Background

Welcome to the wonderful world of movement and learning! Founded in 1999 by Sheila Dobie OBE (originally known as INPP Scotland) the Movement and Learning Centre has a well-established history of assessing and successfully treating children, adolescents and adults with learning and behavioural difficulties.

Movement, learning and behaviour

Movement is something we mostly take for granted except when sometimes it goes wrong. In most cases from conception, through gestation, from birth through childhood, adolescence and into adulthood, coordination, balance and postural control develop perfectly adequately and individuals lead a quite normal life of movement.

Of course in some unfortunate cases of congenital brain dysfunction such as cerebral palsy or of degenerative brain conditions such as Parkinson’s disease or multiple sclerosis motor control will be significantly impaired. However, beyond these medical conditions it is now recognised that motor control can be significantly impoverished in the absence of any identifiable pathology and that this has implications for learning, behaviour and emotional functioning.

Clinicians and academics acknowledge that there is considerable overlap of symptoms associated with specific learning difficulties such as dyslexia, developmental coordination disorder, attention deficit disorder/attention deficit hyperactivity disorder and autistic spectrum disorder. This is referred to as comorbidity. Among the range of presenting symptoms associated with these specific learning difficulties are difficulty with coordination, balance and postural control. Individuals who may experience difficulties in learning, behaviour and emotional control but who have not been diagnosed with a specific learning difficulty may also present with coordination, balance and postural control problems.

In the absence of any identifiable pathology difficulties with coordination, balance and postural control are likely to be a result of certain aspects of early development which may not have unfolded appropriately, which then subsequently adversely impact on later aspects of development. Appropriate intervention has the capacity to significantly address these developmental issues.

A Brief History of Neuro-Motor Dysfunction
Originally neurologists used the term minimal brain dysfunction to describe the condition of individuals who presented with abnormal functioning in the absence of any identifiable pathology. As further understanding of this condition was developed terminology changed to organic brain dysfunction, which began to acknowledge that it was how the brain was connected up that underpinned an individual’s difficulties. This then further developed into neuro-developmental delay to indicate that it was how very early development from conception onwards had unfolded that had implications for later development, learning and behaviour (Blythe and McGlown, 1979). This term also provided hope in that the condition was considered one of delay rather than a permanent deficit. Currently the term neuro-motor immaturity appears to be in vogue (Goddard Blythe, 2009).

The Function of Movement in the Normally Developing Child
Dr Geoffrey Waldon was a neurologist working with children with significantly delayed development. Over the course of his career he developed a theory of child development associated with the fundamental importance of movement. His clinical experiences suggested to him that a child develops fundamental learning and general understanding about himself or herself and of the world through movement. This general understanding is the foundation from which all specific aptitudes and skills develop. This includes motor control since as it develops it encompasses all earlier development and learning (much more on this later). This has powerful implications for understanding later functioning and behaviour since if there have been gaps in early stages of development or if these early stages of development have not been secured then the neurological foundations in support of later development are likely to be weak.  Waldon left little documented accounts of his work but those that he did can be accessed from the Waldon Association website (www.waldonassociation.org.uk).

In support of this understanding of children’s movement Dr Colwyn Trevarthan, emeritus professor of child psychology and psycho biology at the University of Edinburgh, in conversation, said that if we really want to understand how children learn best we should study them from birth to 36-48 months of life. During these early stages of development learning to control the body is extremely effortful requiring considerable attention. It is also very pleasurable and joyful for the developing child! As the child develops increasing mastery of its body less attention is required and the child can begin to attend more to their surroundings than to the body. If development unfolds normally it is likely that the child will develop readiness for starting formal education and be able to respond appropriately to the demands of schooling.

However, in the UK teachers report an increase in children with difficulties in functioning in the classroom. Difficulties reported include fidgety behaviour, difficulty sitting still, poor hand writing and manual dexterity skills, poor concentration and attention, poor emotional control, weak inhibition, difficulty following sequential instruction and poor engagement with learning tasks. An underlying factor associated with these symptoms may be poorly developed coordination, balance and postural control. The good news is that these presenting difficulties are unlikely to be permanent, more a delay in development, which with the right intervention can be remediated to the benefit of the child’s learning, behaviour and emotional development.
Based on the recognised neurological plasticity of the brain these stages of motor development may be described as experience expectant, unfolding through normal brain maturation and the opportunity for the child to interact with his/her environment (play). This is observable in child development throughout the world largely regardless of race and culture. Later development may be described as experience dependent which is influenced by culture including formal learning/education.

How the Brain Produces Movement
From birth the child is equipped with a range of responses to stimuli in the world beyond the womb. These are referred to as primitive reflexes which are involuntary motor responses to specific stimuli and are mediated at the level of the brain stem (where the spinal cord enters the brain). These primitive reflexes have an important role in the survival of the developing baby in the early days, weeks and months of life and also lay the foundations for later development. These are normally active for approximately 6 to 12 months by which time they should become inactive as they are no longer required as higher centres of the brain develop to produce more mature neurological functioning. In the normal population primitive reflexes are reliable indicators of neurological maturity. Primitive reflexes should be active for 6-12 months and inactive beyond that point (Goddard Blythe, 2009). Retained primitive in the normal population can potentially have an adverse effect on all aspects of later development including coordination, balance, postural control, sensory processing, emotional development and cognition.

Examples of Primitive Reflexes

Tonic Labyrinthine Reflex (TLR)
The TLR is present at birth. When the baby’s head is flexed with the chin on the chest an automatic muscular contraction occurs down the front of the baby causing the baby to curl up. When the baby’s head is extended with the chin pushed out an automatic muscular contraction occurs down the back of the body and arms causing the baby to arch.
If this is retained beyond when the child achieves bipedal movement this will cause problems with balance and postural control.

Asymmetrical Tonic Neck Reflex (ATNR)
The ATNR is present at birth. Rotation of the baby’s head to one side results in the arm and leg on the side to which the head is turned tending to straighten and the arm and leg on the opposite side to which the head is turned tending to bend.

If this is retained beyond when the child achieves bipedal movement this will cause problems with balance and postural control. This will also adversely affect the development of mature coordination of the limbs in producing locomotion when crawling on the stomach, creeping on hands and knees and walking. Eye tracking can also be adversely affected with consequent difficulties associated with following a line of print for reading.

Symmetrical Tonic Neck Reflex (STNR)
The STNR emerges at about 6-9 months after birth. In the prone position lifting the head and pulling the knees under the body causes the arms to straighten and the bottom to sit on the heels. On hands and knees when the head drops forward the arms bend and the bottom is extended in the air.

Controlled voluntary movement gradually unfolds through a process known as adaptive responses or purposeful goal directed movement (Ayres, 2005). Higher centres of the brain including the frontal cortex are involved in planning and executing movement. Once a possible plan of neurological pathways to initiate movement has been formulated the primary motor cortex takes over to trigger the movement response. Thereafter the cerebellum is engaged in producing a coordinated movement response. Feedback from the movement allows for future adjustments to the neurological pathway thereby producing ever more controlled movement (Ratey, 2001).

This process is extremely effortful initially. However, neurological pathways established to produce movement are strengthened through repetition until such times as movement becomes largely automatic and relatively effortless. Awareness of our movement retreats to the recesses of our mind (Gallagher, 2005) only to come to our attention, for example, when learning a new movement task, when we stub our toe when walking or if we are standing at the edge of a high cliff!

Motor development proceeds in recognisable stages following three major gradients.
1.    From lower to higher brain centres;
2.    From head to toe (gross motor coordination of the muscles of the neck, trunk, shoulders, arms, hips and legs);
3.    From central to peripheral parts of the body (fine motor coordination of the feet and toes, hands and fingers, face, tongue and eyes).

This describes the normal stages of motor development in the developing child;
1.    Moving all four limbs in the same way at the same time;
2.    Moving the arms together in the same way;
3.    Moving the legs together in the same way;
4.    Moving one arm separately from the other;
5.    Moving one leg separately from the other;
6.    Moving an arm and leg on the same side of the body;
7.    Moving an arm on one side of the body with the opposite leg

Timeline for normal early motor development from 0-16 months.
Reflexes            TLR                        0-2 months
                            ATNR                     0-5 months
                           STNR                     5-11 months

Motor control        Head lift prone                                         0-2 months
                               Sits with support                                      2-4 months
                               Rudimentary reach and grasp              3-6 months
                               Sits without support                                6-7 months
                               Controlled reach and grasp                  6-9 months
                               Rolling front to back/back to front         4-8 months
                               Looking at and reaching for objects    5-9 months
                               Pincer grip                                                 7-8 months

Locomotion          Crawling on the stomach                 6-8 months
                               Creeping on hands and knees        9-11 months
                               Walking                                                11-16 months  
 
(Goddard Blythe, 2009; Eliot, 1999)

Ideally from a developmental point of view it is desirable for the child to pass through the stages of locomotion of crawling on the stomach, creeping on hands and knees and then walking. In each of these stages recognisable stages of control, or patterns of locomotion, can be observed.

Crawling on the stomach:
Following mastering control of the head in the prone position controlled movements of the legs appear. This is followed by attempts to move forwards by the arms pulling the rest of the body along or the legs pushing the rest of the body. At this stage upper and lower limbs do not coordinate (called homologous movement). Next coordination of the arm and leg on the same side of the body appears (called homolateral movement). Finally if everything developmentally has unfolded normally coordination of the arm and opposite leg emerges (called contralateral movement). This is the mature and desired pattern of locomotion.

Creeping on hands and knees:
Following the emergence of the STNR the baby acquires support of its body in the quadruped position i.e. hands and knees. Initial attempts to move may involve ‘bunny hopping’ forwards or backwards with the upper and lower limbs not coordinating (homologous). Following this movement is produced by the hand and knee on the same side of the body coordinating (homolateral). Finally coordination of the hand and opposite knee emerges (contralateral).

Walking:
Following pulling to standing at about 9-10 months initial attempts at walking produce what is known as the simian movement pattern with the arms held up as the legs stumble forwards (homologous). As balance becomes more secure arms and legs then swing together on the same side (homolateral). Finally, the arm and opposite leg coordinate to produce walking (contralateral).
If any stage of locomotion is either omitted or the child progresses too quickly through a stage to allow the appropriate neurological pathways to be secured, this may adversely affect later developing stages of locomotion, coordination, balance and postural control.

Balance and Postural Control
Balance is controlled via the vestibular system located in the inner ear. The vestibular system consists of two main structures. First, there is a complex structure of semi-circular canals. These register rotational movements of the head. Second, there are the otolith organs. The otolith organs consist of the utricle which registers head tilts and the saccule which registers linear movements (Bear, Connors and Paradiso, 2001).

Postural control emerges from the stage of developing head control in the prone position, progressing through stages such as sitting unsupported, kneeling/creeping on hands and knees and then finally standing/walking. The maintenance of balance and posture occurs through a process of modulation. The vestibular system sends information to the brain regarding the status of the body in relation to gravity. The motor centres of the brain then sends information through the Central Nervous System and onward via the peripheral nervous system to muscles and joint to maintain normalised muscle tone and appropriate joint alignment to maintain postural stability and balance control. Normalised muscle tone refers to the minimum level of muscle tension needed to maintain posture and balance. This is contrasted with rigidity, too much tension and flaccidity, too little tension.

The Somatosensory Cortex
The somatosensory cortex is an area of the brain where a map of the body’s surface is located providing an internal reference point for where we end and space around us begins. This body map is referred to as the body schema and is a system of sensory-motor capacities that function without awareness or the necessity of perceptual monitoring (Gallagher, 2005). This allows for sub-conscious monitoring and control of coordination, balance and postural control. This is not to be confused with terms such as body image (a combination of a subject’s perceptual experiences of his/her body, conceptual understanding of the body in general and affect or emotional attitude towards one’s own body).

The body schema develops and is constantly being updated from a number of inputs including proprioceptive information from movement, muscle contractions, joint movement, touch, balance and vision (Gallagher, 2005). Gradually the map of the body’s surface is built up so that the map includes an awareness of back and front of the body, top and bottom and right and left. This precedes the child’s acquisition and understanding of the abstract language describing back and front, top and bottom and right and left.

Proprioception is our sense of knowing where different parts of the body are and to carry out complex manoeuvres without conscious awareness. This term is often incorrectly used interchangeably with kinesthesis. Kinesthesis refers to sensations arising from muscle contraction. Proprioception encompasses all sensations involving body position, either at rest or in motion.     

Peripersonal space refers to the space immediately around the body to the front and back, above and below and left and right (Blakeslee and Blakeslee, 2007). This initially extends only as far as the surface of the baby’s body, hence the importance of lying on the back and also “tummy time” which begins to map out back and front. Then as the baby starts to move its arms and legs peripersonal space begins to extend as far as the child can reach and further extends awareness of space around the child and starts to map right and left. The development head control in the prone position and movement of the lower legs identifies top and bottom space.

Peripersonal space has different significance depending on culture. For the British, north Americans and I suspect also Australians peripersonal space may be described as follows.

Intimate space – extends from the surface of the body to about 6-18 inches away. This is space for embracing, comforting etc.

Personal space – extends 18 inches to 4 feet from the body and is space for speaking to a friend.

Social space – extends 4-12 feet from the body and is space for speaking to acquaintances, strangers and superiors at work etc.

Public space – extends from 12 feet outwards from the body. This is space for addressing a group or audience etc.

Movement and Cognition
For the most part motor development and cognitive development have been studied separately and considered as independent phenomena. Cognitive development has occupied an exalted status in comparison to movement and has been viewed as the last aspect of development to fully mature. This has ignored the fact that motor development is just as prolonged and developmental improvements in coordination can be observed into adolescence. With the development of more advanced methods of measuring brain activity it is now considered that motor development and cognition may be more interrelated that has hitherto been considered to be the case.

Cognitive activity takes place in the frontal cortex which occupies the entire front half of the brain. This is the seat of centres for working memory, motor planning and the ability to inhibit competing stimuli, thoughts and actions (Ratey, 2001). The cerebellum, on the other hand, has been considered to be primarily involved in producing controlled voluntary movement, regulating balance and maintaining postural control (Diamond, 2000). Evidence from functional neuroimaging indicates that both of these areas are intimately involved in cognitive and movement tasks.

It has been shown that the frontal cortex and cerebellum are jointly activated when (1) a cognitive task is difficult as opposed to easy, (2) a cognitive task is new as opposed to familiar and practiced, (3) conditions of the cognitive task change as opposed to when they remain stable and predictable, (4) a quick response is required as opposed to longer response times being acceptable, and (5) one must concentrate instead of being able to operate automatically and effortlessly. Equally the cerebellum is most active during the early stages of learning a new movement task or when conditions change. Once a motor task is no longer novel cerebellar activity decreases.

It is also confirmed that motor impairments are evident in individuals with specific learning difficulties further supporting the view that the cognitive and motor systems are not as separate as has been traditionally thought. However, cognitive and motor difficulties do not always co-vary. Not all individuals with cognitive impairments have motor difficulties and not all individuals with motor problems have cognitive difficulties. Nevertheless, clinical evidence accumulated over the last 40-50 years by developmental practitioners across the globe would strongly suggest that this may be the case more times than not!

Attention
Four distinct components comprise the attention system, which collectively create the brain’s capacity to monitor the environment. These are (1) arousal, (2) motor orientation, (3) novelty detection and reward and (4) executive organisation (Ratey, 2001).

Arousal is the ability to suddenly increase alertness. Incoming information from the senses or thoughts can arouse us for further analysis and consideration. Motor orientation of the body and the sense organs towards the source of the arousal then takes place. Novelty and reward analysis then unfolds taking note of new stimuli and assigning and emotional value to a stimulus. Executive organisation commands our actions. Malfunction of any of the 4 components of the attention system can result in inappropriate motor responses. This may be observed in impulsive behaviour and difficulty with inhibition. A pattern of behaviour such as “act first, reflect after” may ensue in contrast with a more mature behaviour sequence such as “pause, consider then act”.

The brain has a limited capacity for attention and tends to operate in two modes referred to as System 1 and System 2 (Kahneman, 2011).

System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. System 2 allocates attention to effortful mental activities that demand it. This pool of mental effort is shared between all variants of voluntary effort, cognitive, emotional or physical. The operations of System 2 are often associated with the subjective experience of agency, choice and concentration. The extremely diverse operations of System 2 all require attention and are disrupted when attention is drawn away.

Examples of the automatic activities that are attributed to System 1 include:

•    Detect on object is more distant than another;
•    Answer 2 + 2 = ?;
•    Drive a car on an empty road;
•    Sit still;
•    Walk on flat ground.

Examples of activities that require the attention of System 2 include:
•    Count the number commas on page 8;
•    Calculate 17 x 34 mentally;
•    Make a right turn in a car on to a busy road;
•    Learn a new skill e.g. handwriting, tying shoelaces or sports techniques.

System 1 is effortless and this is the default mode we would like to be in most of the time.

System 2 is effortful and also lazy! As we become more accomplished in a task requiring System 2 the demand for energy decreases. A general “law of least effort” applies to cognitive and movement tasks. Simply put if there are several ways of achieving the same goal, people will tend to gravitate to the least demanding course of action. Whenever effortful activities require sustained attention our natural inclination is to accept an outcome that is close enough. This is the case if an activity is one of cognition or of movement, balance or postural control.

Normal development ensures that movement, balance and postural control develop to the point of automaticity and under the control of System 1 requiring little or no attention and effort. When difficulties with movement, balance and postural control exist System 2 is required to devote attention and effort to these functions reducing the capacity to pay attention and give effort to other aspects of functioning.

How can we assess for neuro-developmental delay?
As noted above primitive reflexes are involuntary physical responses to specific stimuli that develop in-utero and are present at birth. These reflexes provide the baby with basic responses to the world outside the womb, help the baby to survive during the early days, weeks and months of life and provide the foundations for later development. Primitive reflexes have a limited period of activity and gradually become inactive as higher centres of the brain develop. The reflexes are active for between 6 to 12 months after which time they should become dormant. They therefore are reliable
indicators of developmental maturity. By using standard non-invasive neurological tests for the presence of primitive reflexes at stages beyond the first year of life should reflexes have remained active this indicates that an important early developmental milestone has not been reached and this can have adverse implications for later development including coordination, balance and postural control, perception, attention, emotional development and cognition.

Further indication of neurological maturity comes from postural reflexes. As primitive reflexes become inactive a range of mature responses called postural reflexes begin to emerge. These responses contribute to automaticity of postural control and fluidity of movement in the bipedal position i.e. on two feet. These should be fully developed by approximately age 3 ½ years. Therefore should they be underdeveloped or absent beyond this age this is another indicator of neuro-developmental delay.

References

Ayres, J (2005)                Sensory Integration and the Child
                                            Western Psychological Services, Los Angeles    

Bear, M.F, Connors, B.W.                     Neuroscience – Exploring the Brain
and Paradiso M.A. (2001)                   Lippincott, Williams and Wilkins, Baltimore
                        
Blakeslee, S and Blakeslee, M (2008)     The Body Has A Mind of its Own
                                                                          Random House, New York

Blythe, P and McGlown, D (1979)    An Organic Basis for Neuroses and Educational Difficulties Insight Publications, Chester, England

Diamond, A (2000)    Close Interrelation of Motor Development and Cognitive Development and of the Cerebellum and Prefrontal Cortex.
                                      Child Development71:1:44-56

Eliot, L (1999)                What’s Going On In There?
                                         Bantam Books, New York

Gallagher, S (2005)            How The Body Shapes The Mind
                                               Oxford University Press, Oxford

Goddard Blythe, S (2009)        Attention, Balance and Coordination
                                                      Wiley-Blackwell, Chichester, England

Goddard Blythe, S (2012)    Assessing Neuromotor Readiness For Learning
                                                  Wiley-Blackwell, Chichester, England

Kahneman, D (2011)            Thinking, Fast and Slow
                                                  Penguin Books, London

Ratey, J (2001)                      A User’s Guide to the Brain

Waldon Association             www.waldonassociation.org.uk