A Learning Environment for Your Child with Cerebral Palsy

Your child has cerebral palsy and you want to give him a good start in life. You enroll him in an early childhood program and take him to the recommended therapy sessions. You attend them regularly and follow home instructions faithfully. Can you do more? Yes, you can. You can give your child many hours of learning at home.

Typically, your young child spends 1-3 hours a week in therapy. If your child sleeps about 12 hours per day, 82 wakeful hours will be free to be filled each week. How your child spends this time matters. How and where your child is held or placed makes a difference. His position and his environment determine which muscles he will use, how he will use them, which movements he learns, and which postures he may master. There is a term for this: motor learning.

Motor learning means learning to use your arms, legs, or your whole body so you accomplish what you set out to do: reach for a toy, lift your head to look, move across the room, and so on. Science tells us that motor learning is an active process. It involves finding an efficient, consistent solution to a motor problem. Motor learning depends on the task and the environment. For instance, when your child lies on her back and reaches for a rattle, the environment and the motor learning that may occur will be different than when she reaches in stomach-lying. The shoulder and arm movements (the muscles that will be working) will be different even though the finger movements may be very similar.

Day-long opportunity for motor learning will help your child develop her optimal potential. All children benefit from a motor learning-rich environment, but for a young child with cerebral palsy this is especially true. Let us look at typical care situations for infants and young children and find out what motor learning may occur.

Situation 1.1

Robert lies on his back and reaches for toys that hang down from a Baby Gym.

Motor learning: Robert learns to bring up his arms against gravity, hold them up, move them towards a target, and use his hands and fingers to swipe, touch or grab the toy. While playing, he will try to keep his head in midline and tuck his chin. This way he can watch his hands best. In addition he may lift his legs and if he raises them high enough he may hit the toy with his feet and make it swing back and forth. What fun – he may kick it again and again. Once he is tired of this game he is free to roll to right or left side and look for another toy within reach. In summary, plenty of motor learning may occur as Robert plays while in the back-lying position.

Situation 1.2

Isabelle sits in her reclined infant seat, plays with her rattle ring, and watches me get dinner ready.

Motor learning: Isabelle learns to manipulate an object with her hands, keep her head in midline, bring her hands to midline, and transfer an object from one hand to another. She may bend her neck, tuck her chin, and turn her head as she observes me.

Please note: The reclined position in the infant seat is helpful for babies with cerebral palsy. Bringing the hands together, holding a toy and looking at it is easier learned in the reclined, seated position than in the back lying position. Yet there is a drawback. Once your child has learned these very basic skills no other motor learning is encouraged or possible. Now the seat limits her options and just confines her.

Situation 1.3

Bill spends time in the baby swing in the morning after his breakfast.

Motor learning: The swinging motion provides vestibular stimulation, which is good. Yet in this situation it does not encourage his own active movement. No motor learning occurs.

Situation 1.4

Leah sits in her car seat while we drive to therapy.

Motor learning: The motion of the car provides vestibular stimulation but the confinement of the car seat does not allow or stimulate active movement. No motor learning occurs.

Question from a parent: I thought children would learn to sit when they are in these seats. Isn’t this true?

No, unfortunately children do not learn to sit when they are in reclined seats. In a reclined position the muscles in front of your body are working. These are the muscles that bend (flex) your joints, such as the neck flexors, the stomach muscles, and the muscles that bend your hips. For sitting your child needs strong back muscles. In reclined sitting, the back muscles do not get strong. They are relaxed and not working.

Situation 2.1

Mike lies on his stomach on the floor. He props on his arms and looks around.

Motor learning: Mike uses the muscles of the back of his neck to lift his head up. As his chin comes off the floor the weight of his upper body shifts towards his lower body and his back muscles will kick in and help. The shoulder muscles will also work. Mike will put weight on his elbows or outstretched arms to stay up and look around some more. Next Mike may start to shift his weight over one side and reach with the other arm. He may start playing while stomach-lying, then learn to move to the side, push up and straighten his arms, push into the 4-point crawl position, and so on. Stomach-lying brings endless opportunities for important motor learning. The skills learned will strengthen the neck, back, and hip extensor (straightening) muscles as well as the shoulder muscles. These are building blocks for more advanced skills.

Situation 3.1

Emma likes to be carried and sit on my lap. I often just hold her.

Motor learning: When I hold Emma upright and carry her, Emma learns to hold her head up. She gains head control – the most basic and most important of all skills. Once she can hold her head I may start to lower the support I give her: around her chest and then around her waist. Now she is gaining upper trunk control. When Emma sits on my lap and I support her trunk in a nice straight position, it will help her build head control and her trunk control similarly.

Plenty of motor learning occurs as you carry your child, play with her, or support her in sitting. Holding your child is very good for her, but remember - some things she does not learn when being held. In order to move independently Emma needs independent practice.

Question by parent: Do you recommend any special equipment that will help my Aaron with motor learning? Aaron is 11 months old and has a diagnosis of cerebral palsy. He does not yet crawl or sit by himself.

Here are things that I recommend for young children with cerebral palsy:

1. A mattress. Get a large mattress, put it on the floor in the room where the family action is, and designate it “Aaron’s place”. It will be his space for independent playtime on his back, his tummy, rolling – whatever he likes to do. The mattress will make this motor learning time more comfortable and fun. Of course he will like it if you join him and relax on his padding. You will give him an extra incentive to move, roll, look up, reach, grasp and so on.

The mattress will also be a good place to implement Aaron’s home program. Stretching exercises, sitting practice, kneeling, pushing into 4-point – whatever your therapist recommends – can safely be practiced on this shock-absorbing surface.

A firm, thin, yet dense foam mattress is preferable. A thicker mattress poses the safety issue of Aaron falling off the edge. If Aaron is well aware of his surroundings he may be ready to learn to scoot off the edge feet first. Now, instead of a safety hazard the height difference may be a good environmental challenge for learning a valuable motor skill.

2. A prone stander. Typically developing children of 11 months or older spend much time in standing. The prone stander will allow Aaron to be upright in a safe and helpful way. He will bear weight on his legs. This will strengthen his bones. The hip, knee, and ankle joints are in a functionally straight position. Standing will help Aaron keep good range of motion in these joints. The forward leaning position of the stander will encourage head control and activate his back muscles. A stander with a tray will encourage weight bearing on elbows or forearms and allow for functional or play activities.
   
   Aaron may enjoy being in his stander eating finger food while watching you get dinner ready. Or in the morning he may spend 15 minutes in the stander as his sister gets ready for school. Standing is just as important for his bones, joints and muscles as it is for normally developing children. For convenience, get a stander that you can roll from room to room. For economic reasons get one that grows with your child and gives you several years of use.

For Further Reading:

Part II: A Learning Environment for Your Child with Cerebral Palsy: 18 Months to 5 Years

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 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).