Development of Childhood Occupations

Neuromaturation

Neuromaturational theory has been used frequently to explain motor development.^34,76 According to neuromaturational theory, brainstem structures develop first, as evidenced by the reflexive responses of the newborn (e.g., automatic grasp, asymmetric tonic neck reflex), which are controlled by neural pathways originating in the brainstem. Cortical structures appear to develop later, as evidenced by the coordinated and planned actions of the child. The infant’s increasing control of action and movement indicates not only development and myelination of the midbrain and cortical structures, but also simultaneous inhibition of brainstem control of movement. Three primary principles of neuromaturational theory are recognized:

In assuming a hierarchy of CNS function, the neuromaturational theory limited the thinking on how a child learns to act in the environment. Using current research models,^{47,52,100,102} it has become apparent that multiple variables at different levels influence the child’s skill development. The child learns occupations through interaction with his or her environment rather than through the emergence of a predetermined scenario reflecting neuromaturational principles.⁵⁷

Development as an Interplay of Intrinsic and Environmental Factors

Piaget expanded our understanding of a child’s maturation by emphasizing that development occurs through the interplay between the environment and the child’s innate abilities (see Chapter 2).⁸³ Piaget emphasized the maturation of cognitive structures that enable the child to understand the environment, language, and social action. Infants develop an understanding of the world by interacting with the environment. The impact of environment on the child’s development changes as the child becomes increasingly able to assimilate the complexities of physical and social events. Piaget also believed the development is stagelike and discontinuous. The infant is an active learner who is motivated to learn about the world. Piaget documented the child’s maturation through stages to the acquisition of symbolic thought and formal cognitive operations. The developmental stages follow a predictable sequence but vary to the extent that they reflect genetic endowment and the child’s experiences. This interplay between the child’s abilities and his experience can be appreciated in the early development of tool use. Piaget observed that children at 8 to 10 months manipulate two objects and can move an obstacle to reach an interesting or novel object. By 12 months, infants can relate an object to other objects, in addition to relating the objects to themselves. At this stage, infants use a stick to rake in an object out of reach and place objects into containers. By 18 months, infants begin to use trial and error to solve problems. At 24 months of age, they no longer exclusively need physical manipulation to solve problems and begin to demonstrate use of mental manipulation.^73,83

Research studies in the 1990s demonstrated that cognitive structures develop at earlier ages than Piaget assumed; they have also demonstrated that child development has more continuity and integration across the stages of development.^13,37 Infants as young as 1 month demonstrate the ability to associate learning from one sensory system with another sensory system. For example, they recognize objects with their eyes that they previously felt in their mouths.⁷⁰ Researchers have also found that 9-month-old infants can remember an event 1 week after it happened.⁷⁵

Other research that has updated Piaget’s demonstrated that toddlers can manipulate and use tools and can solve problems such as how to grasp and use a spoon. McCarty and colleagues found that children 9 to 14 months of age picked up the spoon using an awkward grasp and then attempted to adjust the spoon’s orientation to get the food into the mouth.⁷³ Children 19 months old planned how to grasp and orient the spoon to get the food before acting, avoiding the use of an awkward grasp that required adjusting. This study showed that children as young as 19 months can solve problems without physical manipulation and trial and error to handle a tool accurately. By this age, the child can scoop food, fill the spoon, and correctly angle it toward the mouth,⁵⁶ signifying the early emergence of tool use.

Scholars have critiqued and expanded Piaget’s original theories to fully appreciate how the environment influences development. For example, Piaget’s theories lack appreciation of the influence of culture, society, and technology on children’s development. Current occupational therapy theories consider these variables to have important roles in a child’s development.^10,116 In addition, Piaget’s theories did not address the development of emotions and did not have a coherent explanation for individual differences, individuality, or variability.³⁷ The importance of variability has been highlighted in the work of other psychologists^100,103 and by occupational therapy researchers.⁵⁹

The Influence of Social Interaction

Following Piaget, another developmental theorist, Vygotsky, believed that children learn through social interaction.¹⁰⁹ Vygotsky’s theories emphasized the importance of culture and shared participation in culturally valued activities to children’s development. He demonstrated that children learn when scaffolding, or support, is provided by caregivers and teachers. Parents and other family members intuitively provide environmental challenges that encourage the infant to exhibit a higher skill level and then support the infant’s efforts to reach that level. Parents and siblings naturally promote the infant’s development by modeling actions, assisting the infant’s first attempts to perform an action, and reinforcing his or her efforts with praise and expressions of delight.

Vygotsky explains the role of social interaction in children’s development by defining a “zone of proximal development” as “the distance between the actual development level as determined by [the child’s] independent problem solving and the level of potential development as determined through [his] problem solving under adult guidance or in collaboration with more capable peers” (p. 86).¹⁰⁹ He believed that what children can do with the assistance of others was more indicative of their mental development than what they could do independently. When presented with a just right challenge, e.g., a task that is slightly more difficult than the tasks the child has currently mastered, the child generally attempts and succeeds in this challenge, thereby learning the next step in skill development.

Vygotsky and the many subsequent developmental theorists have examined how human development transpires through a dynamic interplay involving the child and the child’s cultural, social, and physical environments. Researchers of child development have documented differences in the rate of development in socioeconomic groups, regions, and individuals. For example, rates of development appear different in rural versus urban areas.^106,108 Children’s rate of development also differs among cultural groups and generations, in part because of differences in nutrition and child care practices. In human development research, the emphasis currently is on the variations expressed by individual infants and on how human systems and environmental constraints contribute to these variations.

Studies that analyze the uniqueness of individual performance often use longitudinal and qualitative approaches to analyze the performance of children over time and in natural contexts.^11,102 Because these longitudinal studies document the patterns of development over time, they uncover how individual systems are constructed and assembled. Longitudinal approaches make it possible to relate transitions of subsystems to each other and to other dynamic growth parameters.¹⁰⁸ Understanding how children acquire qualitative differences in functional performance and how they become unique individuals can begin by focusing on the variables that influence a child’s developmental course. The following sections examine current theories of development that explain the relationships among a child’s biological functions, occupations, and environments.

Dynamical Systems Theory

Dynamical systems theory refers to performance or action patterns that emerge from the interaction and cooperation of many systems, both internal and external to the child.¹⁰¹ In the context of child development, performance patterns emerge from the interaction of an individual’s systems and performance contexts as the child strives to achieve a functional goal.^71,72 The dynamical systems theory is useful in describing how specific motor and process skills develop.

In this model, a child’s behaviors and actions are initially highly variable, with many degrees of freedom. The first actions of the infant have been described as random and uncontrolled. Development of skill proceeds by means of constraint of these degrees of freedom as the child gains control of his or her actions. Behavior, therefore, is not prescribed by a hierarchical arrangement of the CNS, but rather emerges from external and internal constraints.⁹⁷ These constraints provide information to the brain and body systems that set the boundaries or limits for the child’s behavior.²²

Humans are complex biological systems comprising many subsystems (e.g., motor sensory, perceptual, skeletal, and psychologic subsystems). These subsystems are in constant flux, interacting according to the task at hand and conditions in the environment. The child’s actions during the performance of a task, therefore, are the result of the subsystems’ interaction with each other and with the environment. These individual systems come together and self-organize in a coordinated way to achieve the child’s goal.⁹⁷ For example, initially a child is interested in exploring the sensory characteristics of a toy. As he or she reaches for the toy, grasps it, and brings it to midline in hand-to-hand play and then finally to the mouth, the child’s attention and cognitive focus are not on planning each of these actions. Instead, they are on assimilating the toy’s actions and perceptual features.

Longitudinal studies reveal that children demonstrate unique trajectories of development and that variations in functional performance among children persist into adulthood. Thelen and her colleagues demonstrated the uniqueness of motor development in a study of reaching in 4- and 5-month-old infants.¹⁰² Each 5-month-old infant was able to reach toward an object, but the patterns demonstrated were unique. Some infants demonstrated a slow, cautious first approach to the object, whereas others made ballistic arm movements in an attempt to reach it. Although all first reaches tended to be circuitous, the amount of correction made to obtain the object, the speed at which the attempt was made, and the angle at which arms were held were different. These investigators concluded that the development of reaching did not reflect changes in a single factor, but rather to reach and grasp an object, the infant needed to (1) be motivated, (2) localize the object in space, (3) understand that the object was reachable, (4) plan the trajectory of the reach, (5) correct the movement as the hand approached the toy, (6) lift and stabilize the arm, and (7) grasp the object. How a 5-month-old infant manages all of these components to reach and grasp a toy successfully varies among infants and for different reasons.

In a similar way, between 8 and 10 months, most infants acquire the motivation to be independently mobile. The need to self-initiate movement from place to place emerges as an important task, or goal, to accomplish. This goal reflects the infant’s curiosity about the environment, a desire to explore space, and a determination to reach a specific play object. Although mobility becomes a common goal for the infant toward the end of the first year, the method used to achieve that mobility varies greatly. Some infants roll to another space in the room, whereas others scoot on their buttocks in a sitting position. Some infants push backward while lying in a prone position, and others creep forward to explore their environment. How the infant achieves mobility is influenced by many contributing body systems (e.g., strength, coordination, and sense of balance and movement). Conditions in the environment also influence infant mobility (e.g., the surfaces on which the child plays, the encouragement provided by caregivers, and the way in which the task is presented). The child’s energy level, motivation, and curiosity about the environment also influence when independent mobility is achieved. In addition to the factors that influence the maturation of mobility skills, becoming mobile influences the development of skills in other performance domains. When an infant achieves mobility, he or she becomes more independent in initiating a social interaction or in seeking help. Therefore, independent mobility contributes to the acquisition of social skills, self-determination, problem solving, and motivation to explore (see Chapter 21). A child learns perceptual skills, spatial relations, form perception, and object relations by moving through the environment.

Perceptual Action Reciprocity

Perception and action are interdependent and inextricably linked. An individual’s perception of the environment informs action, and the individual’s actions provide feedback about movement, performance, and consequences in the environment. Initially, many of the child’s actions are exploratory in nature—that is, the child moves fingers over the surfaces of objects to learn their shape, texture, and consistency. The child waves an object in the air to hear the sounds it makes and feel its weight. These actions help the child perceive sensory and perceptual features (affordances) of objects. Affordance is the fit between the child and his or her environment.^46,48,49 The environment and objects in it offer the child opportunities to explore and act. This action is based on what the environment affords, as well as the child’s perceptual capability to recognize affordances in that environment. For example, colorful noise-making toys afford manipulation because they have movable parts and rounded surfaces and fit easily into an infant’s hand. Learning about affordances entails exploratory activities. Individual finger movements, thumb opposition, hand-to-hand transfer, and eye-hand coordination are facilitated by the physical characteristics of the toy.

Manipulation is guided by visual, tactile, and kinesthetic input.^86,94 Exploration of objects begins with visual exploration and mouthing.⁸⁷ By 6 months, infants prefer exploring with their eyes and hands.⁸⁶ Fingering and manipulation skills increase substantially between 6 and 12 months, enabling infants to gather more precise information about objects. By 12 months, infants detect object properties with increasing specificity and learn to adjust their exploratory action.¹ For example, to perceive the consistency of a soft, squishy object, a child squeezes it, and to perceive the texture of velvet or corduroy, he or she runs the fingers back and forth over it.

Through object manipulation, the child develops haptic perception (i.e., an understanding of objects’ shape, texture, and mass). Bushnell and Boudreau propose that specific motor skills are required to develop haptic perception.¹² They note that infants learn to identify an object’s sensory qualities (e.g., texture, consistency, temperature, contour) only when they develop the motor skills to explore each different sensory quality. For example, an infant does not accurately discriminate texture until he or she can explore texture by moving the fingers back and forth (at about 6 months). The child also cannot discriminate hardness until 6 months, when he or she can tighten and lessen the grip while holding an object.¹² Because configural shape requires that two hands be involved in exploring an object’s surfaces, children typically cannot accurately perceive shape until 12 months. By 2½ years, children can identify common objects through their haptic sense, and by 5 years, children recognize common objects using active touch (without vision).¹⁶ By 5 years, the child has also fully developed in-hand manipulation skills,⁸² suggesting that haptic perception develops in association with the child’s development of manipulation skills. Maturation of haptic perception and manipulation underlies the child’s ability to use tools for written communication (e.g., handwriting and keyboarding) and activities of daily living.

Functional Performance: Flexible Synergies

As mentioned, the infant begins life with few constraints on performance, which permits the greatest variability in the system for the generation of spontaneous movements. This variability permits flexibility for exploration of the environment and rapid perceptual and cognitive learning. The infant quickly selects functional synergistic movement patterns. For example, from birth the infant demonstrates a pattern of hand-to-mouth movement (e.g., for self-calming by sucking on a fist) (Figure 3-1). Only minimal adaptive changes are made in this synergistic pattern (shoulder rotation and horizontal adduction, elbow flexion and forearm pronation, followed by supination and neutral wrist position) as the child learns to self-feed with various utensils (Figure 3-2).

Because synergies that enable tool use are softly assembled around the goal of the task at hand, they are stable but flexible units. Synergies have specific consistent characteristics, such as the sequence of movements and the ratio of joint movement, which can be adjusted to accommodate each new situation. This adaptable stability is a hallmark of normal movement.²¹ Soft assembly is critical to allow the child to act in changing and variable environments. It also allows the child to explore and select a response to the environment, because his or her response patterns are variable and flexible.⁹⁷

The functional synergies that characterize a child’s development of occupations are highly adaptable and reliable. The child self-organizes these synergies around tasks and goals, and his or her first goals are embedded in and organized around play (as described later in this chapter).

How Do Children Develop New Performance Skills?

How does a child learn new performance skills? Although learning new skills is not limitless and is constrained by biologic and contextual factors, human development is believed to have relative plasticity.⁶⁶ This concept has obvious importance to occupational therapists, who provide intervention services designed to change and promote children’s performance. Gottlieb defines plasticity as a fusion of the organism (the child) and the environment (including its cultural, physical, and socioeconomic characteristics).⁵² Individual development involves the emergence of new structural (e.g., cellular) and functional components (e.g., body systems). The child’s experiences produce new neurologic connections (i.e., new associations) and structural changes (e.g., physical growth), and it is the relationships among components, not the components themselves, that are most important to development. Acknowledgment of the system’s plasticity places the focus on the child’s potential for change and on the contextual features that promote or limit the child’s performance.

How does competence develop during childhood? Children generally pass through three stages of learning to acquire a new skill.^48,84,103 The first stage involves exploratory activity. The first year of life is primarily a period of sensorimotor exploration. Exploration occurs naturally in all human beings, generally when an individual is presented with a new object or task. Through exploration, a child learns about self and the environment. In this stage, the child experiments with objects and activities using different systems, new combinations of perception and movement, and new sequences of action. In this exploratory stage or when challenged by a new and difficult task, a child tends to demonstrate primitive movement. New challenges tend to elicit lower levels of skills, because these can be accessed more easily than the child’s highest-level skills, which demand more energy and effort.⁵³ By using lower-level skills to address new problems, the child can focus on perceptual learning about the task before beginning to use higher-level skills, which ultimately allow more success in performing the task. Gilfoyle, Grady, and Moore noted that when children are first challenged with a new and difficult performance task (e.g., a first step), they use primitive movement patterns (e.g., balance by stiffening the legs and trunk) before progressing to integrated skill.⁵⁰

In the second stage of learning, perceptual learning, the child begins to use the feedback and reinforcement received from his or her exploration. In this transitional stage, the child exhibits more consistency in the movement patterns used to accomplish tasks. Because this second stage is a phase of perceptual learning, certain actions that were tried initially are discarded as ineffective. Interest in the activity remains high as perceptual learning continues and is inherently motivating and meaningful to the child. In this stage, the child appears focused on learning and attempts activities multiple times. The child may fluctuate between higher and lower levels of skill. Connolly and Dalgleish found considerable variability when toddlers attempted to use a spoon.²⁶ Greer and Lockman found similar variability when 3-year-olds attempted to use a writing tool.⁵⁵ At times, the children grasped the tool using an adult gripping pattern, and at other times, they used a primitive, full-hand grasp. Mature patterns are selected more often as children enter the third stage of skill learning.

In the third stage of learning, skill achievement, the child selects the action pattern that works best for achieving a goal. The pattern selected is comfortable and efficient for the child. Selection of a single pattern indicates both perceptual learning and increased self-organization. During this end stage of learning, the child demonstrates flexible consistency in performance. He or she uses the same pattern and approach to the task but easily adapts the pattern according to task requirements. High adaptability is always characteristic of a well-learned task. Another attribute of learned performance is the use of action patterns that are orderly and economical. Children continue to practice performance when given opportunities in the environment. The third stage of learning leads to exploration of new and different activities; therefore, a child’s learning continues into new performance arenas, expanding his or her occupations.

For most children, new experiences and new learning are sought and are a source of pleasure. Learning occurs when children seek opportunities for skill development; it also occurs when children adapt to the natural environment and daily activities in which they participate. Ayres explains that children make adaptive responses to the environment.^3,4 An adaptive response is one in which the child responds to an environmental change in “a creative or useful way” (p. 14).⁴ These adaptive responses allow skill mastery and help to organize the child’s CNS. Therefore, an adaptive response helps to integrate the child’s sensory and perceptual systems to respond more skillfully to new challenges to the sensory system. For example, once the infants can pull themselves up to a standing position using a piece of furniture, they have acquired an adaptive skill that enables them to pull up to the mother’s lap to ask to be held or explore the objects on a coffee table. This organization of movement patterns was achieved because the vestibular, proprioceptive, and visual systems are innately organized toward achieving upright posture (Figure 3-3).

The Role of Motivation and Self-Efficacy

Children engage in the process of learning with innate motivation and apparent enjoyment. An infant’s inner drive motivates her to explore novel objects in the environment, learning their sensory characteristics, their relationships to each other, and their functions. A toddler or young child is motivated to solve problems and to attempt new skills, persevering until it is mastered. The concept of inner drive suggests that children attempt activities that will promote their development without specific teaching by adults. Occupational therapists view this innate drive as the child’s inner motivation to engage in occupations (task with meaning and purpose). Learning occurs when the match among child, task, and environment is optimal; hence, this match becomes the occupational therapist’s goal.⁵⁸ When a child has a disability, motivation to learn and attempt new activities may be lower and the match among child, occupation, and environment may be less than optimal. In this case, a child may not learn independently and adult support may be needed to motivate, provide a just right challenge, support actions, and reinforce performance.

When a child’s inner drive leads to mastery of tasks, he or she develops a sense of self-efficacy.^5–7 Bandura believes that children are inherently self-organizing and goal-directed; they typically have interest in new events and activities, initiate new tasks, and persevere in those tasks. When they succeed, positive self-efficacy is reinforced and they attempt other challenges. When they do not succeed, they are at risk for developing poor self-efficacy and eventually do not attempt new or challenging activities. Therefore, self-efficacy is highly linked to learning and occupational development because it influences levels of motivation, initiative, and perseverance.

Temperament and Emotional Development

The congruence, or goodness of fit, between the child and his or her social and physical context determines the quality of development, influencing which occupations are reinforced and which are hindered. Positive goodness of fit, meaning that the social and physical environment support the child’s skill development, can increase the child’s developmental trajectory. Lack of goodness of fit can create disruption of psychologic development and may put the child at risk for behavioral or academic problems.

Chess and Thomas asserted that if a child’s characteristics provide a good fit (or match) with the demands of a particular setting, adaptive outcomes result.^19,20 The child’s temperament is an important determinant in how well a child matches the caregiving environment⁶⁷ and is an important attribute in the child’s social interaction. According to Thomas and Chess, temperament refers to the child’s behavioral style, and it is believed to be innate and learned.¹⁰⁴ Nine areas of temperament have been identified: (1) activity level, (2) approach or withdrawal, (3) distractibility, (4) intensity of response, (5) attention span and persistence, (6) quality of mood, (7) rhythmicity, (8) threshold of response, and (9) adaptability. Each of these areas contributes uniquely to the child’s ability to form social relationships and respond to the social environment.¹⁰⁴

Taken together, these areas of temperament have their own continuum: extreme temperament levels are associated with problematic behaviors, and moderate levels are related to easy and appropriate behaviors. Children who exhibit extreme temperament characteristics (e.g., those who are highly active, moody, or irritable) have been identified as difficult. The difficult child may not fit with the expectations and schedules of caregivers. Others with happy moods and moderate intensity of response are considered easy. A child with an easy temperament may be rhythmic (exhibiting regular sleep/wake cycles) and have positive moods and may have a better fit with caregivers. A match of parent and infant temperament can facilitate strong attachment, just as a mismatch can create difficulties in attachment.

To illustrate how temperament affects goodness of fit, children with arrhythmic, poorly regulated sleep/wake cycles were reported to be difficult to manage by European American families in which the parents worked and needed a consistent routine of sleeping patterns. Puerto Rican parents did not have difficulty in accommodating children with poorly regulated sleep/wake cycles because they molded their schedules around them and allowed their children to sleep when they wanted. In the Puerto Rican families, the incidence of child behavior problems was very low, particularly before school age when a school schedule was imposed.⁶⁶ These studies and many others suggest that the child’s temperament and behavior affect goodness of fit between the caregiver and the child, which in turn influences developmental outcomes.²⁰

Emotions also play an important part in the child’s appraisal of his or her experience and in the child’s readiness for action in response to contextual change. Emotions relate to how a child evaluates the meaning of an experience in relation to his or her goals. Therefore, if a child engages in an activity with the goal of succeeding but does not, he or she may become disappointed or frustrated. If a child engages in an activity simply to participate and without expectation for success, he or she may experience pleasure irrespective of success. Emotions and temperament (see Chapter 13) influence the child’s interest in attempting new activities, the amount of effort demonstrated, and attempts to engage others. These variables influence how a child approaches an activity (e.g., joyfully, reluctantly) and influences its social nature (e.g., whether the child solicits the involvement of others).

Risk and Resiliency

As suggested in the previous section, developmental outcomes have been attributed to the child’s personality. Research has shown that certain children attain positive developmental outcomes despite a poor caregiving environment. Resiliency refers to a child’s internal characteristics that enable him or her to thrive and develop despite high-risk factors in the environment. The concept of resiliency emerged from studies of child development in which the context included risk factors known to have negative effects (e.g., child abuse, parental mental illness or substance abuse, socioeconomic hardship).^107,110 A resilient child has protective factors that enable him or her to develop positive interpersonal skills and general competence despite stressful or traumatic experiences or social environments known to limit developmental potential (e.g., that of an adolescent, single parent). Both child protective factors (e.g., intelligence, prosocial behavior, and social competence) and family protective factors (e.g., material resources, love, nurturance and sense of safety and security, quality of parent-child relationship) are important to positive child outcomes. Researchers have demonstrated that a high-quality relationship with at least one parent, characterized by high levels of warmth and openness and low levels of conflict, is associated with positive outcomes across levels of risk and stages of development.¹¹¹

A child’s resiliency versus vulnerability also seems to relate to basic physiologic and regulatory characteristics. Children with low cardiovascular reactivity and high immune competence cope better with stressful situations and are less vulnerable to illness when stressed.¹¹⁰ In middle childhood, well-developed problem solving and communication skills are important to a child’s ability to deal with stress. Resilient boys and girls tend to be reflective rather than impulsive, demonstrate an internal locus of control, and use flexible coping strategies in overcoming adversity.¹¹⁰ Therefore, not only are intelligence and competence important to positive outcomes, but so is emotional regulation, that is, being able to monitor, evaluate, and modify the intensity and duration of emotional reactions.¹⁰⁷

These concepts suggest that in the interpretation of the influence of environmental factors on a child’s development, variables internal to the child can overcome negative contextual variables, including those believed to have a profound influence (e.g., poor caregiving). Although the evidence suggests that children with strong resilience can overcome a high-risk environment (e.g., abusive situations, poverty), a recent research synthesis of risk and resilience studies found that both internal (e.g., child’s intelligence, positive affect, emotional regulation) and contextual (e.g., supportive family relationships) protective factors are needed for positive outcomes (e.g., school success, positive relationships).¹⁰⁷ Taken together, the theories that explain how children grow and develop into competent adults and full participants in the community suggest that a child’s development of occupations must always be understood as an interaction between the child’s biological being and his or her cultural, social, and physical contexts.

Development of Occupations

Humphry proposes that three broad mechanisms enable children to develop occupations.⁵⁸ These mechanisms, society’s investment in children and their participation in the community, interpersonal influences including caregiving adults and peers, and the dynamics of the child’s occupational performance, are briefly described next.

The broadest influence on children’s occupations is the community in which the child is raised. Communities and society in general have invested in children’s occupations by providing playgrounds, preschools, child-oriented music, child-oriented restaurants, and soccer fields. A community’s orientation toward children determines available opportunities to play organized sports, learn about art and music, safely play in neighborhoods, and gain friendships with diverse peers. Communities that value organized sports and outdoor activity may have soccer or baseball teams, horseback riding, and swimming specifically designed for children with disabilities (e.g., Special Olympics, Miracle League Baseball, therapeutic horseback riding). Characteristics of the community become barriers or opportunities for the child and family and their desired occupations. As advocates for children with disabilities, occupational therapists can influence the development of programs that are accessible and appropriate for children with a wide range of ability. They can emphasize the importance of supporting the participation of all children in community activities, recognizing the different levels of support and accommodation needed.

Humphry suggests that children learn through both direct and indirect social participation.⁵⁸ A young child’s first learning about an occupation is often through observing his parents, siblings, and other adults or peers. The first representational pretend play is typically imitation of the mother’s actions when cleaning and cooking. Children imitate their parents’ gestures and speech without being explicitly taught to do so. They also learn the consequences of actions by observing how their parents respond to each other or to their siblings. They can learn that an action is wrong by observing punishment of a peer for that action. Vicarious learning appears to be particularly important to a child’s assuming cultural beliefs and values. Children learn the traditions and rituals of a culture by observing their family’s participation in these. Inclusive models of education are believed to be effective learning environments for children with disabilities based on the known benefit of observing and interacting with typical peer models.^31,32 When in a child’s presence, therapists should always be conscious that their actions and words influence children’s learning and of whether these actions are directed toward the child.

Learning is generally more vigorous when the child actively participates in an occupation. Children’s play with each other is an integrated learning experience in which the child acts, observes, and interacts. Play involves most or all performance areas, including affective, sensory, motor, communicative, social, and cognitive. When children play together, they learn from, model for, challenge, and reinforce each other. This flow of interactions occurs in meaningful activities that generally bring pleasure and intrinsic reinforcement and enable learning.

To learn a specific skill, the child must actively practice it. Specific scaffolding, guidance, cueing, prompting, and reinforcement by an occupational therapist can assist the child in learning to perform a skill. This direct support from the therapist (or other adult) can facilitate performance at a higher level or at a more appropriate level so that the fit between the child and desired occupations and context becomes optimal. In the case of a child with disabilities, a more intensive level of direct support and scaffolding may be necessary for learning new skills. Adult guidance and support of the child during play can facilitate a successful strategy, help the child evaluate his or her performance, and encourage and reinforce continued practice. Therapists can also optimize the environment to support and reinforce the child’s performance. Participation in play occupations in a natural environment results in integrated learning across performance areas (e.g., including sensory, motor, cognitive, and affective learning).

The child’s play and actions are always within a social, cultural, and physical context. To understand the development of occupational performance, the occupational therapist must understand the child’s play and actions as coherent occupations within specific contexts.

Contexts for Development

Children develop occupations through participation in family activities and cultural practices. As a child participates in the family’s cultural practices, he or she learns occupations and performance skills that enable him or her to become a full participant in the community. Rogoff explains: “People develop as participants in cultural communities. Their development can be understood only in light of the cultural practices and circumstances of their communities” (pp. 3–4).⁸⁸ Variations in the child’s play activities (e.g., how he or she builds with wooden blocks, draws a picture of himself or herself, or sings a song) reflect the child’s biological abilities and the influence of cultural, social, and physical contexts.

A child’s cultural, social, and physical contexts change through the course of development and tend to expand as the child matures. The environment surrounds and supports the child’s action; it also forces the child to adapt and assists or accommodates that adaptation. As a child perceives the affordances of the environment, he or she learns to act on those affordances, expanding a repertoire of actions. At the same time, the child’s understanding of how the world responds to his or her actions increases. Rogoff argued that culture affects every aspect of the child’s development, which cannot be understood outside this context.⁸⁸ The child is nested in his or her family, culture, and community, which have influenced the child’s genetic makeup and continue to provide the learning environment. By recognizing this influence, occupational therapists view each child in his or her cultural context and work as change agents within that context.

Cultural practices are the routine activities common to a people of a culture and may reflect religion, traditions, economic survival, community organization, and regional ideology. The child learns motor and process skills through his or her participation in these cultural practices. Reciprocally, a child’s motor and process skills enable participation in the occupations and cultural practices of the child’s family and community.

Infants: Birth to 2 Years

Early Childhood: Ages 2 to 5 Years

Middle Childhood: Ages 6 to 10 Years

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