Referral guide for healthcare professionals
Roles of pediatric PTs in early intervention
A pediatric PT helps infants catch up on gross motor milestones. Gross motor skill acquisition is closely connected to an infant’s cognitive development, thus implying that movement is a precursor to learning.
Inamdar and colleagues found a strong, significant association between prone motor scores and motor-based problem-solving scores in all infants (ρ = 0.72, p < 0.001).1 This finding implies the importance of tummy time in fostering play and learning during early development. Tummy time helps develop upright head control and allows the infant to observe and explore their environment.
Referral to pediatric PT may be prompted with developmental delays. PTs can teach skills such as transitions to help build a child’s movement repertoire, and tummy time, intentionally targeting postural and proximal muscles.
Tools and resources for development surveillance
CDC’s Watch Me! Celebrating Milestones and Sharing Concerns
A free online training course with resources, tools, and best practices to help monitor children’s development
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Alberta Infant Motor Scales (AIMS-2)
• assesses the occurrence and manner of motor skill and performance
• Ages: birth to 18 months
• Duration: 20-30 minutes
Excellent inter-rater reliability1 pre-term infants: ICC = 0.99
full-term infants: ICC > 0.96
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Assessment of Problem-Solving in Play
• assesses the early problem-solving skills
• Moderate-to-large construct validity with the cognitive raw scores of the Bayley Scales of Infant Development, Third Edition (rs > 0.36 – 0.56)
• Excellent inter-rater reliability (ICC=0.98)
• Excellent intra-rater reliability1 (ICC=0.94)
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Other tools to assess risk for developmental delays2
• Ages and stages questionnaire
• Parents’ evaluation of developmental status
Roles of pediatric PTs and tools in managing children with physical disabilities
Gross Motor Function Measure (GMFM-88)
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Cerebral palsy (CP)
The neurological affectation in children with CP remains static but may bring about skeletal and musculoskeletal pathologies as a child grows older because of the neurological impairments.
PTs work with the patient, family, occupational and speech therapists and orthotists to perform a comprehensive evaluation of the child’s body alignment, mobility, and level of participation in their environment. They make a shared, informed decision about prescribing therapy, orthosis, adaptive equipment, and environmental modifications.3
Foot Posture Index 6 (FPI-6)
• High intra-rater reliability (ICC=0.97, p=0.001)
• Sensitivity: 83.7%
• Specificity: 80.4%
• Positive predictive value (in reference to the X-ray): 64.7%
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Flexible flatfoot
Higher foot pronation, as measured by the Foot Posture Index (FPI-6), is a significant predictor of increased pain (b=0.41, p=0.001) and decreased physical activity (b=-0.21, p=0.022).4
The medial-longitudinal arch (MLA) is reduced during weight-bearing in children with flexible flatfoot. The MLA helps absorb and distribute ground reaction forces during walking.5
PTs address foot alignment, strengthen intrinsic foot and leg muscles, and aid in decision-making for orthosis prescription or referral.
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Other cases handled by pediatric PTs
• Muscular dystrophies
• Genetic syndromes
• Children with difficulties in postural control
• Children with difficulties in mobility
Prompt referral and comprehensive assessment are urged as pediatric PTs consider and work on overlooked factors such as risks for hip subluxation and dislocation, inefficient and exhaustive performance of activities such as gait and transitions, and pain.
Roles of PTs and tools in assessing sensory processing disorders (SPD)
Autism Spectrum Disorder (ASD)
“Motor differences in ASD are significant and underrecognized.”6
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Attention Deficit Hyperactivity Disorder (ADHD)
Physical exercise was found to significantly improve inhibitory control, working memory, cognitive flexibility, attention, motor skills, and executive function.7-8
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Developmental Coordination Disorder
Developmental Coordination Disorder Questionnaire (DCDQ)6
• Positive predictive value (with the Movement-ABC): 92%
Diagnosis:
• Follow-up
• Standardized motor assessment
• Clinical judgment of a trained movement clinician
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Tools generally used to assess function
Pediatric Evaluation of Disability Inventory (PEDI)
• assesses the child’s ability to function in their natural environment
• High interrater and intrarater reliability (ICC = 0.95-0.99)
• Moderately high concurrent validity (r=0.70-0.80) with the Batelle Development Inventory Screening Test
• High correlation (r=0.88) with the Functional Independence Measure for Children (WeeFIM)
• High correlation (r=0.64-0.94) with the Peabody Developmental Motor Scales, Second Edition (PDMS-2)
Armstrong and colleagues found a significant difference in the self-care domain between the PEDI scores of children with SPD compared to typically-developing children (p=0.002).9
Functional Independence Measure for Children (WeeFIM)
Kim and colleagues verified the reliability and validity of WeeFIM for children with CP.10
Vineland Adaptive Behavior Scale6
• Content validity (domain structure): >0.80
• Concurrent validity (motor domain; established with the PDMS): r=0.77
Achievement of developmental milestones is not enough to rule out the need for pediatric PT services. Although movement can easily be targeted, pediatric PTs promote movement with specific goals, targeting body awareness, reflex integration, coordination, and visuomotor integration, which are areas not easily assessed by standardized tools.
Zampella and colleagues stressed how motor impairments are underrecognized in children with ASD (85-87% at risk for motor impairment & only 32% receiving PT).6
Other roles of PTs and tools in daily activities
Feeding and swallowing
In the immediate postnatal period, pediatric PTs apply the promotor approach and work on the buccal muscles to effectively support newborns with feeding and swallowing.11
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Executive function
Individuals who went through cognitively-enriched physical activity had significant improvements in working memory accuracy (t = -6.77, p<0.001).
Gross motor quotient was found to be significantly correlated with inhibitory control completion time (r=0.44, p=0.007), and flexibility completion time (r=0.55, p=0.001).12
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Fine motor skills
Burnett and colleagues found significant correlation between balance and precision (r=0.187, p=0.049), and strength and integration (r=0.27, p=0.004).13
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References
1. Inamdar K, Tripathi T, Molinini RM, Fang W, Salgaonkar A, Dusing SC. Relationship between prone skills and motor-based problem-solving abilities in full-term and pre-term infants during the first 6 months of life. Dev Psychobiol. 2024;66(6):e22525. doi:10.1002/dev.22525
2. HealthyChildren.org – from the American Academy of Pediatrics. HealthyChildren.org. https:// http://www.healthychildren.org/
3. APTA Pediatrics. PediatricAPTA.org. https:// pediatricapta.org/
4. Kardm SM, Alanazi ZA, Aldugman TAS, Reddy RS, Gautam AP. Prevalence and functional impact of flexible flatfoot in school-aged children: A cross-sectional clinical and postural assessment. J Orthop Surg Res. 2025;20(1):783. Published 2025 Aug 21. doi:10.1186/s13018-025-06207-y
5. Hegazy FA, Aboelnasr EA, Salem Y, Zaghloul AA. Validity and diagnostic accuracy of Foot Posture Index-6 using radiographic findings as the gold standard to determine paediatric flexible flatfoot between ages of 6-18 years: A cross-sectional study. Musculoskelet Sci Pract. 2020;46:102107. doi:10.1016/j.msksp.2020.102107
6. Zampella CJ, Wang LAL, Haley M, Hutchinson AG, de Marchena A. Motor skill differences in autism spectrum disorder: A clinically focused review. Curr Psychiatry Rep. 2021;23(10):64. Published 2021 Aug 13. doi:10.1007/s11920-021-01280-6
7. Sun W, Yu M, Zhou X. Effects of physical exercise on attention deficit and other major symptoms in children with ADHD: A meta-analysis. Psychiatry Res. 2022;311:114509. doi:10.1016/j.psychres.2022.114509
8. Song Y, Fan B, Wang C, Yu H. Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder. PLoS One. 2023;18(8):e0289732. Published 2023 Aug 17. doi:10.1371/journal.pone.0289732
9. Armstrong DC, Redman-Bentley D, Wardell M. Differences in function among children with sensory processing disorders, physical disabilities, and typical development. Pediatr Phys Ther. 2013;25(3):315-321. doi:10.1097/PEP.0b013e3182980cd4
10. Kim GW, Kim H, Jeon JY, Jang JS. Validity and Reliability of Functional Independence Measure for Children (WeeFIM) for Children With Cerebral Palsy. Inquiry. 2022;59:469580211072454. doi:10.1177/00469580211072454
11. Kanniappan V, Rajeswari AJ, Padma Lawrence PE, Sundar S. Understanding the perspectives of paediatric physicians on physiotherapy in paediatric rehabilitation in Chennai, India: A qualitative approach. J Prev Med Public Health. 2024;57(2):157-166. doi:10.3961/jpmph.23.426
12. Biino V, Tinagli V, Borioni F, Pesce C. Cognitively enriched physical activity may foster motor competence and executive function as early as preschool age: A pilot trial. Physical Education and Sport Pedagogy. 2021;28(4):425-443. doi:10.1080/17408989.2021.1990249
13. Burnett R, Cornett N, Rekart G, et al. Investigating the Associations between Core Strength, Postural Control and Fine Motor Performance in Children. University of Dayton Physical Therapy Faculty Publications. 2011;4(2). https://ecommons.udayton.edu/dpt_fac_pub/46