ArticlePDF Available

Weak evidence supports intensive, task-oriented, early intervention with parent support for infants with, or at high risk of, cerebral palsy

Critically Appraised Paper
Weak evidence supports intensive, task-oriented, early
intervention with parent support for infants with, or at high
risk of, cerebral palsy
E. G. (2017). Effect of early intervention in infants at very
high risk of cerebral palsy: A systematic review. Develop-
mental Medicine and Child Neurology, 59(3), 246258.
Objective: Review the evidence for early intervention with
infants with, or at risk of, cerebral palsy.
Design: Systematic review
Methods: PubMed, CINAHL, Embase, reference lists,
review articles and Developmental Medicine and Child Neurol-
ogy were searched to January 2016. Inclusion criteria: peer-
reviewed research of moderate to high methodological
quality; written in English; a prospective group design
with comparison group or period; mean age of the infants
at study entry less than 12 months corrected age and indi-
vidual infants younger than 18 months; and intervention
intended to influence neurodevelopmental outcome. Exclu-
sion was severe comorbidity unrelated to cerebral palsy.
Outcomes of interest were motor, cognitive and family and
parental wellbeing, and their relationship to brain lesion
and type and dose of intervention. Three reviewers inde-
pendently extracted data, completed quality appraisal and
reached consensus through discussion.
Main findings: Seven randomised trials (high (n=1) and
moderate (n=6) methodological quality) of 299 infants
(groups sizes 654) with brain lesion, “neurological
deviancy”, “high suspicion” of cerebral palsy or abnormal
general movements were included. Heterogeneity of inter-
vention type and intensity precluded pooling of results
and drawing firm conclusions. Weak evidence suggests
that developmental stimulation may improve cognitive
outcomes (two of three studies showed a positive effect)
and parent support improves family wellbeing (three out
of three studies). No convincing evidence that neurodevel-
opmental therapy (one of two studies suggested positive
effect) or developmental stimulation (one of four studies)
improves motor outcomes. Insufficient evidence to draw
conclusions about the impact of sensory input (one study).
Insufficient information was available to identify a relation-
ship between type of brain lesion and intervention effec-
tiveness. Several flaws in the evidence base were noted
including small sample size, ill-defined brain lesions, short
follow-up, inadequate comparison group description, and
adherence to intervention fidelity not addressed.
Authors’ conclusions: Weak evidence in the included stud-
ies leads to the suggestion that intensive early intervention
and multifaceted intervention may be required to optimise
outcomes for infants with, or at risk of, cerebral palsy. Sub-
stantial high-quality research is required to advance the
Contact details of original author:MHadders-Algra,
Margaret Wallen
CAPs Advisory Board Member
Spittle, A., Johnson, R. & Fetters, L. (2016). Effectiveness
of motor interventions in infants with cerebral palsy: A
systematic review. Developmental Medicine and Child
Neurology, 58(9), 900909. doi:10.1111/dmcn.13105
Objective: To review the evidence for effectiveness of inter-
ventions to improve motor outcomes for children with
cerebral palsy aged 02years.
Design: Systematic review
Methods: Systematic searches of six databases (PubMed,
Embase, CINAHL, Cochrane, Web of Knowledge, PEDro)
were undertaken in 2014 and updated in 2015. Inclusion
criteria: all research designs with participants aged birth-
2 years diagnosed with, or at high risk of, cerebral palsy;
motor intervention implemented and motor outcomes
assessed. Motor intervention defined as “therapeutic inter-
vention with motor development or skills as one primary
outcome” (p. 901). Studies were excluded if not written in
English or if the intervention was medical, pharmaceutical
or surgical. Reviewers independently selected studies for
inclusion. Interventions were classified by reviewer con-
sensus using the International Classification of Functioning
Disability and Health framework. Risk of bias was assessed
©2017 Occupational Therapy Australia
Australian Occupational Therapy Journal (2017) 64, 423–425 doi: 10.1111/1440-1630.12426
using American Academy of Cerebral Palsy and Develop-
mental Medicine guidelines. Effect sizes assessed according
to Cohen’s dand quality and strength of evidence ranked
using the Grading of Recommendations Assessment,
Development and Evaluation system. Meta-analysis was
not possible due to heterogeneity.
Main findings: Thirty-six included papers reported 34 stud-
ies published 19842015; 10 randomised controlled trials
(RCT), 4 cohort, 10 single-subject design and 10 case stud-
ies or case series designs. Methodological quality collec-
tively assessed as low. The median sample size of the
RCTs and the cohort study with a control group was 26.
Confirmed diagnosis at study exit ranged from 22% to
77%. Activity level outcomes were most commonly mea-
sured. Only 4 (of 10) RCTs reported statistically significant
findings with “effect sizes ranging from 0.14 (small) to 0.75
(moderate-high)” (p. 906). The single-subject and case ser-
ies designs all showed positive findings. Duration and
intensity of intervention varied from 6-days/week for
6 weeks to monthly for 12 months. Interventions included
neurodevelopmental therapy, Vojta (passive application of
reciprocal limb movements), environmental enrichment
and constraint-induced movement therapy. Interventions
were complex; the most common component was parent
education. The commonly included intervention elements
in the two RCTs with largest effect sizes were child-
initiated movement, task specific training and environmen-
tal modifications.
Authors’ conclusions: Low quality evidence was ‘weakly
positive.’ Recommendationsweretoimplementearly,
intensive motor intervention with infants with, or at high
risk of, cerebral palsy consistent with contemporary prac-
tice around neuroplasticity and motor learning principles,
and positive outcomes identified in studies of older chil-
dren that is, interventions which elicit active movement
in task-oriented activities in a high intensity program.
Contact details of original author: Catherine Morgan,
Christine Imms
CAPs Advisory Board Member
Premature birth, brain lesions and abnormalities place
infants at high risk of cerebral palsy (CP). Recently, the
increased use of magnetic resonance imaging (MRI), com-
bined with prognostic tools such as the General Move-
ments Assessment (GMs) and the Hammersmith Infant
Neurological Examination (HINE), has made detection of
infants with, or at risk of, CP possible during the first half-
year of life (McIntyre, Morgan, Walker & Novak, 2011;
Romeo, Ricci, Brogna & Mercuri, 2016). Early detection is
crucial, as animal studies show that the timing of interven-
tion is the most critical factor for maximising treatment
outcomes (Friel, Chakrabarty, Kuo & Martin, 2012). Further
to this, is evidence that most gross motor and bimanual
performance potential in children with CP is experienced
in the first 2 years of development (Nordstrand, Eliasson &
Holmefur, 2016; Rosenbaum et al., 2002). Early detection
should trigger immediate referral to infant specific inter-
vention programs. But what is the evidence for these pro-
grams? Two recent papers aimed to systematically review
the evidence for early intervention for infants with, or at
high risk of CP (Hadders-Algra, Boxum, Hielkema &
Hamer, 2017; Morgan et al., 2016).
These two reviews fill an important knowledge gap by
focussing specifically on children younger than 2 years of
age when intervention can drive neural circuit develop-
ment during the most dynamic phase of plasticity. Had-
ders-Algra et al. (2017) made special effort to highlight
differences in methodology compared to the earlier review
by Morgan et al. (2016). These include a focus on children
<1 years old, methods used for rating the quality of
included studies, inclusion of family outcomes, the effect of
disease state on intervention response and the dose and
type of intervention provided. These differences led to
inclusion of significantly fewer studies in Hadders-Algra
et al. (n=7) compared with Morgan et al. (2016) (n=34).
Despite this, outcomes for each review are similar. Evi-
dence for intervention remains weak. Studies are mostly
small with low methodological quality. There is consider-
able heterogeneity across studies including participants,
interventions and outcome measures. As a result, meta-
analysis of data for pooled effect, the ability to make defini-
tive conclusions on the effect of disease state on treatment
response, or on the dose and type of intervention provided,
are not possible. Both reviews concluded that trends in the
data support intervention models based on motor learning
theory (e.g., child-initiated movement), environmental
enrichment and parent education underpinned by ecologi-
cal and family-centred frameworks.
One point of difference between the reviews relates to
neurodevelopmental therapy (NDT). Hadders-Algra et al.
(2017) suggested that minimal hands on postural support
techniques may be useful for infants with CP. Morgan et al.
(2016) suggested that trends in data do not support neuro-
maturational approaches such as NDT. Despite these dif-
ferences, we agree with comments by Morgan et al. that
whatever the intervention type, a comprehensive descrip-
tion of the key ingredients is essential, especially where
there is a diversity of interpretation (Mayston, 2016).
While evidence remains weak, the consistent outcomes
and emerging evidence described by both reviews, have
important implications for occupational therapists. Work-
ing with infants with CP means focussing on occupation,
rather than using neuro-maturational approaches that seek
to normalise movement. The core philosophies of our occu-
pation-based profession are entirely consistent with the
key ingredients of evidence-based models of early inter-
vention proposed in these reviews including child-initiated
movement, task specificity, environmental modification
and parent support and education.
©2017 Occupational Therapy Australia
Paediatric occupational therapists should abandon gen-
eralised, low intensity models of intervention. Alongside a
specific, targeted, therapist-guided program, interventions
should include a goal-directed home program as a prag-
matic solution to achieving optimal intensity and to ensure
generalisation of skills (Novak, Cusick & Lannin, 2009).
Evidence-based occupational therapy with infants at high
risk of CP includes collaborating with medical profession-
als in the early detection of CP by using diagnostic tools
such as the GMs and HINE; confident application of evi-
dence-based early intervention models including COPing
with and CAring for Infants with Special Needs (COPCA)
(Dirks, Blauw-Hospers, Hulshof & Hadders-Algra, 2011),
Goals, Activity and Motor Enrichment (GAME) (Morgan,
Novak, Dale, Guzzetta & Badawi, 2014), baby constraint-
induced movement therapy (Eliasson, Sjostrand, Ek, Krum-
linde-Sundholm & Tedroff, 2014) and bimanual therapy
(Hoare & Greaves, 2017). New measures such as the Hand
Assessment for Infants (HAI) (Krumlinde-Sundholm et al.,
2015) and the Mini-Assisting Hand Assessment (Greaves,
Imms, Dodd & Krumlinde-Sundholm, 2013) are available
and enable targeting of upper limb interventions to the just
right challenge, and objective evaluation of outcomes of
early intervention.
In Australia, the introduction of the National Disability
Insurance Scheme provides great opportunity for families
of children with CP to access occupational therapy. For
children older than 2 years of age with CP, there are effec-
tive interventions supported by strong evidence (Novak
et al., 2013). Evidence-based interventions implemented
with strong treatment fidelity in clinical practice, including
for younger infants, are required. Current evidence-based
interventions are not transdisciplinary approaches, but are
highly specific and targeted interventions provided by
skilled therapists who have gained experience in, and
knowledge about, working with very young infants.
Organisations need to ensure specialist training opportuni-
ties for staff, adapt services based on the evolving evi-
dence, and foster and recognise clinical expertise.
Brian Hoare
Department of Paediatrics Monash University and School of
Occupational Therapy,
La Trobe University,
Melbourne, Victoria, Australia
Susan Greaves
Occupational Therapy Department, The Royal Children’s
Melbourne, Victoria, Australia
Dirks, T., Blauw-Hospers, C. H., Hulshof, L. J. & Hadders-Algra, M.
(2011). Differences between the family-centered “COPCA” program
and traditional infant physical therapy based on neurodevelopmen-
tal treatment principles. Physical Therapy,91,13031322.
Eliasson, A. C., Sjostrand, L., Ek, L., Krumlinde-Sundholm, L. & Tedr-
off, K. (2014). Efficacy of baby-CIMT: Study protocol for a ran-
domised controlled trial on infants below age 12 months, with
clinical signs of unilateral CP. BMC Pediatrics,14, 141. https://doi.
Friel, K., Chakrabarty, S., Kuo, H.-C. & Martin, J. (2012). Using motor
behavior during an early critical period to restore skilled limb move-
ment after damage to the corticospinal system during development.
Journal of Neuroscience,32, 92659276.
Greaves, S., Imms, C., Dodd, K. & Krumlinde-Sundholm, L. (2013).
Development of the Mini-Assisting Hand Assessment: Evidence for
content and internal scale validity. Developmental Medicine and Child
Neurology,55, 10301037.
Hadders-Algra, M., Boxum, A. G., Hielkema, T. & Hamer, E. G. (2017).
Effect of early intervention in infants at very high risk of cerebral
palsy: A systematic review. Developmental Medicine and Child Neurol-
Hoare, B. & Greaves, S. (2017). Unimanual versus bimanual therapy in
children with unilateral cerebral palsy: Same, same, but different.
Journal of Pediatric Rehabilitation Medicine,10,4759.
Krumlinde-Sundholm, L., Sicola, E., Ek, L., Guzzetta, A., Sj
ostrand, L.,
Cioni, G. et al. (2015). The Hand Assessment for Infants, a new test
for measuring use of hands and possible asymmetry in infants
310 months of age. Developmental Medicine and Child Neurology,57
(Suppl 5), 5455.
Mayston, M. (2016). Bobath and NeuroDevelopmental Therapy: What
is the future? Developmental Medicine and Child Neurology,58, 994.
McIntyre, S., Morgan, C., Walker, K. & Novak, I. (2011). Cerebral palsy
Don’t delay. Developmental Disabilities Research Reviews,17,114129.
Morgan, C., Novak, I., Dale, R. C., Guzzetta, A. & Badawi, N. (2014).
GAME (Goals Activity Motor Enrichment): Protocol of a single
blind randomised controlled trial of motor training, parent education
and environmental enrichment for infants at high risk of cerebral
palsy. BMC Neurology,14, 203.
Morgan, C., Darrah, J., Gordon, A. M., Harbourne, R., Spittle, A., John-
son, R. et al. (2016). Effectiveness of motor interventions in infants
with cerebral palsy: A systematic review. Developmental Medicine and
Child Neurology,58,900909.
cation/doi/10.1111/ dmcn.13105.
Nordstrand, L., Eliasson, A.-C. & Holmefur, M. (2016). Longitudinal
development of hand function in children with unilateral spastic
cerebral palsy aged 18monthsto 12years. Developmental Medicine
and Child Neurology,58,10421048.
cation/doi/10.1111/ dmcn.13106.
Novak, I., Cusick, A. & Lannin, N. (2009). Occupational therapy home
programs for cerebral palsy: Double-blind, randomized, controlled
trial. Pediatrics,124, e606e614.
et al. (2013). A systematic review of interventions for children with
cerebral palsy: State of the evidence. Developmental Medicine and Child
Neurology,55, 885910.
Romeo, D. M., Ricci, D., Brogna, C. & Mercuri, E. (2016). Use of the
Hammersmith Infant Neurological Examination in infants with cere-
bral palsy: A critical review of the literature. Developmental Medicine
and Child Neurology,58,240245.
Rosenbaum, P. L., Walter, S. D., Hanna, S. E., Palisano, R. J., Russell, D.
J.,Raina, al. (2002). Prognosis for gross motor function in cere-
bral palsy: Creation of motor development curves. The Journal of the
American Medical Association,288, 13571363.
©2017 Occupational Therapy Australia
Full-text available
BACKGROUND: There is high-level evidence supporting constraint-induced movement therapy (CIMT) and bimanual therapy for children with unilateral cerebral palsy. Evidence-based intervention includes time-limited, goal-directed, skills-based, intensive blocks of practice based on motor learning theory. AIM AND METHODS: Using supporting literature and clinical insight, we provide a theoretical rationale to highlight previously unreported differences between CIMT and bimanual therapy. DISCUSSION: The current emphasis on total dosage of practice for achieving positive outcomes fails to recognise the influence of other critical concepts within motor learning. Limitations exist in the application of motor learning principles using CIMT due to its unimanual nature. CIMT is effective for development of unimanual actions brought about by implicit learning, however it properties can be adapted to trigger goal-related perceptual and cognitive processes required for children to learn to recognise when two hands are required for task completion. CONCLUSION: CIMT and bimanual should be viewed as complementary. CIMT could be used to target unimanual actions. Once these actions are established, bimanual therapy could be used for children to learn how to use these actions for bimanual skill development.
Full-text available
Aim: The aim of the study was to describe the development of hand function, particularly the use of the affected hand in bimanual tasks, among children with unilateral cerebral palsy aged 18 months to 12 years. Method: A convenience sample of 96 children (53 males, 43 females) was assessed with the Assisting Hand Assessment (AHA) at regular intervals from the ages of 18 months to 12 years. The children ranged from 17 to 127 months (median age 24mo) at recruitment. Subgroups were created to identify differences in development using the child's AHA at 18 months and the Manual Ability Classification System (MACS). A nonlinear mixed effects model was used to analyze data according to a 'stable limit' development model. Results: The results were based on 702 AHA sessions. The children showed a rapid development at a young age and reached 90% of their stable limit between 30 months and 8 years. The subgroups, based on the 18-month AHA and the MACS levels respectively, had distinctly different patterns of development. Interpretation: The AHA at 18 months may be used to make a crude prediction of future development.
Full-text available
The Hammersmith Infant Neurological Examination (HINE) has been proposed as one of the early neurological examination tools for the diagnosis of cerebral palsy (CP). The aim of the present study was to critically review the existing literature and our experience with the use of the HINE in infants at risk of CP. The published papers confirm that the HINE can play an important role in the diagnosis and prognosis of infants at risk of developing CP, and provide information on aspects of neurological findings impaired in different forms of CP and brain lesions. © 2015 Mac Keith Press.
Full-text available
Background: Cerebral palsy is the most common physical disability of childhood and early detection is possible using evidence based assessments. Systematic reviews indicate early intervention trials rarely demonstrate efficacy for improving motor outcomes but environmental enrichment interventions appear promising. This study is built on a previous pilot study and has been designed to assess the effectiveness of a goal - oriented motor training and enrichment intervention programme, "GAME", on the motor outcomes of infants at very high risk of cerebral palsy (CP) compared with standard community based care. Methods/design: A two group, single blind randomised controlled trial (n = 30) will be conducted. Eligible infants are those diagnosed with CP or designated "at high risk of CP" on the basis of the General Movements Assessment and/or abnormal neuroimaging. A physiotherapist and occupational therapist will deliver home-based GAME intervention at least fortnightly until the infant's first birthday. The intervention aims to optimize motor function and engage parents in developmental activities aimed at enriching the home learning environment. Primary endpoint measures will be taken 16 weeks after intervention commences with the secondary endpoint at 12 months and 24 months corrected age. The primary outcome measure will be the Peabody Developmental Motor Scale second edition. Secondary outcomes measures include the Gross Motor Function Measure, Bayley Scales of Infant and Toddler Development, Affordances in the Home Environment for Motor Development - Infant Scale, and the Canadian Occupational Performance Measure. Parent well-being will be monitored using the Depression Anxiety and Stress Scale. Discussion: This paper presents the background, design and intervention protocol of a randomised trial of a goal driven, motor learning approach with customised environmental interventions and parental education for young infants at high risk of cerebral palsy. Trial registration: This trial is registered on the Australian New Zealand Clinical Trial register: ACTRN12611000572965.
Full-text available
Infants with unilateral brain lesions are at high risk of developing unilateral cerebral palsy (CP). Given the great plasticity of the young brain, possible interventions for infants at risk of unilateral CP deserve exploration. Constraint-induced movement therapy (CIMT) is known to be effective for older children with unilateral CP but is not systematically used for infants. The development of CIMT for infants (baby-CIMT) is described here, as is the methodology of an RCT comparing the effects on manual ability development of baby-CIMT versus baby-massage. The main hypothesis is that infants receiving baby-CIMT will develop manual ability in the involved hand faster than will infants receiving baby-massage in the first year of life. Method and design The study will be a randomised, controlled, prospective parallel-group trial. Invited infants will be to be randomised to either the baby-CIMT or the baby-massage group if they: 1) are at risk of developing unilateral CP due to a known neonatal event affecting the brain or 2) have been referred to Astrid Lindgren Children’s Hospital due to asymmetric hand function. The inclusion criteria are age 3–8 months and established asymmetric hand use. Infants in both groups will receive two 6-weeks training periods separated by a 6-week pause, for 12 weeks in total of treatment. The primary outcome measure will be the new Hand Assessment for Infants (HAI) for evaluating manual ability. In addition, the Parenting Sense of Competence scale and Alberta Infant Motor Scale will be used. Clinical neuroimaging will be utilized to characterise the brain lesion type. To compare outcomes between treatment groups generalised linear models will be used. The model of early intensive intervention for hand function, baby-CIMT evaluated by the Hand Assessment for Infants (HAI) will have the potential to significantly increase our understanding of how early intervention of upper limb function in infants at risk of developing unilateral CP can be performed and measured. Trial registration SFO-V4072/2012, 05/22/2013
Aim: First, to systematically review the evidence on the effect of intervention applied during the first postnatal year in infants with or at very high risk of cerebral palsy (CP) on child and family outcome. Second, to assess whether type and dosing of intervention modify the effect of intervention. Method: Relevant literature was identified by searching the PubMed, Embase, and CINAHL databases. Selection criteria included infants younger than 12 months corrected age with or at very high risk of CP. Methodological quality including risk of bias was scrutinized. Results: Thirteen papers met the inclusion criteria. Seven studies with moderate to high methodological quality were analysed in detail; they evaluated neurodevelopmental treatment only (n=2), multisensory stimulation (n=1), developmental stimulation (n=2), and multifaceted interventions consisting of a mix of developmental stimulation, support of parent-infant interaction, and neurodevelopmental treatment (n=2). The heterogeneity precluded conclusions. Yet, two suggestions emerged: (1) dosing may be critical for effectiveness; (2) multifaceted intervention may offer best opportunities for child and family. Interpretation: The literature on early intervention in very high-risk infants with sufficient methodological quality is limited, heterogeneous, and provides weak evidence on the effect. More studies are urgently needed. Suggestions for future research are provided.
Aim: To systematically review the evidence on the effectiveness of motor interventions for infants from birth to 2 years with a diagnosis of cerebral palsy or at high risk of it. Method: Relevant literature was identified by searching journal article databases (PubMed, Embase, CINAHL, Cochrane, Web of Knowledge, and PEDro). Selection criteria included infants between the ages of birth and 2 years diagnosed with, or at risk of, cerebral palsy who received early motor intervention. Results: Thirty-four studies met the inclusion criteria, including 10 randomized controlled trials. Studies varied in quality, interventions, and participant inclusion criteria. Neurodevelopmental therapy was the most common intervention investigated either as the experimental or control assignment. The two interventions that had a moderate to large effect on motor outcomes (Cohen's effect size>0.7) had the common themes of child-initiated movement, environment modification/enrichment, and task-specific training. Interpretation: The published evidence for early motor intervention is limited by the lack of high-quality trials. There is some promising evidence that early intervention incorporating child-initiated movement (based on motor-learning principles and task specificity), parental education, and environment modification have a positive effect on motor development. Further research is crucial.
The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP). This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health. Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red). Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist.
To describe the development of the Mini-Assisting Hand Assessment (Mini-AHA) for children with signs of unilateral cerebral palsy (CP) aged 8 to 18 months, and evaluate aspects of content and internal scale validity. The ability of the video-recorded Mini-AHA play session to provoke bimanual performance in children with unilateral CP and typical development was evaluated. Original AHA test items were examined for their suitability for younger children and possible new items were generated. Data from 108 assessments of children with unilateral CP (86 children, 53 males, 33 females; mean age 13mo, SD 3mo, range 8-18mo) were entered into a Rasch measurement model analysis to evaluate internal scale validity. A Spearman's correlation analysis explored the relationship between age and ability measures for children with unilateral CP. The frequency of maximum scores in 40 children with typical development (22 males, 18 females; mean age 12mo, SD 3mo) was examined. The Mini-AHA play session provoked bimanual responses in typically developing children 99% of the time. Person and item fit criteria established 20 items for the scale. The resultant unidimensional scale also demonstrated excellent discriminative features through high separation reliability. The item calibration values covered the range of person ability measures well. Age was not related to the ability measures for children with unilateral CP (rs =0.178). All children with typical development achieved maximum scores. Accumulated evidence shows that the Mini-AHA validly measures use of the affected hand during bimanual performance for children with unilateral CP aged 8 to 18 months. The Mini-AHA has the potential to be a useful assessment to evaluate functional hand use and the effects of intervention in an age group when potential for change is high.