Author: Ann Markee, Senior Community Physiotherapist for Children, Rugby Child Development Centre, Warwickshire, UK
Curtis is just six years old. He lives in the Midlands with his mother, father and brother. He goes to a local infant school, has lots of friends and is often invited round to play or to go to parties. Curtis is a great communicator, even though his talking is sometimes very difficult to understand.
You see Curtis has Athetoid Cerebral Palsy, affecting his speech as well as his movement and thus to some extent inhibiting his cognitive development as well. He has a Statement of Special Educational Needs.
Curtis can’t yet walk independently – his postural state and his voluntary movement are disordered. He looks very wobbly and uncoordinated. He gets around school using a posture walker, or by crawling where easier. He’s good at making transfers to take up different positions for learning, e.g. from stand or with his posture walker to sitting on a chair, or moving from sitting at a table to sitting on the floor. He joins in PE, which teachers try very hard to differentiate to accommodate him. His determination to dress or undress to make himself ready for this session is remarkable but very hard. However what makes life extremely problematic for Curtis in the classroom is his difficulty with manipulation.
Children learn much through using hands in various ways. Visually directed reaching and conscious control of hands and fingers begins early. Accuracy will be poor at first but quickly improves until thumb/forefinger opposition is achieved at around eight to ten months and a child learns object release. Once this is achieved active manipulation and exploration provide constant practice and refinement of newly learnt skills. The grasp matures from a crude palmar grab or scoop to a pincer or dynamic tripod grasp using thumb and first, or first two fingers. At the same time the child begins to learn about size, weight and texture of the objects handled. He also learns about using tools and controlling the force, which are spatial and temporal requirements for any activity. Finally he learns about fixing one part of the body so that another may move efficiently e.g. shoulder girdle and/or trunk stability will enable precision distally of elbow, wrist, hand and fingers. Thus the child eventually learns the skills for drawing and writing, to control the force of the fingers on the pencil and its pressure on the paper to make marks within confined spatial limits.
Hands are used in a vast range of everyday activities. In some tasks one hand has a primary function, the other a supportive role (e.g. writing with one hand, the other holding the paper), in others hands co-ordinate by performing two separate aspects of the same task (e.g. tying shoe laces). In reaching for, grasping and using tools for example, the whole upper limb and trunk may be involved and where fine manipulation is required, the object is moved within the hand itself. Such organisation and co-ordination of finger and hand movement depends on sensory reception and perception of visual, tactile, proprioceptive and kinaesthetic feedback, informing motor planning and execution. It is a combination of power and precision, the ability to pick up and retain and to handle with skill.
For a child like Curtis who has problems with postural fixation and with motor execution, manipulative skills are very hard to learn. All new tasks may need to be attempted first at an earlier developmental level, presented in exciting ways, which will hold his concentration and allow enough practice to achieve success.
One of the most important skills that children need in school is recording their thoughts and ideas (usually handwriting). For Curtis, who already has difficulty speaking, acquisition of this skill has added significance. He may find handwriting an impossible task to learn (and may eventually have to rely in one way or another on IT) but he is determined to have a go at mastering the necessary skills.
Handwriting is a complex perceptual motor skill resulting in the manipulation of a writing implement to make marks on paper. It also requires the visual perceptual recognition of shapes and the ability to reproduce them and recognise them as meaningful. It is also therefore a cognitive skill in that it has rules which need to be taught and understood, i.e. words (in English) are written left to right, capital and small letters are used differently.
Curtis has problems learning to write for several reasons:
- His sitting balance is not always secure so his stability needs to be checked as regards chair suitability, table height etc. A delicate balance has to be struck, however, because he wants to be the same as everyone else.
- When he’s attempting to use his hands, Curtis manages in various inventive ways to fix shoulder girdle or wrist so as to get maximum control. His hand/wrist and finger control are not yet efficient enough to hold a pencil or crayon firmly or to make consistently recognisable marks or letter shapes.
- He has taken longer than some children of his age to recognise letter shapes.
As indicated earlier, the control of wrist and fingers essential for manipulation of a writing implement is preceded developmentally by control of the area as a whole, that is shoulder girdle ? elbow ? wrist? fingers. Imagine a young child’s first efforts at painting and drawing – brush or crayon held firmly in the whole hand – big movement of the whole arm up, down, round and round. Curtis draws or tries to write most easily like this.
He fixes the paper with his right forearm (taking weight through his right shoulder and elbow) using his left to hold the pencil. Ordinary pencils and even very fat crayons are quite difficult for him to manage.
Recently we came across the Dexball, which uses “a unique method to hold a pen, pencil or spoon in position. A new and innovative product for all those who have a gripping problem”.
It is in fact a ball made of high density foam (two sizes available) and a special fixture to take the implement – spoon or pencil) to be held with a whole hand grasp (rather than a more specialised one involving fingers). It slides easily on the paper so that the whole arm can make the movement for drawing or writing. For Curtis this was a breakthrough and he immediately had much greater control – he was delighted. I’m sure Curtis would want me to say “Thank you” to Insight Medical Products.
For further information contact Wayne at:
Insight Medical Products
Units 1-4 Silk Mill Studios
2 Charton Road
Tetbury, Gloucestershire, U.K.
Tel: 01666 500055
The Dexball is currently available from here.