes that (a) infants thrive most
approaches are effective in early intervention studies, and within secure, responsive relationships and (b) caregivers
collaborative coaching between caregivers and therapists are best equipped to be agents of the intervention in the
increases caregivers’ confidence and competence in intervention context of responsive, collaborative relationships with
planning and implementation (46, 47). the therapist. Relationship focused intervention increases
Motivational interviewing is a widely validated therapeutic caregiver engagement and satisfaction, decreases therapist
skill used to elicit caregivers’ unique motivations, treating them burnout, improves caregiver-infant interactions, and
as the experts of their own experience, and working with them ultimately improves developmental outcome (14). The shift

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Peyton et al. CARES Framework for Neuromotor Health

TABLE 1 | Heuristic comparison of CARES framework compared to commonly established therapies.

Principle Therapeutic feature Established therapy CARES framework (definition) Strategies

Active learning Therapeutic action Therapist-led Movement is infant-directed and focuses • Wait-Model-Support-Stop Scaffolding
movement treatment on exploration of their surroundings • Social, environmental, object exploration
Environment Therapeutic context Therapy clinic or use of Settings and/or activities are relevant to • Just-right challenge
enrichment equipment and/or toys everyday life • Build active learning opportunities into
not accessible for Balance task difficulty with achievability baby’s environment
families. through supports, object manipulation, • Selection of objects, settings, and
and/or social scaffolding for the infant caregiver interactions within the infant’s
family context
Caregiver engagement Therapeutic delivery Therapist as expert and Caregivers take an active, leading role in • Caregiver coaching (collaborative goal
caregiver as recipient the intervention for their infant setting, problem-solving, circle of care)
Focus is child-centered Focus on relational health between • Motivational interviewing
Therapist trains mostly caregivers and infant • Attentiveness to relational health
one or Multiple caregivers involved in
“primary” caregiver intervention delivery
Strengths-based Therapeutic frame Problem-focused Opportunity-focused • Reframing and positive self-talk
framing Medical, deficit model A balanced approach to bring about • Labeled praise and celebration of
change by framing goals and mechanisms developmental goals and activities
using positive attributes and strengths of
the infant, caregiver, and family

from child-centric to relationship-focused intervention labeled praise to encourage an infant’s behavior or skill and/or
requires therapist competence in not only neuromotor empower caregiver confidence. Labeled praise provides a clear
therapy, but also in intervention practices that support connection to a behavior or action of the infant to the desired
the caregiver-infant relationship, as the foundation of outcome (63). This technique can also be used to increase
developmental growth. Key therapeutic actions include: caregiver confidence and engagement by recognizing their efforts
promoting caregiver feelings of confidence and competence, and affirming their capacity in caring for their infant (64).
fostering collaborative caregiver-therapist relationships via Positive reframing broadens caregivers’ perspective of
empathic listening and reflection, and having the capability themselves, their circumstances, or their infant, allowing family
to sensitively manage emotionally fraught interactions or members to see beyond the challenges or perceived deficits (65).
engagement challenges in a manner that promotes trust Reframing interventions using a strengths-based approach places
and engagement. the focus on opportunities for growth, rather than problems to be
Taken together, caregiver engagement strategies holistically fixed (60). A traditional problem-based approach can contribute
promote family active participation in the intervention, to a power imbalance between the family and therapist when
accounting for each family’s unique ecological context, and the therapist imposes their own ideas to solve problems instead
supporting delivery of the intervention to the infant. of enabling families to develop their knowledge and skills as an
opportunity for learning in an ecologically relevant way (62).
Employing a strength-based approach as the therapeutic
Cares Principle 4: Strengths-Based frame of the intervention also invites caregivers to think more
Approach (Therapeutic Frame) optimistically about their infant’s potential and imbues a sense
A strengths-based approach emphasizes the positive attributes, of strength and competency in their care of their infant and in
capacities, and resources of the infant and their family. celebrating infant gains.
This approach contrasts with a typical medical model that
is pathology-driven, focused on correcting deficits (57–
59). Importantly, a strengths-based approach does not DISCUSSION
minimize neuromotor risk or delay, but rather views them
as multifaceted, comprising strengths, supports, and challenges. We followed a comprehensive, integrative, transdisciplinary
Clear communication about areas of growth is paramount and approach to identify common principles and strategies
framed in a positive, capacity-building manner. This paradigm underlying effective intervention components. We drew
shift is evident in early childhood education and social services from the fields of developmental psychology, infant mental
(60, 61), and may increase support and participation amongst health and prevention- implementation science to develop a
families and their children with complex needs, including those framework that is transdiagnostic, sensitive to diverse families’
at risk for poor neuromotor health (62). needs, and scalable.
Specific strategies used to operationalize the strengths-based CARES principles are interrelated, and implementation of
principle include techniques that enhance the strengths of each principle facilitates the others. Active learning is at the
families, including cultural strengths. One example is the use of center of the intervention as the driver of therapeutic change, a

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Peyton et al. CARES Framework for Neuromotor Health

concept that is now emerging in the field. Employing strategies of neuromotor risk from an early age using a variety of study
environmental enrichment for the infant and caregivers creates designs including randomized control trials, implementation
more opportunities for active learning in naturally occurring frameworks, and comparative effectiveness paradigms. We found
contexts. Engaging caregivers and building their capacity to extensive value in the contributions from stakeholders with a
participate in their respective caregiving roles will enhance their wide range of lived experiences, and would encourage the use of
confidence and competence to effectively deliver the intervention community participatory research design to ensure an equitable
within their unique family ecology. Finally, the strengths- approach that can be implemented in diverse situations. Finally,
based approach pervades each level of the therapeutic action, although this study was targeted toward children at high risk
environment, and delivery as the therapist works with families for delay based on preterm birth or early adverse events, these
to recognize their strengths, including their support systems and principles are likely to extend to other infants based on a broad
available resources to best support their caregiving capacity. range of perinatal risk as well as those with conditions diagnosed
The use of caregiver engagement as an approach to therapeutic at birth.
delivery is not often described in the fields of rehabilitation
science or motor learning. Because of the age-specific context DATA AVAILABILITY STATEMENT
of infant intervention, the relationship between the infant
and caregivers and ecology of the family system must be The original contributions presented in the study are included
considered for successful and scalable intervention delivery. in the article/Supplementary Material, further inquiries can be
By harnessing methods from the fields of infant mental directed to the corresponding author.
health and developmental psychology, the CARES framework
focuses on a relational health model, rather than an infant- AUTHOR CONTRIBUTIONS
centered model, further enhancing the environment in which
the infant and family co-develop. The therapist plays a role CP, TS, AC, SK-J, LW, AB, EA, JH, and JV contributed to
in understanding and supporting these principles, creating a conception and design of this perspective. CP, TS, and AC wrote
positive and supportive therapeutic alliance with the family, so the first draft of the manuscript. All authors contributed to
that new opportunities for learning and problem-solving are manuscript revision, read, and approved the submitted version.
afforded to both the infant and caregivers and can be tailored
toward family-specific goals. FUNDING
This paper lays out the CARES framework as an integrative
novel conceptual approach. We believe this is a promising This work was generously supported by the Patrick G and Shirley
avenue to explore but note that our model development process W Ryan Foundation. CP receives support from National Center
was comprehensive, though not exhaustive. The inclusion of for Advancing Translational Sciences, Grant KL2TR001424. SX
local clinical stakeholder feedback in the tailoring of the model recognizes support from the Hartwell Foundation.
is a strength. Still to enhance generalizability of the model,
integration of feedback from a broader representation of national SUPPLEMENTARY MATERIAL
stakeholders is needed. Finally, we have not yet tested the CARES
framework and thus it is still theoretical. The Supplementary Material for this article can be found
The next critical step will for application of the CARES online at: [Link]
framework will be rigorous scientific testing for addressing 2021.787196/full#supplementary-material

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