A child does not move by neurophysiology alone. The ability to move is also dependent on learning processes.

Learning depends on active movement initiated by a child as much as possible.

Strengthening of muscles and decreasing stiffness of muscles, soft tissues and joints improve the motor apparatus but not necessarily the everyday motor functions.

Achievement of motor control in a clinic (or research laboratory) does not necessarily carry over into daily life, which includes self-care, school activities, play, hobbies and household chores.

When a child learns to use motor function in the context of his life, this motivates and also activates his motor control and promotes the motor learning.

Special clinical therapy sessions are important but need to be used simultaneously with therapy sessions within other contexts of a child’s life.

Carry over from the treatment sessions to a child’s everyday life depends on motor learning.

In which therapy aims for a child do learning principles apply?

A child with brain damage learns motor functions such as sitting, standing, changing postures, using hands and the various forms of locomotion.

A child learns how to use equipment such as walking aids, wheelchairs and playthings.

A child learns to use his motor functions to achieve activities such as self-care, play and interaction with people and objects in most daily tasks.

In Chapter 2, my priority was to start with motor patterns and functions in the context of the daily lives of children with their parents, originally based on the need to translate my technical knowledge into what has meaning for them in our culture (Levitt 1991b, 1994) and in other cultures (Levitt 1991a, 1999). This is followed by specific therapy for motor patterns which are observed to be useful for what parents and child state they want to achieve in their daily lives. This includes specific activation of motor actions which are dormant but necessary for any daily life activity. On the other hand, therapy minimises those motor patterns which are inefficient or block motor function relevant to daily tasks. In Chapter 2, a collaborative learning model shows how therapy programmes relevant to daily lives of parents and people with cerebral palsy can be jointly created involving therapist, child and parents in a learning process (Levitt & Goldschmied 1990).

Learning methods

Many experienced paediatric physiotherapists and occupational therapists do intuitively select training methods which suit an individual’s learning style. This art and common sense of therapists can be supported by some of the knowledge and research presented by experts in the behavioural sciences. It is nevertheless of much value to learn from such experts so that a therapist comes to understand more deeply and analytically what she is already doing so that she can be more precise in the way she works. This also allows the therapist to further develop her way of working. These studies are quoted by therapists and psychologists who also offer theories for our work, and new ideas are being developed (Carr & Shepherd 1987, 2003; Forssberg & Hirschfeld 1992; Russell and Cotton 1994; Shumway-Cook & Woollacott 2001; Mulder & Hochstenbach 2002; among others).

Learning methods are also developed through interaction of paediatric physiotherapists with occupational therapists, teachers and other professionals. Child psychologists experienced in child development and disabilities give therapists many ideas about learning. These ideas need to be adapted for learning motor control. Community therapists interested in motor learning in different environments have found home, playgroup and school visits enlightening.

A behaviour

This is a term used by psychologists and teachers to convey any action of a child that can be observed. When behaviours are troublesome for therapists and parents – in that a child refuses to cooperate, dislikes handling or having splints applied, these are discussed with team members. A clear description of what a child does, when he does it and people’s response to his behaviour is discussed so that a constructive approach can be worked out.

The behaviours which are more directly the concern of physiotherapists are motor acts. A description of what a child does with the criteria for success of a motor act is called a behavioural objective for therapy or training (Presland 1982; Steel 1993). For example, ‘Sitting on a potty for one minute independently without extending backward or falling to the right’ (Bower & McLellan 1992). This gives the motor act, how it is done and for how long. This is also called ‘setting a goal’ with a child and his carer. We need to go further than setting a goal and clarify a carer’s or a therapist’s response to a child’s efforts and his motor achievement as is done with other behaviours. This will affect a child’s learning of any motor function.

‘Feedback’ by a therapist on ‘goal-directed’ trials made by a child and on his end results either assists learning or may cause feelings of pressure, of fears of failure and of disappointing people whom he likes and are helping him.

Emotions and learning

There may be feelings of discomfort or distress in a child when a change in that child’s familiar motor behaviour is expected by a therapist. The responses of children when confronted by new tasks may be fear, frustration and anxiety. These emotions in such situations have been interpreted as fear of the unfamiliar and self-protection against failure or from past experiences of failure. This is understandable caution and hesitation about change. On the other hand, many therapists know that using specific play activities, most children may be motivated to try new motor skills and derive pleasure in positive achievement. However, there are children who even find a new toy or novel play activity too unfamiliar and hesitate to act. This is especially so when a child prefers not to use a part of their body for play which previously resulted in failure and frustration. Children have also experienced medical language focused on their abnormalities during the making of a diagnosis, when using a measure of impairment and during treatments which aim to correct abnormalities. Statements and words such as ‘he or she can’t do this’, ‘no’, ‘that’s wrong’, ‘you’re not trying’, ‘stop that movement’ are some examples.

There are children who may not understand what is expected of them or how to use a toy. Children who have no or minimal speech, especially any words to express feelings, when asked to carry out a task, will cry or scream, show anger or withdraw. Children use their extensor spasms, involuntary movements and total flexor posturing to show that they are upset. These strong feelings of unease are also shown for all the situations above.

The significant tasks for adults to manage when they are involved with a child are as follows:

(1) Their own protective impulses. They need to balance their wish to challenge a child to develop with a desire to protect that child against possible failure and fears.

(2) Their own examination about failure. A child learns from the mistakes he makes so that he can improve his function. So-called failure can be a spur to better function. Failure may also not be true failure if the task is too far beyond a child’s developmental stage or too easy so he is not interested.

(3) Their body language and words so that adults learn to reframe their language in a more positive way.

There are various options that therapists already use to achieve this, and the following need special emphasis:

Therapists first need to examine what a child can do and which activity is familiar and then build on that. Offer variations or add manual resistance to actions all within an individual child’s competence.

When training a new function, gradually give less manual support, less guidance and less supervision. Use equipment for one part of the body so that another can function, and decrease use when a child’s abilities develop. A task is broken down into smaller and smaller components so success is possible.

Therapists understand and feel that mistakes are learning tools so they do not show disapproval or disappointment when a child does not manage a task. They wait calmly, when those children want to ‘try again and again’ and find their own way of achieving a task.

Therapists offer information for achievement of tasks or for improving them, but while doing so avoid conveying assumptions of inadequacy of a child or disapproval of a child’s own abnormal efforts. Otherwise a child can be discouraged and feel a failure. This can increase what might be a ‘normal’ anxiety about an unfamiliar task.

The therapist gives information for initial or better performance through ‘hands on’ procedures, or other methods given in this chapter and Chapter 9. There are methods to manage fears of falling in procedures given in Chapter 9.

Therapists share a child’s success and pleasure of achievement with smiles, looking approvingly at his actions, commenting on what was specifically achieved. However, overenthusiasm on children’s achievement may well make many children feel that only success pleases adults and earns approval. Children’s mental and emotional energy is then wasted on fear of failing to please adults helping them. We therapists need to reflect on how our responses to the ‘failure’ or achievement by a child will be sensitive to a child’s needs to be accepted and valued as a person.

Therapists assess whether tasks are develop-mentally appropriate for individual children. This is likely to ensure success. The task includes developmental levels of understanding, perception and motor function. An individual child is offered tasks which he can just manage to achieve (the ‘just right challenge’).

These tasks need to be interesting and enjoyable for a child as well as challenging at his level.

All these suggestions facilitate and depend on the positive relationship of a therapist with a child. In the security of this relationship, there is trust which assists a child to cope with the unfamiliar tasks he needs to achieve. The trust is by a therapist for a child’s developmental potential and trust by a child for a therapist’s emotional support and for discovery of what and how he can achieve.

The development of a child’s attention and learning

The cerebral palsies may create apathy, hyperactivity and fleeting attention in children. Besides the brain damage which causes these difficult behaviours, they may be due to some drugs, fatigue and emotional stress of a child. Parents find their child’s demand for non-stop attention with play activities and his restlessness very difficult. Their child cannot maintain concentration and play on his own. Parents are enabled to understand that therapy tasks need concentration for learning and therapy is not necessarily only a set of procedures during which a child ‘receives treatment’. Therapy with learning tasks of interest to a child will, therefore, improve not only the motor tasks but also a child’s attention span. The child’s general behaviour improves with successful experience of achievement through active learning of tasks.