Introduction to the series
In the first part of this serialised essay I suggested hospital and clinics are not favourable environments to promote education/learning in babies and young children who have conditions that affect their development and learning in the long term. I characterised these medical environments as busy, neurotic and morbid and in the second part set them in contrast to places where, typically, babies and children can be relaxed, inquisitive, respected, secure and ready for learning. In the third part I suggested some moves from the health atmosphere and mind-set towards the education mind-set and in the fourth part offered a very personal perspective in joint working between health and education workers. In the fifth part I explored how and why early child and family support has been wrongly medicalised since the middle of the last century. In this sixth part I will compare and contrast two approaches to helping a child learn to roll – the educational approach and the health approach.
Positive environments for early child and family support. Part 6: contrasting a therapy approach with an educational approach to the early skill of moving on the floor
At the end of Part 5 of this serialised essay I promised in the next part to contrast a therapy approach with an educational approach to the early skill of moving on the floor. My reason for this very practical focus is that ideas and theories in early child and family support must be shown to be directly relevant and applicable to children and parents, otherwise they remain as only ‘academic’ arguments. If I am suggesting changes from a health environment and approach towards an educational environment and approach then I am obliged to describe changes in how children are supported and to show how they will benefit.
In this exercise I am creating situations based on practical experience. While I put the two approaches at the opposite ends of a spectrum, I am aware of all the good work that goes on in the middle. The exercise will help get my argument across about the need for change and it might also be a measuring rod for parents and practitioners to position their child or their work on the spectrum.
A therapy approach to the early skill of moving on the floor
For this, we are a fly on the wall observing a single session in a hospital’s paediatric physiotherapy department or clinic. A baby boy or infant is supine on a therapy mat with a physiotherapist kneeling at his side and the parent nearby but not too close.
The therapist knows the child well. He has significant motor issues with a neurological cause. She had carried out an assessment schedule before attending a multidisciplinary assessment meeting to compare notes with other practitioners and agree a plan for the child’s future treatment. This plan had included regular physiotherapy sessions in the hospital with some home visits if possible.
The therapist is working on the new skill of rolling from supine. Her work to date has shown that the child is developmentally ready for this and she has told the parent what the new task is. She will help the child roll from back to side and observe how he responds. From this she will know how to proceed. She manages the child with kindness.
One approach she uses is to turn the child’s head to one side and to hold it with one hand. She uses the other to press at a particular point on the child’s torso. The child’s knees come up and he rolls to the side. In another approach she initiates rolling by bringing one leg up and over the other which is held straight. She began the session with some relaxation exercises and was careful to practice rolling to both sides from supine. The parent is pleased to see some progress. The child has not been entirely happy with the explorations and has shed a few tears. At some point, in this session or a later one, the therapist will suggest how this new rolling skill could be practised at home.
In very vague terms I have described work that requires deep knowledge of motor development, of infant reflexes and of dangers to be avoided. I hope no one uses my crude outline (written by a teacher and not by a therapist) as a guide to action.
An education approach to the early skill of moving on the floor
We are a fly on the wall now in part of a children’s centre or nursery with one or two staff members and a few babies and infants. Staff members are teachers, early years’ educators or nursery nurses and all referred to here as ‘teachers’. The child we are focusing on has the same motor issues as the child with the physiotherapist above.
One teacher is observing the baby or infant who is lying on his back not doing anything particular. She kneels at his side, talks to him very gently and holds a toy above him. It is a toy she knows he has responded to before so she talks to him about it and jiggles it so it makes its noise. She might even have a familiar song to go with this toy. Seeing that she has got his attention, she slowly puts the toy on the mat to his side. The child shows he is excited now and seems to be trying to turn his head to see where the toy has gone. Still talking or singing to him, she helps him roll with gentle pressure at his shoulder or hip. Once on his side he looks at the toy and she helps him touch it with the hand that is free (i.e. not down on the mat). There is much praise and excitement. She returns him to his back and then plays the same game going to the other side. Quite soon, they both decide the game is over and she changes the activity to something less demanding. When she gets an opportunity she will show the child’s parent what they were doing because rolling to the side is something new which he might do again at home. This staff member makes a note of the child’s response intending to discuss it with colleagues. She wonders if she was helping him in the right way.
Now that I have used two imagined scenes based in my own experience placed at opposite ends of a spectrum, many readers will jump to the same conclusion as me that it would be ideal for the two practitioners to join their knowledge, skills and experience in a joint effort of collective competence (and including the parent who knows so much more about the child). Staying with the ideal, this should happen in an education setting to avoid as much as possible the busy, neurotic and morbid mind-sets and atmospheres in general hospitals. The physiotherapist’s support would be intermittent.
To reinforce my argument, I will compare and contrast the two approaches. The child in the hospital session will be Child A and the child in the education setting will be Child B. There is no reason why they cannot be the same child. For simplicity, practitioners are female and children are male.
- Both practitioners are motivated to help the child and both are bringing their care and skills to the child. Both will share all or some of these skills with the parent so the parent is better equipped to bring up their child.
- Child B is helped in the education setting that is part of his normal life. Child A has had a journey to hospital that has disrupted normal feeding/ sleeping/ playing routines. Child and/or parent might be nervous and apprehensive in the hospital environment and consequently unable to make the most of the session – or even react against it.
- The therapist with Child A might feel that a few tears are inevitable and will sensitively continue the work. The teacher with Child B might want to avoid tears as much as possible and will take comforting a crying child as a priority. It is possible that Child A’s tears come in part from the strangeness of the environment and/or is picking up the parent’s feelings.
- Child A was a patient fitted into a planned treatment slot of fixed duration. There is pressure here for the therapist to make the best of the time available. Child B is in a familiar environment with familiar child-centred routines and is relaxed. He is more or less available for un-forced interactions with staff members depending on many factors including tiredness, mood...
- Both practitioners know the child’s development and learning so far and can judge readiness for new learning. It is possible the therapist had set a rolling-to-the-side target before the session or even at the end of the previous session. The teacher had no such target in mind. She initiated the rolling game spontaneously when the child looked at the toy and some instinct made her move the toy to the side.
- Therapist and Child A might perceive the rolling activity as an exercise, while teacher and Child B saw it as a game (but, for the teacher, of developmental significance).
- The teacher was aware of the Child B’s pleasure/displeasure, attention, interest, motivation, vision, hearing, preference for a particular toy and, perhaps, of an emerging skill of touching the toy with his hands when in an appropriate position in which he could see both toy and hands. All of this came into the game. At the most basic and clinical level, the therapist might have focused only on Child A’s motor activity. [I have seen this basic clinical approach but I assume it is rare. On the other hand, any parent who tries to learn from videos on the internet will see this clinical approach to rolling.]
- Both of these activities could have been in the child’s home with practitioners doing home visits.
I hope this comparison helps justify my ambition for early child and family support to move out of hospitals into education settings and for a child’s on-going development and learning to be considered an education issue rather than a health issue. I acknowledge I have described two opposite ends of a spectrum without describing what happens in the middle where perhaps, therapy becomes less clinical and, regrettably, teachers are less whole-child in their knowledge and skills.
In Part 7 of this essay I shall describe my ideal approach to early child and family support in which paediatricians have a key part to play.
Peter Limbrick, October 2020