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. 2012 Sep 20;93(1):94–103. doi: 10.2522/ptj.20120158

Grounding Early Intervention: Physical Therapy Cannot Just Be About Motor Skills Anymore

Michele A Lobo 1,✉, Regina T Harbourne 2, Stacey C Dusing 3, Sarah Westcott McCoy 4
PMCID: PMC3538987  PMID: 23001524

Abstract

This perspective article provides support for 4 interrelated tenets: grounded perceptual-motor experience within cultural and social contexts forms cognition; exploration through early behaviors, such as object interaction, sitting, and locomotion, broadly facilitates development; infants and children with limited exploration are at risk for global developmental impairments; and early interventions targeting exploratory behaviors may be feasible and effective at advancing a range of abilities across developmental domains and time. These tenets emphasize that through the promotion of early perceptual-motor behaviors, broader, more global developmental advancements can be facilitated and future delays can be minimized across domains for infants and children with special needs. Researchers, educators, and clinicians should build on these tenets to further demonstrate the effectiveness of targeted early interventions. The goals of these interventions should be not only to advance targeted perceptual-motor skills in the moment but also to more broadly advance future abilities and meet the early intervention goal of maximizing children's learning potential.

The purpose of this article is to support the proposition that early intervention focused on key perceptual-motor behaviors can improve an individual's ability to function and participate in the present moment, as well as advance his or her future development across domains. First, we define cognition and defend the idea that cognition is grounded in everyday experiences.1,2 Second, we briefly review the literature on the effectiveness of early intervention, noting the lack of support for current perceptual-motor interventions. Third, we use object interaction, sitting, and locomotion as examples to demonstrate that exploration through early perceptual-motor behaviors significantly affects future ability across developmental domains,3,4 that infants with limited exploration are at risk for a broad range of impairments,5,6 and that early intervention programs targeting key exploratory behaviors within social contexts (as opposed to practicing less variable behaviors in more isolated social situations and environments) may be optimal for improving a range of abilities across developmental domains and time. We conclude by discussing the implications of applying a grounded cognition lens to early intervention practice, therapist education, and research.

Grounded Cognition

What does the term “cognition” encompass? According to Matlin,7 “cognition or mental activity describes the acquisition, storage, transformation, and use of knowledge.” Cognition includes a wide range of mental processes, such as those involved with perception, action, memory, language, problem solving, reasoning, decision making, and social interaction. Therefore, when we discuss cognition, we mean not only more traditional cognitive abilities but also broader perceptual-motor, language, and social abilities.

Depending on the theory of development used, the terms “development” and “learning” can represent different processes. In this article, we use the term “development” to represent the compilation of behaviors, abilities, and knowledge already learned and established by an individual. We use the term “learning” to represent the compilation of behaviors, abilities, and knowledge presently being acquired by an individual.

A primary goal of early intervention is to advance cognition and readiness to learn for infants and children with special needs. Achieving this goal requires an empirically supported model for how these abilities emerge. In the 20th century, cognition was predominantly viewed as a process occurring independently of the body, environment, and other people.8 Perceptual information served as input and behavior resulted as output from a cognitive system that was separate and unaffected by perceptual-motor experience (Fig. 1A). This view has been challenged recently as proponents of grounded, or embodied, cognition have argued that perceptual-motor experience plays an integral role in cognition.8,9 In this view, rather than serving simply as input and output for an independent cognitive structure, perceptual-motor experience within environmental, social, and cultural contexts actively builds, maintains, and alters cognition (Fig. 1B).2,10 This view revisits ideas proposed more than 2,000 years ago by ancient philosophers and more recently by Piaget and Vygotsky.10–12 Although this concept of grounded cognition is not novel, what is new is that technology and research methods that allow scientific testing of this concept have been developed over the past several decades.

Figure 1.

Figure 1.

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(A) More traditional view of cognition as something that exists outside of one's everyday experiences. (B) Grounded view of cognition as something that is created, maintained, and altered by everyday perceptual-motor experiences within social and cultural contexts.

The concept of grounded cognition is supported by mounting evidence of the effects of perceptual-motor experience on processes such as myelination of axons,13 maturation and connectivity of white matter,14 and temporal activation and volume of gray matter.15 The grounded cognition perspective has gained increasing support in disciplines ranging from philosophy to cognitive psychology, education, and robotics.2,16,17 Research support over the past decades has demonstrated the influence of perceptual-motor experience on tasks involving memory, knowledge, language, thought, and social interaction.10,18 The concept of grounded cognition is already embedded in certain theoretical frameworks, including dynamic systems theory and ecological systems theory.19,20 As empirical support continues to grow for the concept of grounded cognition and theories that encompass it, it is clear that physical therapy interventions should be redesigned on the basis of these theories; redesigned interventions should replace more traditional, less effective interventions based on theories lacking support, such as those based primarily on maturation, reflex control and inhibition, and more passive experience.21

Early Intervention

Reviews of current early intervention practices do not offer clear guidance to those searching for a model for best practice. There is evidence that some early intervention programs are effective at advancing long-term development, although to varying degrees. For instance, some early intervention programs can have long-lasting effects on outcomes such as school performance,22 psychosocial skills,23 and perceptual-motor skills.24 For infants born preterm, some interventions provided in the first years of life may advance cognition, receptive language, visual-motor, and spatial skills at preschool age.25,26 There also are studies suggesting that other early intervention programs do not result in long-term developmental advancements. For instance, children who participated in a special literacy program in Head Start before school age did not have better literacy outcomes in first and second grades than children who received typical Head Start services.27 A systematic review of the early intervention literature demonstrated that early perceptual-motor interventions based on the neurodevelopmental treatment approach were not effective at advancing development, whereas interventions focused on advancing general motor development and enhancing caregiver-child interactions did advance development.21 Similarly, a recent review of randomized trials of early intervention for children at high risk found that motor skills were not consistently affected by early intervention.28

It is clear that there is a gap in the current knowledge about which early interventions facilitate the best outcomes. The costs of minimal efficacy for early interventions are high both financially and in quality of life for families receiving services. Therefore, identifying which interventions can reliably improve perceptual-motor ability, cognition, and readiness to learn is imperative.

Object Interaction, Sitting, and Locomotion as Models for Grounded Cognition

Object interaction, sitting, and locomotion are examples of early perceptual-motor behaviors that allow infants to explore their environment and to acquire knowledge.9 Here we describe how these behaviors broadly affect development, thereby serving as models for grounded cognitive theory. Next, we provide evidence suggesting that delays in each of these behaviors can negatively affect development. Finally, we suggest potential interventions to improve these behaviors. These interventions are aimed at improving targeted perceptual-motor function to advance cognition and to prepare children to learn in school.

Object Interaction, Sitting, and Locomotion in Relation to Grounded Cognition

Object interaction, sitting, and locomotor abilities are important because they allow infants to gain information about the interrelationships among their bodies, objects, and people.3,29 These behaviors are complex, dynamic, and continually coevolving throughout the first years of life.30 Infants with typical development begin to perform these behaviors sequentially during the first year of life. Although developmental trajectories for these behaviors can be variable, we outline here an example of what is typical.

Object interaction is the ability to hold, manipulate, and explore objects. It begins with grasping at birth and becomes increasingly more controlled and targeted to object properties throughout the first years of life.31 Infants with typical development begin to retrieve desired objects at approximately 4 or 5 months of age by reaching.32 In the months after the onset of reaching, infants are able to maintain a vertical position as they learn to sit. This upright position allows infants a novel perceptual view of their world, as well as a new play position on which they can impose their already developing object interaction behaviors. In the months after the onset of sitting, infants are able to move around their environment, crawling at approximately 8 months of age and walking at approximately 12 months of age. This freedom of movement greatly expands opportunities to interact and learn, as infants move to desired objects, locations, and people who are out of their stationary reach.

Infants' abilities to explore objects and to interact with people through object interaction, sitting, and locomotion broadly affect their development. The frequency and variety of interactions that infants and children have with objects teach them about object properties and how to represent or form memories of objects.33 Object interaction facilitates the ability to segregate or group objects, to recognize objects when only parts of the objects are in view, and to recognize objects that are familiar.34,35 Object interaction even teaches infants novel, more sophisticated ways in which they can act upon objects to gain more knowledge.36 For instance, infants who were developing typically and who reached earlier had more mature object exploration ability in the following months,37 and infants who had experience using hook-and-loop mittens to help retrieve and explore objects earlier had greater object engagement and more sophisticated object exploration performance 1 year later.38

Sitting advances cognition by providing infants with an improved ability to process visual information.39,40 The interaction of postural control during sitting and visual attention in infancy facilitates future cognitive development because visual attention is a key factor in problem solving.41 The coordination of improved gaze stabilization and manual skills during sitting is accompanied by increased possibilities for object interaction and learning.42 For example, sitting allows infants to use their hands freely to put objects together and take them apart, a behavior that forms the foundation for understanding important mathematical concepts.43

In the second half of the first year of life, infants demonstrate significant advances in problem solving and spatial memory in association with locomotor experience. For instance, infants with more locomotor experience are more successful at spatial problem solving and memory tasks, such as choosing the most efficient path for reaching a desired goal and finding hidden targets.44,45

Object interaction, sitting, and locomotor behaviors also affect language development and social interaction. The information that infants gather through object interaction aids in infants' learning to categorize and discriminate objects, 2 foundational abilities for language development.46,47 Placement of objects in the mouth during oral exploration leads to use of the vocal tracts in new ways to produce novel types of vocalizations with unique phonetic characteristics.48 The performance of rhythmical arm movements (banging) facilitates the emergence of babbling.49 From 9 through 26 months of age, the way in which infants use objects based on their specific properties for construction play is more strongly associated with the emergence of words and an increase in vocabulary size than is chronological age.50 Object interaction also affects receptive language abilities. For instance, 20-month-old infants are better able to learn the names of objects when the objects can be explored using a greater number of actions.51

The ability to explore objects also affects infants' social interactions. For example, while infants spend more time looking at people than objects before the onset of reaching, they learn to share their attention between people and objects and to involve objects in their social interactions after the onset of reaching.52 After the onset of reaching, caregivers use objects more in their play with infants, and infants show objects to others as tools to elicit social interactions.53

The ability to sit also greatly affects language development and social interaction. Sitting upright elicits physical changes in respiratory and articulatory structures that affect the types of sounds that infants produce.54 Sitting is associated with a larger number of utterances per breath, a decrease in simple vowel production, and greater variability of consonant-vowel utterances.55 In addition, sitting upright prompts the tongue to fall further forward in the vocal tract, enhancing the production of consonant-vowel utterances.46

The ability to locomote affects how infants communicate and interact.3,56 As infants gain locomotor experience through crawling, they use more gestures to communicate with others, they demonstrate less negative affect (crying or fussing), their parents perceive them as more emotionally positive (smiling and laughing more), and they initiate interactions with others more often during free play.3,56 Compared with crawling infants, walking infants use even more gestures and vocalizations as they engage in early shared attention with people and objects.57

Thus, the research strongly suggests that early object interaction, sitting, and locomotor behaviors are important vehicles for promoting future cognitive, perceptual-motor, language, and social-emotional development.

Object Interaction, Sitting, and Locomotion in Relation to Grounded Cognition in Populations at Risk for Developmental Delays

A growing body of literature suggests that for infants and children at risk for and with developmental delays, object interaction, sitting, and locomotor behaviors play similar key roles in development. Consequently, delays in the performance of these behaviors would be expected to limit infants' abilities to gain information about the interrelationships among their bodies, objects, and people.

Delays in the ability to interact with objects have been found to broadly and negatively affect other areas of development. For example, 4-month-old infants born preterm at high risk required longer time periods to explore objects before they could recognize them as being familiar and had difficulty identifying other objects as being different; these infants then had poorer intelligence quotients at 8 years of age.58 Likewise, the amount of focused examination of objects at 7 months of corrected age in infants born preterm was predictive of hyperactivity or impulsivity problems and cognitive disabilities through 5 years of age.59 At 9 months of corrected age, infants born preterm at high risk had less sophisticated object exploration ability, with less fingering, rotating, and transferring of objects between hands, than infants born full-term or preterm at low risk; this finding was related to poorer cognitive performance at 24 months of age.6

Infants born with Down syndrome had less sophisticated object exploration behavior than infants with typical development from 6 through 10 months of age.60 At 8 to 16 months of age, infants with Down syndrome had less object exploration behavior and less coordinated attention with people and objects than infants with typical development.61 At 22 months of age, infants with Down syndrome had decreased object engagement, shorter sequences of goal-directed behavior with objects, higher rates of object rejection, and less pleasure when their actions on objects caused an associated reinforcement compared with infants with typical development.62

Infants later diagnosed with autism spent less time in functional and symbolic play with objects between 9 and 12 months of age.63,64 At 12 months of age, infants later diagnosed with autism spent more time spinning, rotating, and performing unusual and persistent visual explorations with objects.65 These repetitive behaviors with objects at 12 months of age were significantly related to future cognitive outcomes and severity of symptoms at 36 months of age. Thus, infants and children with a variety of special needs show delays and differences in their object interaction behaviors that are related to future cognitive abilities.

Some literature supports the idea that delays in sitting or locomotor abilities broadly and negatively affect other areas of development. Infants who were born preterm and had abnormal sitting behaviors (characterized by excessive neck, arm, and trunk extension) during infancy had poorer cognitive and problem-solving abilities at 18 months of age than did infants who were born preterm but had normal sitting behaviors during infancy.66 Children who had myelomeningocele monitored from birth through 14 years of age and who attained the ability to walk had significantly higher intelligence quotients than children who had myelomeningocele at similar neurologic levels and similar brain abnormalities but who did not attain the ability to walk.67 Early delays in self-locomotion can negatively affect future school performance and accomplishment of activities of daily living. For instance, delays in higher-level motor skills such as locomotion were associated with diminished visuospatial abilities, perceptual-motor cognition, and attention in school-age children who were born preterm,68 and delays in locomotor abilities were associated with poorer future life habits in children with cerebral palsy (CP).69 Thus, the literature suggests that object interaction, sitting, and locomotion are important early behaviors that facilitate global development and should be a focus of early intervention.

Potential Interventions to Advance Object Interaction, Sitting, Locomotion, and Grounded Cognition

Recent studies suggest that interventions can be provided to infants to improve their object interaction, sitting, and locomotor behaviors and, as a result, to more broadly advance their cognition. For example, the onset of reaching in infants with typical development can be advanced by encouraging general arm movements through play involving tethering an infant's arms to an overhead toy that is out of reach yet moves when the infant's arm moves.70 In addition, reach onset as well as future object exploration and means-end (cause-effect) learning abilities can be advanced by performing early reaching and object exploration play with infants.29,37,70 A host of future behaviors—from reach onset through object exploration, sitting, and locomotion—in infants with typical development can be advanced through a 3-week education program for caregivers on how to handle and position their 2-month-old infants.4,37

A recent randomized clinical trial suggests that these same experiences provided for a longer duration are similarly beneficial for infants born preterm.71 In that trial, infants born preterm were provided with these intervention experiences from 2 through 4 months of age. The preterm infants in the group receiving the intervention reached earlier, reached more consistently, and maintained contact with objects to explore them for longer durations than a control group of preterm infants who did not receive the intervention.71

There may be ways to encourage caregivers of children with autism to interact and play with their children to promote more advanced object exploration and cognitive development. For instance, a recent study showed that preschoolers with autism performed increased object exploration with more sustained attention when their parents used 3 or more cues to encourage them to maintain focus on the object in play.72 When parents used fewer cues or used cues that redirected children's attention away from the object of focus, the children were less likely to engage in sustained exploration of the object. The cues that parents used included bringing the object into contact with the child, vocalizing, moving the object within the child's view, creating visual or sound effects for the object, and moving their hands within the child's view.

The literature also suggests that there are ways to improve sitting ability. For example, sitting ability in infants with typical development can be improved by allowing the infants opportunities to reach for objects during play while sitting.73 Sitting ability and underlying postural control can be advanced in infants who are younger than 2 years of age and who have CP or are at risk for CP by providing interventions that focus on the exploration of one's body, objects, and others and that incorporate variability, complexity, and the refinement of multiple sitting strategies.74 Such interventions have been more effective at advancing sitting and postural control abilities than practice during static sitting with assistive equipment. These findings suggest that the use of adapted seating for infants and children unable to sit independently should be complemented with frequent opportunities to sit without assistive devices so that these infants and children can develop the active learning and movement adjustments required to control sitting, to explore, and to learn.

There is a growing body of literature highlighting some effective ways to advance early locomotor behaviors. The onset of independent walking in infants with Down syndrome can be advanced, and walking ability in children born preterm and children with CP can be improved through treadmill walking practice.75,76 Another interesting and growing area of research aims to provide infants and young children with the developmental benefits of independent locomotion through child-driven powered-mobility equipment. Studies have shown that cognitive, social, and language development can be advanced through powered-mobility interventions for infants and young children with myelomeningocele, CP, and other developmental disabilities.77,78

Therefore, there is growing support for the premise that object interaction, sitting, and locomotor behaviors can be advanced in infants and children with or at risk for disabilities if the appropriate interventions are used. Such interventions are characterized by their focus on exploration, active trial and error hypothesis testing, variability of practice, high frequency of practice, and caregiver education and involvement.71,74,79 Building skills that are valuable to the child and family can broadly support development and improve learning.

Conclusions and Clinical Implications

In this perspective article we supported the proposal that early intervention providers should view perceptual-motor behaviors not only as means to improve function and participation in the present moment but also as vehicles to broadly facilitate future development across domains and to advance readiness to learn in school (Fig. 2). We supported this view by highlighting evidence demonstrating that cognition is grounded in perceptual-motor experiences within social and cultural contexts. We presented object interaction, sitting, and locomotion as models to demonstrate that early perceptual-motor behaviors can broadly affect development. We provided evidence that delays in these behaviors often are present and are related to future broader delays in infants and children with a variety of diagnoses. Finally, we provided examples from the literature of how the development of these early behaviors can be effectively advanced to increase participation and to address the primary goal of early intervention to promote readiness to learn. Understanding the concept of grounded cognition and its supporting evidence is important because it can allow physical therapists and other early intervention providers to focus on minimizing future delays before they happen; to target their interventions at behaviors that are foundational in development; and to reaffirm the significance of physical therapy in early intervention, where the focus is on preparing children to be ready to learn in school.

Figure 2.

Figure 2.

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Hypothetical trajectories from birth toward level of readiness to learn and participate in preschool at 3 years of age. The hypothetical onsets of object interaction, sitting, and locomotion behaviors are indicated by the circle, triangle, and square, respectively, on each trajectory. In the typical development trajectory, object interaction, sitting, and locomotion emerge in the first year of life and act as vehicles to provide children with the tools needed to be successful in school. In the trajectory for children who have developmental delays and are provided ineffective or no early intervention services, object interaction, sitting, and locomotion behaviors emerge later and are performed less frequently and less variably—resulting in poorer cognitive development and lack of readiness to learn and participate by preschool age. The trajectory for children with developmental delays shows how this situation can be transformed with effective early intervention targeting early perceptual-motor behaviors to advance cognition and readiness to learn in school.

We propose that the concept of grounded cognition should be actively incorporated into physical therapist practice, education, and research (Table). In pediatric clinical practice, physical therapists should be aware of the impact of perceptual-motor experience on other aspects of development and learning. They should account for this in determining whether a child requires physical therapy services and how those services should be provided. For instance, the concept of grounded cognition reinforces the idea that it is not sufficient to assess whether a child can perform a behavior in isolation; it must be determined how the child uses this behavior to explore objects, people, and events in social situations because these are the processes through which learning and participation occur.1 Goal setting should reflect the link between perceptual-motor experience and grounded cognition. Thus, instead of a goal being “The child will sit independently for 1 minute,” the goal could be “The child will use sitting posture to explore objects during group play on the floor with peers for 1 minute.”

Table.

Recommendations for Incorporating the Concept of Grounded Cognition Into Early Intervention Practice, Education, and Research

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Physical therapists also should advocate for the role of active experience in learning and development by educating other team members, including families, teachers, speech therapists, occupational therapists, and other physical therapists, who may not be aware of the broad role that perceptual-motor experience plays in development. Recent studies have linked interventions focused on education, family involvement, and active performance of variable, appropriately challenging tasks with more positive future developmental outcomes.80 Because physical therapists have expert knowledge regarding perceptual-motor behaviors, educating government agencies and insurance companies that approve funding for services about the empirical support for grounded development can help justify the need for physical therapy services for infants and children with special needs. To meet these goals, pediatric clinicians need to be uniquely qualified to assess and intervene across traditional domains. They also need to be able to translate scientific information to a host of people—from children to legislators—across a variety of settings—from the playground to legislative buildings.

Therapists should use the concept of grounded cognition in concert with tools such as the International Classification of Functioning, Disability and Health (ICF) to guide their interventions.81 These tools can guide therapists to think beyond impairment and perceptual-motor function to participation in activities with objects, people, and events that afford learning. Furthermore, they can guide therapists to consider how this participation can broadly advance future development and learning abilities. For instance, it is not sufficient to provide interventions to advance early locomotor behavior in social and behavioral isolation. Therapists can best advance future development for their clients by setting goals and designing interventions that allow clients frequent, daily opportunities to use their perceptual-motor abilities to maximize their interactions with objects, people, and events. Thus, in the case of locomotion, 1 component of an intervention could be to educate team members to provide daily opportunities for a child to crawl or walk among caregivers and peers while gesturing, naming, turn taking, and exploring a variety of objects rather than locomoting in isolated environments separate from peer interactions, play, and problem solving.

Incorporation of the concept of grounded development into physical therapist practice requires rethinking the way in which physical therapist students and practicing physical therapists are taught about learning. Currently, physical therapist education programs emphasize and teach students about the concepts of motor learning. Yet, mounting evidence for the proposal that the broader construct of cognition is grounded in perceptual-motor experience presents a challenge to think about learning less as a domain-specific phenomenon and more as a phenomenon with consistencies across domain and time. Thelen2 argued that across the life span, the processes at work when people learn perceptual-motor behaviors must be the same as those at work when they learn cognitive skills. Therefore, it is no longer sufficient to teach about theories of motor learning in isolation.

On the contrary, physical therapists need to be educated about the grounded cognition literature from fields such as developmental psychology and education so that they can design the most effective interventions and understand the broader impact of those interventions. Educators and researchers in the field of physical therapy are the best equipped to assimilate and translate the growing body of research findings across disciplines, all of which have their own challenging jargon, so that clinicians can make use of the most recent findings to benefit their clients. We encourage these professionals to pursue these activities by creating book chapters, review articles, perspective articles, and continuing education courses. Physical therapists need to be aware of such research to ensure that theories and methods of practice evolve to reflect and keep pace with what current science suggests is best practice.

Finally, we propose that physical therapist researchers incorporate the concept of grounded cognition into their studies. Most research supporting this concept is fairly recent (within the last few decades) and has not been conducted in the field of physical therapy.10 Dynamical systems theory is likely a useful tool for capturing and describing the mind-body-world interconnections underlying the concept of grounded cognition.2 Yet, although the dynamical systems theory is predominant in much of the current physical therapy literature, the concept of grounded cognition has not been incorporated into physical therapy research. Perhaps the greatest challenge to incorporating grounded cognition into physical therapy research involves identifying the behaviors and abilities across domains that may be influenced through perceptual-motor interventions and choosing the appropriate assessments to capture these broader changes.

We propose that physical therapist researchers begin to meet this challenge and incorporate the grounded cognition concept into their research designs by reviewing the literature more broadly, using a greater range of assessment tools, and collaborating with experts in complementary fields of development. Pursuing these activities can provide answers to important questions relating to clinical practice and can determine how perceptual-motor interventions can positively affect cognition, communication, social interaction, and other abilities that are important in improving daily function and quality of life for children and families. This information would lend critical empirical support to best clinical practices and would further solidify the importance of physical therapy to those outside of the field who make important decisions about the provision of and payment for physical therapist services.

Footnotes

Dr Lobo, Dr Harbourne, and Dr Dusing provided concept/idea/project design. All authors provided writing. Dr Lobo provided project management. Dr Dusing provided fund procurement.

The authors acknowledge the following funding sources for bringing them together to form the Early Learning Consortium: American Physical Therapy Association, Section on Pediatrics, Planning Grant 2008 (Does Early Postural Intervention Affect Sitting Balance or Reaching in Infants Born Preterm? Principal Investigator: Susan C. Dusing, PT, PhD, January 1, 2009–July 1, 2011); and NIH/NCMRR/NICHD/NINDS grant 1K12HD055931-01 (Multicenter Career Development Program for Physical and Occupational Therapists and Comprehensive Opportunities in Rehabilitation Research Training Program. Principal Investigator: Michael Mueller, PT, PhD, FAPTA, September 15, 2007–August 31, 2012).

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