Attending To instead of Intervention

Milani`s and Pikler's Influence on the Therapy of handicapped children.

Autor:in - Monika Aly
Textsorte: Vortrag
Releaseinfo: For an interdisciplinary Symposium in Sidney Sussex College, Cambridge. March 21 - 25 1992; organized by: The Internatinal Cerebral Palsy Society
Copyright: © Monika Aly 1997

Attending To instead of Intervention

I began my carrier as a young energetic physical therapist in a rehabilitation Center for spastic children. I was eager to carry out perfect treatments such as Bobath and a little Vojta on children with cerebral palsy. I focused on deficits , the disability. Any improvement on the part of my patient felt like a result of my acts. I realized, that to avoid handicap, I needed to start with small babies and Early Treatment. The parents believed in my so called golden hands more than in the development of their own child. The major theme was the motor development of the little child, so that I considered any progress in movement as an expression of overall progress.

Gradually I became more sensitive to the lives of these handicaped children outside the therapeutic setting. I became curious about attemps in Italy to integrate handicapped children in various nursery- and school programs. So I decided to learn and work for one year in Florence as a student of Milani and Gidoni.

At first I was very proud of being a "tüchtige" (industrious) German Bobath-Physical-Therapist and I was sure that the Institution in Florence would be a very good field for me to perfect my techniques.

Initially I hardly noticed, that my approach to treatment was quite different. Little by little I became uncertain how to treat spastic children. Perfekt according to Bobath, would be to demonstrate posteral positions to the parents or teaching some "handlingexercises" for them to use in their daily lives with their children. When Milani told me that the best physical therapist is "la terapista senza mani", I didn`t get it; what can I do without my hands? I got very upset about this simple statement. It was a real challenge to my professional image and my professional foundation began to crumble.

Gradually I realized that the integration of handicapped children demands a quite different approach to therapy.

As a result of my field work in Florence, I had learned what I no longer wanted to do as physical therapist. But what form my future work with children would take, was still quite unclear. Repetitive exercises like placing the child over a roll or practising equilibrium

on a ball seemed to me to be more and more artificial because these exercises had nothing to do with the child's momentary interests or his everyday life. I no longer found it acceptable to force parents to use these programmed exercises at home as a must, while such exercises were a forced interuption of spontanious activity. But should I gave up these exercises, what was to remain? I was familiar with movement exercises. The child's participation was a sign of my succes as a therapist. I felt competent when I could control the child's body through my properly positioned hands. As a therapist I was used to taking an active part in the therapeutic process, often I was more active as the child himself. At first, it was extremly difficult for me to give up this accustomed role.

Next came a phase of insecurity during which I began to observe how a disabled child moved without my manipulating and correcting hands. I noticed that it was difficult for me not to focus on the more visible movement disorder in order to discover other positive qualities in development which each normal child demonstrates although perhaps earlier. I was impressed by Milani`s clinical examinations in which he appreciated merely through observations "senza mani" the skills and therefore the hidden skills, of a child and could pronounce prognoses. It was not as important to him to cite diagnoses; it was more important to describe a child's competencies in respect to his future in a way that the parents could understand and forsee. Each child, stated Milani, likewise the handicapped child has his own normality which one has to discover and amplify.

I realized more and more, that I had few experiences with the detailed processes in the pysiological development of infants and children and still less insight as to the conditions necessary which would allow independent development. During my observations I began to see that there is a therapeutic level in approaching each child`s handicap, which could appreciate the particular problem of the child as well as his normal development.

With these interests in mind I encountered Emmi Pikler. She was a pediatrician in Budapest and had dealt with the physilogical development of movement in children for nearly a half of a century. Her central thesis was the respect forthe child's own initiatives, as well as for his own personal rhythm as a essential predisposition to indepentent development. What could this concept mean for "my" handicapped children?

During my stay in Loczy, which is the name of the Pikler institution in Budapest, Emmi Pikler emphasized repetitively that she has never worked with handicapped children. Nevertheless there were so many occasions in which Milani's statement "one must amplify the child's individual normality" came to mind through obvious examples here. I realizedduring my first visit that the respect for the competence of a child is not only a question of attitude. I experienced concrete daily routines which took into account the individual needs of a child. Interactions during normal child care practices were such that a child was at no time helpless, but rather was as a competent partner irrelevant of his age. This appeared to be the basis from which a child developed his own initiative. For example, dressing and undressing can be done with the newborn together. In the beginning, the mother has a major role; the child, a participant in the process, becomes more and more an active partner until he can master this activity himself. These very concrete childcare and play-activities in this environmental setting gave me the idea that much of what I had seen, could very easily be applied to the car of handicapped children.

From Emmi Pikler I learned to observe the many minute details in the interaction of the child with himself and his environment, like how an infant prepares his next developmental steps, how long he practices a myriad of variations, before he uses a new position in play. It was new for me how persistently a child, if it's not pushed into its next step, hangs on to his achieved developmental milestones until he is secure enough to again try out something new. That meant that the infant shouldn`t be manipulated into positions when he isn't secure enough to seek them out himself. How much more time might a handicapped child need to feel secure and initiate complexer movements within the realm of his possibilities.

Intervention programs aimed at stimulating development paradoxically can disrupt independent motor development. They cause insecurities by bringing the handicapped child out of his own rythythm, and, above, all they perpetuate dependence on adults.

Are there Similarities between Milani and Pikler?

I was quite impressed during the time that Emmi Pikler spent at our institution with which exactitude she could observe and describe the smallest of movements or play activities, although she frequently emphasized that she knew nothing about handicapped children. She often pointed out to me, during a treatment session, that I was again doing to much, offering too many suggestions for play activities, although I had been convinced I was doing very little, particularily during her presence. For a rather long period of time I was torn between viewing our children as having special "normal problems" or as having "special problems" which needed therapy. With which children is it enough to be a participant observer and with which children, because of their handicapps, must I do more?.When is it too much and when could it be too little? I looked for parallels, but did not believe they would exist;-disabled children need something "special", nonh-andicapped, the "normal". As physical therapist how could I apply my techniques? The more I preoccupied myself with differences between healthy and defect, between pathological and normal development, the more I realized that actually these were not contradictions.

Milani and Gidoni investigate the development of fetal movements. They have discovered the fetus`s ability to move and quiet itself. They have discovered correlations to patterns of movement long before birth; these movements, with which the fetus has for some time experimented, allow for an active participation in the birth process as well as for survival outside of the womb; fetal movments can not longer be relegated to early primitive reflexes. That, according to Milani and Gidoni, the newborn has his own competencies need not further be emphasized here, though perhaps, that both also ascribe competences to a newborn even though he may be premature, or for some other reason congenitively damaged.

Emmi Pikler has not been concerned with the development of the fetus nor with questions such as how active the infant has participated in the birthing process, but she has the same respect for the newborns competences. Pikler's studies concern far more the conditions necessary to optimize the expression of further competence.

Milani and Gidoni have made early prognoses while studying the development of the C.P. child. They decided if it all, the child may benefit from late therapeutic intervention rather than the recently proclaimed multiple early interventions, because, these interfere too soon with the infant's self competence.

Emmi Pikler and Milani do not apply direct interventions. They influence environmental conditions which will support the child`s development. Both give much attention to the child's first contacts with his environment - his first initiative. Milani describes a spiral effect of proposal - counterproposal. Development spirals in a dialogue in which the child effects and responds to interactions compatible with his present competence. The child's new achievements to his creativity lands momentum to the dialogue and it spirals on.

How Has This Indluenced my Approach Today; What is my Concept Today?

I would like to relay an example:

Nora is a brain damaged child; In her extremely slow development, she tries out each developmental step 6 times longer and more thoroughly than most other children. She needs no help in doing this, only a calming milieu, interesting toys and the security of the ground. It was clear from the very beginning, that she would at some time be able to stand. Any intention to help, left her stiff.

She needed a very long time to develop her own concept and strategy for movment. She laid on her back for over one and a half years without being on the least interested in rolling over to touch a toy. She did not allow herself to become confused; she practiced and trained for a developmental step so long until she herself decided she felt secure enough to procede. Her later attemps to maintain her balance were so careful that one hardly noticed she was practicing, but these were enough for her. She eventually learned to stand her way with many detours. At times I tried to correct her, but any touch aimed at change caused such insecurities that she again went back to the ground and began all over again. For our physical therapeutic eyes the, at first, unacceptable "faulty positions" of feet and knees regulated themselves by themselves according to how secure Nora felt. She almost never looked for help; she is with her spastic movments completely independent. She knows, what she can do, and when it is too much. Therapy consisted of providing a setting appropriate to Nora's ability to move around and her cognitive interest. Demands were not so difficult that they demoralized nor were they too boring, that she lost interest. Most important is to accompany her and encourage her in her movement excursions. My hands are close to behind her, or next to her, but do not correct her.

What about the severely handicapped child who will not be able to move against gravity? In this case, it is just as important to focus on to increasing the child's abilities to move at the level in which he feels secure. At first this will be lying in the supineposition. Emmi Pikler states, motor development begins on the back. Isn't that the same for a handicapped child? A severely handicapped infant needs the supine position to be active and to move by himself if only to role from one place to another. It doesn't help this infant at all to be brought into a position or to practise approaching a goal which in the long run will be unattainable. Naturally it needs encouragement to move by providing an exciting environment and motivating toys. Some children may need, in addition, careful assistence in movement. In contrast to a therapy with stimulation I call this a caring therapy in which I also use my hands. My role as therapist is, as for each child, 1. I observe development (which takes place here very slowly) and I make sure that the child has the necessary preconditions for development; for example: caring attention, appropriate toys, environmental structures, and ortheses. It is important, after an initial assessment, to have an idea about prognoses. If one is aware of the child's potentials for development he can be offered the appropriate setting he needs relevant to the appropriate developmental phase.

If the demands are set too high, the child may lose interest. Goals, the child can't reach by his own efforts, will be discouraging and frustating. In this manner he will neither learn to estimate his abilities nor to see results as his own success. He remains dependent.

In order to present my concept more transparently and also to demonstrate that such therapeutic changes need a special milieu, I would briefly like to tell you about our practice in the Ambulatorium der Pikler Gesellschaft:

12 years ago we established the first Ambulatorium as a center for medical and physical therapy as well as a psychological counseling for handicapped children and their parents. As of 1991 we have two institutions with 18 interdisciplinary team members consisting of physical-, occupational and speech therapists, psychologists and pediatricians and educationalists. Our tasks are, on the one hand, to counsel and accompany parents of handicapped children, as well as to other therapy as needed to the children. On the other hand we offer support and counseling to preschools, which have integrated handicapped children. On occasion we also offer counseling to the schools. In that way we accompany children and the families through a longer period in their lives. Family counseling takes on a larger role than therapy.

Practically it looks like this: Parents come to us in order to present their "problem" child. They expect from us, as everywhere else, an offer of therapy which will alleviate their concerns. We begin with a long assessment period through observations, which may be divided over a number of sessions in which we place the child in a- for-him-planned-setting. We watch what the child does with this. If he prefers to sit on his parent's lap we watch what he does there. At the same time we take a thorough history from the parents and listen to their concerns and wishes. Our main emphasis is on observation: observation of communication, of movement, of the child's strategies and planning during his play. After a sufficient observation period, we share our assessments with the parents and suggest an appropriate therapy form for a limited time period. A child is assigned to one of our therapists depending upon his needs or deficits, and the therapy may emphasize either movement, speech, or occupational support. Adjunct problems calling on the expertise of another team member may be handled in our numerous team sittings. Alternatively we offer, for example Ki-Aikido groups for school age children. Through this martial art for self-defense the children learn a combination of movment, breathing exercises and meditation, which give them a feeling for themselves in their bodies. Handicapped as well as normal children, who participate in our groups, learn to have a sense of mastering their movments through encountering difficult situations with one another. This is not therapy, rather a free-time-activity.

Early treatment no longer means early intervention for me. Early treatment means recognizing the infant's developmental compentencies by observation and arranging an environment which will allow their expression. That means "to attend to" the parents and help them to arrange appropriate tasks. Milani calls this task-management. Of course you would say we are losing time. I would say, through early treatment I am more likely to lose the child and his parents. Parents need time a lot of time to become close to their child to accept him as he is and to live an everyday life together. The way is long, and need not be complicated by parents becoming co-therapists.

We all know that inspite of the many neurophysiological methods, certain damage is irreversible and cannot be altered. We can, however, influence personality development in the handicapped child in that we attempt to assist his environment to adjust to him. In that way the child has the opportunity to increase his competencies not only in the therpeutic setting. Therapy should ask questions and elucidate problems rather than offer solutions. A child learns trough difficult tasks, if appropriate for him and through this experience, he will widen his own possibilities to confront the increasing complexity of his life.

Through experiences he will learn to be more conscious of his abilities as well as the limitations inherent to his disorder, and thus learn to live more independently.

Therapy of handicapped children need not longer be a long-term project. We accompany a child and his family and as needed, after short-term problem oriented interventions - we are available.

For our future in the next twenty years, Anna Gidoni and I suggest the folloing slogan:

From treatment to "attending to" by observation.


Monica Aly: Attending To instead of Intervention - Milani`s and Pikler's Influence on the Therapy of handicapped children

Interdisciplinary Symposium in Sidney Sussex College, Cambridge. March 21 - 25 1992

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