A Learning Environment for Your Child with Cerebral Palsy

Part II: 18 Months to 5 Years

Sieglinde Martin, MS PT | February 2010

motorskilllearningYour child is no longer a baby. He is two - but he is no toddler. He may not even be a sitter. All he may like to do is roll. Stretched out on the floor, he rolls wherever he wants to go. Your house is roomy. You try to keep it reasonably picked up and vacuumed - even though Jared does not mind dust bunnies, and the stuff on the floor is most interesting to him. Especially so if it is not a toy but sister’s hairbrush or, even better, grandma’s purse. It is good for Jared to be all stretched out and to move about freely.

At 20 months old, Ann is on the floor: she only rolls to her side and then onto her back again. This is what she can do independently. She enjoys it and you want to provide the opportunity for her. Yet, you are the parent and you want your child to do more then just roll. You want her to sit, to crawl, to stand and to walk. You want to give her opportunities to learn these skills. “How can you do this?” you wonder.
Most likely, you have already taken the most important steps on behalf of your child’s motor development. You followed your doctor’s recommendations, and you take your child to therapy sessions. You attend them regularly, and you follow the home instructions to the best of your ability. In addition, your child may attend a program for special needs children designed to help her reach her fullest potential in all areas of development. For instance, Ann is in an early intervention program and Jared attends a special needs pre-school program. Like Ann and Jared, most young children with cerebral palsy are pretty busy during the week. So when they are home you want to give them some relaxing, unstructured playtime. But you also want to challenge your child to learn new motor skills, and you want to implement her therapy home program, and maybe you also want to work on her speech, improve her feeding skills, teach her colors, and . . .love her . . .?

Doesn’t it become overwhelming at times? I am sure it does. Nevertheless, helping your child’s motor development deserves to be a priority. All young children, including children with cerebral palsy, learn basic motor skills more quickly and easily during the pre-school years than later. So let’s look how you can make the time you have with your child most effective.

Cerebral palsy is a condition that affects posture and movement. Most people notice the lack of movements, or the presence of some abnormal movements, and want to fix them. Yet, it is the insufficient postures that need to be improved first and foremost. Usually it is the poor postural control that is the cause of the absent movements. For instance, because your child has trouble maintaining a sitting posture, he does not use his hands well when he sits; because your child cannot maintain a 4-point position he cannot crawl; and because he cannot stand, he cannot walk.

It usually takes a long time for your child to acquire the strength, stamina, control and balance to maintain a posture. But once he masters it, learning to move in the position may need little training. He may start to crawl on the floor or to cruise along furniture on his own. I am sure that your therapist talked to you about the importance of postural control. He or she is right. So let’s not try to do everything at once. Instead, when you help your child, focus on his posture and worry about movements later.


Postural Control

What does postural control mean? In a practical sense postural control means that your child can maintain a position without falling. If you place your child in sitting on the floor and he stays seated without losing his balance, he has postural control in sitting. If he stands and does not fall, he has postural control in standing.

Postural control is specific to a position. Marie sits nicely on the floor when her legs are crossed (tailor sitting) but when her legs are stretched out (long sitting) she loses her balance quickly. We can say that she has postural control in tailor sitting, but not in sitting in general.

Before your child can develop postural control in a position, she needs to have the strength to hold the position with some support. For instance, if you place your child in sitting, and support her firmly around her hips, can she keep her trunk straight? If she does, she has the trunk strength for sitting. If you place your child on hands and knees and with your hands at the sides of her trunk you hold her trunk still, does she keep the position? If yes, she has the hip and arm strength for 4-point.

After your child has the strength to maintain a position briefly, she has to gain the stamina to keep it for longer time periods. She won’t develop postural control in sitting if she tires after 1 minute. However, when she can sit with hip support for 10 minutes or longer her therapist may recommend that you work with her on independent sitting.

Independent sitting means that your child gains the balance and control to sit without help. This is a great achievement. However, to be fully independent your child also needs to be able to get into and out of sitting. The same is true for kneeling and standing.

You really want to help your child develop postural control. The big question is how to do this and how much time it will take. There are so many positions to work on. Marie can tailor-sit by herself. It took many therapy sessions and much work at home until she mastered this. Right now she still needs help to get in or out of the tailor sitting. And she needs help with 4-point, long sitting on the floor, side sitting, chair sitting, kneeling, and standing. So many more positions to work on!

Tim can sit on a bench if his parents place him and watch him. From sitting he pulls to stand all by himself. He loves to do this and is so proud of his achievement. Because he is unsteady in standing someone has to be with him at all times to keep him from getting hurt. Wouldn’t it be nice if he could get into a position on his own and play in it safely without help?


The Two Easiest Positions

Instead of spreading yourself thin and trying to work on everything at once, I recommend that you concentrate your effort on the two easiest positions for children with cerebral palsy: modified 4-point and short kneeling. You want to practice them until your child becomes fully independent with them. Practicing these positions is intense, but it does not take long. Many children are able to learn them.

Modified 4-point is also called the bunny position. Here the child is on hands and knees with her legs bent as much as possible at the hip and knees. Her bottom will touch, or almost touch her heels. The arms are straight at the elbows, the open (or almost open) hands are firmly planted on the floor and the head is up. Initially, the position is difficult because it requires arm strength. Most children will need arm support during the first practice sessions. For weeks Jared could not stay up unless his arms were supported. The bunny position provides a wide stable base of support. Once Jared has gained the strength to bear his upper body weight over his arms, it won’t take long for him to acquire the balance and control needed to stay up independently.

What is so difficult about practicing the bunny position? Frequently, children do not like the position. With both arms needed for support, they cannot reach and play. They find the position confining and try to get out of it. Maybe your child cried when she practiced the position during therapy and you had no desire to do more of it at home. For these reasons the position is usually not practiced enough. This is unfortunate, as the bunny position is such an easy, fundamental position. Mastering it will advance your child’s motor development in so many ways.

Making the activity fun is the key to successful practice. Initially, 2 people are needed. One person assists the child in the position, and the other person entertains the child so nicely that she likes the 5 minutes of practice. This entertaining has to be done without using a toy she likes to play with. So you talk to her, sing, make some rhythm, or create a funny situation. Your helper may get pretty creative, so Marie, Jared, or Tim will not cry, and no one will be bored. Even Ann’s parents can try the position with her.      

The key to success is to practice the bunny position consistently every day for 2-8 minutes or longer, if your child likes it and you have the time for it. Practice until your child is comfortable in the position, pushes into it and gets out of it without bumping his nose. Eventually Jared will be able to support himself with just one arm while playing with the other. Now he likes the position; he starts to use it on his own.

Short kneeling is also called heel-sitting. In this position the child’s legs are bent at the hip and knees and the bottom touches the heels as in the bunny position. But instead of leaning forward the trunk is upright. In heel-sitting, the child’s hands are free. He can use them to hold on and for play. “So the children like the position, right?” “Yes, once they have mastered the position, they like it very much. It will be their preferred position for play. ”  Yet there is a big problem. As long as the children cannot keep their balance in heel-sitting, the position is really scary to them. They are higher off the ground than in sitting. They are afraid to fall and get hurt. The fear is not unfounded. Falling forward or backwards onto a toy may even cause an injury.

Heel-sitting does not seem to require more advanced balance skills than sitting. Most likely, Marie will learn it rather quickly. But it is best to practice the bunny position first. Once the children are able to bear weight on their arms, they are ready to catch themselves when they lose their balance in heel-sitting. With good protective responses they feel safer and are more willing to push into heel-sitting.

Before Tim had the balance skills to heel-sit without support, he enjoyed playing in the heel-sitting position at a toy box. He would hold onto the rim of the box whenever he felt that he may lose his balance. But holding on had to be trained. Initially his dad would sit next to him and place his hand over Tim’s to secure his grip and to keep him from taking the hand off for play without any support before he was ready for this challenge. Slowly but surely Tim mastered heel-sitting. His dad felt that his effort had paid off well. Tim had a new, safe play position that he enjoyed. And the more he played in heel-sitting the easier he moved in and out of the position, and the quicker and surer his protective responses became.

The bunny and heel-sitting are two positions that go together, are fairly easy to learn, and allow for early independent play and movements other than rolling. I hope you are motivated to teach your child these positions. Do it with the help of your child’s physical therapist. He or she can show you how, help you, and guide you as you go about teaching your child. The above descriptions are not how-to-do instructions. They are meant to peak your interest.  

For Further Reading:

Part I: A Learning Environment for Your Child with Cerebral Palsy: 0 to 18 Months

Part III: Your Home: A Motor Learning Environment for Your Child with Cerebral Palsy

Sieglinde Martin, M.S., P.T., is a physical therapist with more than thirty years of experience working with the families of children with cerebral palsy. Ms. Martin obtained her degree in physical therapy from the University of Cologne, Germany, and her Master of Science degree at Ohio State University in Columbus, Ohio.

Currently she works at Nationwide Children's Close To Home Health Care Center in Westerville, Ohio. She is the author of Teaching Motor Skills to Children with Cerebral Palsy and Similar Movement Disorders: A Guide for Parents and Professionals (Woodbine House 2006) and of Pediatric Balance Program (Therapy Skill Builders, 1998). 

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