Starting out in the field of pediatrics, I was incredibly fortunate to work with and learn from a phenomenal Physical Therapist, Pamela Hansford. Through many years of practical experience, she developed a theoretical explanation of how apparently “minor problems” may have a significant effect on a child’s life. Even the most subtle degree of postural instability caused by any problem, be it medical or environmental, can affect a child’s learning experience, leading to subtle problems with handwriting and cutting at school to more significant problems of clumsiness or delayed milestones. Normal development is like a continuous spiral where each new skill builds on previous ones. If there is a gap, then a child will find a different way to achieve the required skill. Unfortunately, these adaptations can lead eventually to more problems as tasks become more complex.
Normal vs. Abnormal Development
Motor development is a dynamic process that occurs throughout our lifespan and changes the way we interact with our environment. Motor development occurs from changes in the neural and body systems that are influenced by exploration, stimulation and learning in different contexts. Acquisition of each new developmental skill allows children to work on the next skill in the developmental “spiral.”
Development of midline control allows a child to move forwards and backwards, shift their weight sideways, and eventually be able to turn. As a child develops core control and stability in their shoulders and pelvis, this stability frees up their head, hands, and feet for fine motor functions – important for success with tasks like handwriting and cutting with scissors that are important in the classroom.
The ability to keep the body still – something most typical adults and children take for granted – is also important in the classroom. The simple act of keeping still requires automatic postural adjustments that provide a dynamic, yet stable, base that allows a child to free his attention to the many activities in the classroom. Postural control provides the background for all skilled movement. Any disturbance of tone – either too high or too low – or problems in the sensory system will lead to disorders of posture and movement patterns.
For children with cerebral palsy, hard neurological signs are easily recognizable and these children are usually referred early for intervention before they ever reach the classroom. But a slightly hypotonic (low toned) child may simply appear “clumsy” or awkward or unproductive. These children have many strengths and will use these strengths as a coping style to mask their difficulties. In these cases, discrepancies are often missed early on and it is only when these coping mechanisms cause difficulties in the classroom environment that they are referred for intervention.
How Gross Motor Challenges May Appear in the Classroom
As the levels/grades increase in school, so do the complexities of motor patterns needed to cope with the changing environment. It is often at this point when the coping mechanisms of a child with movement/posture disturbances fail them. They have a limited behavioral repertoire that they rely on, and these limited coping mechanisms may prevent them from reaching their potential.
In these cases, the child’s focus is often limited to maintaining an upright posture against gravity or staying still, rather than focusing on the learning opportunity, being free to learn from it, listening to the teacher and completing their work on time with required neatness. Think about when you were learning a new skill such as driving a car: how much attention could you pay to other information you were receiving, say from the radio? If a motor task (such as sitting still) is difficult, then being able to listen to the teacher at the same time is more of a challenge.
There are many different patterns that children with postural issues may fall back on as their coping mechanism. Some common signs of postural instability include:
- Child may clown around or act cute, trying to distract from what they cannot do
- Child may rush around appearing hyperactive, in an attempt to build up muscle tone to keep upright against gravity
- Child may fidget constantly in an attempt to gain stability to free up head, arms and hands for fine motor tasks
- Child may use extraordinary verbal skills when they cannot keep up motorically
- Child may be the ultra good child who does not move around a lot, rather they are propped against any supporting surface available
- Child may hold a pen or pencil very tightly and/or push down hard on the paper because the have difficulty with neatness at speed, which leads to a build up of tension in the shoulders, joint stiffness or restriction, writer’s cramp or needing extra time to complete work
- Child may be used to Mom translating for them or taking over with difficult tasks – these children may rely on others in the classroom to come to their rescue
- Child may appear not to listen to teacher, as they are so focused on the task
- Child may develop ‘splinter’ skills for each task which are not transferable – these children can perform a task in one environment but not another
All these coping mechanisms may work initially for the child as a distraction from what they find difficult. Over time, though, these coping behaviors actually block the progress of development because the child puts excessive effort and attention into avoiding what is difficult.
A greater variety of motor patterns, complexity of skills and the development of efficient balance reactions, control and postural skills are needed to cope with the demands of daily living. If you feel that your child fits this profile, consider addressing their problems of posture and movement (PT) as well as addressing their school readiness and behavioral issues.
Justine Louw, BS, PT, c/NDT
1. Hansford,P. Motoric Competence, Behavioral Confidence and Classroom function.
2. Judith C. Bierman; Mary Rose Franjoine; Cathy M. Hazzard; Janet M.Howle; Marcia Stamer; Neuro-Developmental Treatment, A Guide to NDT Clinical practice.