Young school age children are expected to be able to sit erect on a chair at a table for many school tasks that involve using the hands to interact with tools and materials: drawing and handwriting, cutting with scissors, craft activities, different games and puzzles.
Assessment of sitting needs to consider the interaction between the child, the task and the environment as well as the factors that constrain and enhance task performance.
A comprehensive assessment of a child's ability to comfortably and easily maintain an erect and stable sitting position when engaged in in table top work includes assessment of:
- The basic musculoskeletal and postural abilities needed for sitting erect and maintaining an erect posture when moving the head and upper extremities (UEs).
- The child's ability to maintain an erect sitting posture when using the hands for school related tasks.
- The child's ability to maintain an erect sitting posture while engaged in different tabletop activities in the classroom.
Musculoskeletal and postural control abilities
When sitting on a chair or bench of the right height, typically developing young children are able to:
- Sit with the trunk erect, pelvis vertical, hips, knees and ankles flexed to approximately 900, the neck in neutral F/E position and the face vertical.
- Maintain an erect sitting posture with ease and comfort for extended periods of time.
- Turn the head to look in different directions.
- Keep the trunk and head steady when moving one or both UEs in any direction within arm's reach.
Assessment of ability to maintain and erect sitting posture
1 Let the child sit on a bench of the right height and observe his habitual / preferred posture.
2 Next instruct the child to sit upright with the feet flat on the floor about hip width apart. You may need to manually correct the child's posture to indicate what is required.
3 Instruct the child to maintain this position while you count to 20.
Depending on the age of the child's age and abilities you can also let the child count forwards from 1 or backwards from 20. The counting introduces a second attention demand and can make sitting erect more difficult.
4 Let the child stay sitting on the stool and ask him whether he likes sitting erect, or is it easy, uncomfortable or boring?
Observe and record
► Can the child assume and maintain an erect posture for the 20 seconds as requested.
► The child's response at the end of the counting: does he stay sitting erect or does he resume his habitual posture.
► Child's reporting of discomfort or pain.
Notes
► Most children can assume an erect posture in sitting for a short period of time - however this require effort and attention and the child may quickly revert back to his typical slumped posture.
► Difficulty maintaining an erect posture may be related to restricted mobility/extensibility in the neck, trunk or hip joint, muscle and fascial structures,
Assessment of the flexibility of the neck, trunk and lower extremities will provide clues to underlying musculoskeletal factors affecting the child's ability to sit erect easily.
Assessment of postural stability when lifting the UEs
Many task require the child to lift one or both UEs forwards and maintain the head and trunk erect and steady.
In this assessment task the child is instructed to reach forwards with the UEs and maintain this position for 20 seconds. Lifting the UEs initiates anticipatory postural adjustments needed to keep the head and trunk steady. Children with good postural and shoulder control can do this easily.
Task: reach forwards for 20 seconds
1 Let the child sit on a bench of the right height.
2 Next instruct the child to sit upright with the feet flat on the floor about hip width apart and the shoulders flexed to 900 and the elbows in extension.
3 Instruct the child to maintain this position while you count to 20. Depending on the age of the child's age and abilities you can also let the child count forwards from 1 or backwards from 20
4 Instruct the child to lower the hands to the lap and stay seated. Ask him whether it was easy to keep the arms up, or did he get tired or uncomfortable.
Observe and document
The child:
► Was able to stay sitting erect with the UEs held steady.
► Had difficulty holding the trunk steady - the shoulder girdle tended to drift backwards.
► Had difficulty holding the UEs steady - they tended to drift up or down.
► Elevates the shoulder girdle in an attempt to maintain the shoulder position. This is usually associated with restricted shoulder lateral rotation.
Notes
Lifting the UEs forwards requires adjustments in alignment of the head and shoulder girdle to maintain the COM over the base of support. This is usually accomplished by small adjustments in the position of the pelvis and the tipping the trunk backwards slightly while keeping the head steady in space.
Assessment of postural stability when lifting and lowering one arm
Many activities performed in sitting involve lifting one or both arms, such as reaching for and manipulating objects or tools.
Lifting up and reaching with one hand involves two types of anticipatory postural response:
1 Adjustments in the alignment of the body segments (pelvis, lumbar and thoracic spine, head) to maintain balance in anticipation of the change in the relative position of the COM brought about by the movement of the UE.
2 Anticipatory contraction in the abdominal and neck flexor muscles to counteract the reactive forces created by the moving UE.
Task: lift one hand up
1 Let the child sit on a bench of the right height.
2 Instruct the child to sit upright with the feet flat on the floor about hip width apart and the hands resting on the thighs.
3 Next instruct the child to copy you as you perform the following movements, each time returning the sitting with the hands resting on the thighs.
- Lift one UE into full elevation and then lower the arm again.
- Flex the right shoulder to 900 with the elbow in extension
- Abduct one arm in the scapular plain and hold the position for 10 seconds
4 Next let the child hold a 1-2 kg weight in one hand and do the same movements.
5 Finally do the same movements with 5 fast repetitions in quick succession holding the weight with the elbow extended.
Observe and document
The child's ability to keep the head and trunk erect and steady during each movement.
Assessment of sitting posture when performing hand tasks
Maintaining an erect posture when performing hand tasks adds an additional challenge for the child for two reasons:
► Firstly, postural control requires attention and when attention needs to be allocated to a hand task, the amount of attentional resources for maintaining posture may be limited.
► Secondly, the child may need time to learn to meet the demands of the postural adjustments that need to be made to effectively accommodate the movement of the head needed for visual pickup and guidance and for the sequences of movement that form part of the hand task.
For this reason it is important to assess the child's ability to maintain an erect and stable posture during the hand tasks commonly encounters in the classroom. It is very important to keep in mind that if the child does not like doing a particular activity, the anxiety that follows will affect his ability to keep an erect and steady posture.
Protocol for assessing posture during hand tasks
Let the child sit facing a table with the height of the chair and table adjusted to allow the child to sit with the feet flat on the floor (or some other stable support surface) and the table height more or less level with the child's waist.
Observe the child performing a selection of the tasks listed below. For each task note:
- The child's ability to maintain an erect and stable trunk and head position during most of the task.
- Whether the child seems to tire over time.
- What aspects of the task are associated with changes in the quality of postural control.
Table top hand tasks
Building and puzzle activities
Using wooden building blocks to build a castle or other appropriate structure.
Setting up and playing with a marble run
Playing a game with Jenga/Tower blocks
Building with large interlocking blocks or tubes.
Building a puzzle
Playing board games
Elastic board games.
Drawing and painting activities
Provide the child with a large sheet of paper (A3) and some crayons and encourage the child to draw long lines and curves that cross the page from one side to the other:
Sit opposite the child and demonstrate how you draw long lines down or across the paper, large overlapping circles, large zig-zags across the paper. Encourage the child to copy your actions.
What next?
This assessment protocol provides the therapist with an overview of the child's ability to maintain an upright posture and identifies the factors that contribute to poor sitting posture in the classroom. An intervention program to improve any
In many cases improving flexibility, muscle strength and postural stability will improve the child's ability to sit comfortable and erect in the classroom.
However, it must be remembered that maintenance of an erect and alert posture is affected by a variety of psychological and emotional factors.
The child needs repeated opportunities to work on hand tasks that are enjoyable to increase endurance and good habits for sitting erect. The child also needs practice maintaining a good posture when performing hand tasks that are challenging and tend to lead to avoidance and fidgeting.
The advantage of improving the child's ability to sit erect with ease and comfort means that the parent and teacher know that the poor sitting posture and complaints of tiredness and being bored are not related to musculoskeletal factors.
