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Goal directed training

Last update: 6 May 2016

► Goal directed training can help children with cerebral palsy learn activities needed for everyday life, like doing up buttons, or using a knife and fork
► Daily or regular practice is important for success

Who is it for?

Goal directed training may be suitable for infants, children and adults who have the following characteristics:
Age: Infants and Toddlers, Preschoolers, School-aged, Adolescents, Adults, Older adults
Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

Who can assist?

A clinician, usually an occupational therapist, physiotherapist or speech pathologist, will use a range of strategies to help a child achieve their goals.

Specialist therapists at Cerebral Palsy Alliance are skilled at goal directed training and can help a family decide if it is a good choice.

Find a Cerebral Palsy Alliance service

Fees

Fees will apply for assessment and intervention with health care practitioners and will depend on the provider and the number of sessions needed. A home program is typically provided as part of goal directed training. Check with the practitioner whether fees will also apply for development of the home program, report writing or therapist travel. There may be equipment costs which would depend on the goals and would be discussed at the time of assessment.

Ask health care providers if you are eligible for funding to assist with fees and equipment. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Time

Goal directed training is often carried out over a two to three-month period – if the goal can be achieved in this time.

More about goal directed therapy

Goal directed training (GDT) involves a child with cerebral palsy practicing specific tasks that are needed for everyday life and which they find a challenge1. The tasks that are practiced are those that the child and family has chosen as the goals for therapy. These tasks could be gross motor, self-care, communication, play or school-based activities. Many interventions for children with cerebral palsy involve setting goals or practising activities. However, for an intervention to be truly goal directed training it must begin with a goal and then the goal must be practiced until it is achieved.

Goal directed training uses principles of motor learning theory and dynamic systems theory, which propose that a child, the task itself and the everyday setting in which the task is carried out all have a part to play when learning or improving a movement or motor skill1.

Examples of goals

Examples of goals involve becoming proficient in everyday activities like doing up buttons, climbing the ladder to a slippery dip, using a knife and fork, walking upstairs or catching a ball.

Regular, real-life practice is essential

A clinician will use a range of strategies to help the child learn the target goals, including breaking down the task into achievable parts. Some or all of the components are practised until the goal is achieved. Practice in real-life situations is an important part of this intervention. Importantly, this means families will have lots of opportunities to integrate practice time into their everyday routines.

Things to note

  • Goal directed training is appropriate for children with cerebral palsy of all ages and all levels of severity. Children with significant disability (intellectual or physical) may take longer to achieve their goals or may aim to achieve parts of a goal.
  • Research suggests children up to six years old and at GMFCS Levels I and II may make larger gains than children who are older and at GMFCS Levels III to V
  • This intervention is also referred to as activity based functional therapy, task oriented therapy, task specific training, goal focused task practice or functional therapy2
  • Goal directed training can be used by itself or alongside other interventions3.
  • More research is needed on how frequently children should practice.
  • The goals for this intervention are developed in close collaboration between a child, their family and clinicians. Collaboration is critical to ensure that goals are achievable, meaningful and motivating for the child and family.

Assessments

There are two types of assessment that are required when undertaking goal directed training:

To guide intervention

It is really important for a child and their family to be part of a detailed assessment to identify strengths, and the factors that may prevent the child achieving their goal3. This will involve assessing the physical requirements of the task, the resources and equipment that are needed, and the settings in which the task is done3. The clinician will then work with the family on a plan for achieving the goal.

To measure the outcome of the intervention

The second type of assessment is used to measure whether goal directed training is effective for meeting a child’s goals. The clinician, together with the child and family will decide on the most suitable measure. Two important outcome measures are:

Best available research evidence

Where did we search?

We searched the medical and allied health literature to find research evaluating the outcomes of goal directed training for children with cerebral palsy.

What were we looking for?

The search aimed to find the best available evidence about whether goal directed training improves a child’s ability to complete everyday activities like doing up buttons, climbing the ladder to a slippery dip, using a knife and fork, walking upstairs or catching a ball. Research was included if the children in the studies predominantly participated in goal directed training (rather than doing it in combination with other interventions).

What did we find?

The best available evidence was from seven studies investigating the effects of goal directed training for children with cerebral palsy. These included three randomised controlled trials3-5 (RCTs; Level 2 evidence), two non-randomised controlled trials6-7 (Level 3 evidence) and three cohort studies8-10 (Level 4 evidence). The way that goal directed training was delivered varied between studies and included home programs, parent education, individual therapy appointments and group sessions.

Four primary outcomes were measured in the goal directed training studies - goal attainment, self-care skills, gross motor skills, and upper limb skills.

Overall, moderate quality evidence supports the effectiveness of goal directed training for enhancing goal attainment, self-care skills, gross motor and quality of upper limb movement. Children in the studies maintained the gains made following the intervention. More practice is required, however, to improve on the goals or achieve new goals.

Many children achieved the goals that were set

Goal attainment was measured in four of the seven studies. Many of the goals developed by children and families related to self-care skills and abilities. Goals were achieved by 66%-85% of children3,6,9-10.

Significant improvements made to self-care skills

Self-care skills were measured in all studies. Significant improvements in the ability to complete self-care activities3,4-10 and a significant reduction in the amount of care giver assistance2,7,10 were reported.

Younger and more mobile children experienced significant improvements to gross motor skills

Gross motor skills were measured in seven studies. Significant improvements were reported in each of these studies4-10. Younger children, aged one to five years old, tended to improve more than older children. Children who were classified as GMFCS Levels I and II improved more than children who were classified as GMFCS Levels III to V. There was a trend for improvement earlier rather than later in the intervention period e.g. within the first one to two months9-10. Improvement in the quality of upper limb movement2 was reported in one study.

It is unclear how often children should practice

Children in the studies participated in therapy for periods of time ranging from three weeks to six months. Most training was completed at home with goals integrated into family routines. Clinicians were involved in different ways. Children attended regular (usually weekly) group sessions9 with clinicians in some studies while in other studies, clinicians visited the home4-5. Equal or better results appear possible from goal directed training provided in the home, delivered by parents with support and coaching from a therapist, compared with other approaches3. It remains unclear how often a child should practise a skill or task to master it.

Date of literature searches: July 2014

  1. Dodd, K., Imms, C., & Taylor, N. (2010). Physiotherapy and occupational therapy for people with cerebral palsy: A problem-based approach to assessment and management. London: MacKeith Press.
  2. Law, M., & Darrah, J. (2014). Emerging therapy approaches: An emphasis on function. Journal of Child Neurology, 29(8), 1101-1107. See abstract
  3. Novak, I., Cusick, A. & Lannin, N. (2009) Occupational therapy home programs for cerebral palsy: Double-blind, randomized, controlled trial. Pediatrics, 124(4), e606-14. See abstract
  4. Law, M., Darrah, J., Pollock, N., Wilson, B., Russell, D., Walter, S., Rosenbaum, P., & Galuppi, B. (2011). Focus on function: A cluster, randomised controlled trial comparing child versus context-focused intervention for young children with cerebral palsy. Developmental Medicine and Child Neurology, 9, 1-9.
  5. Morgan, C., Novak, I., Dale, R. C., Guzzetta, A., & Badawi, N. (2016). Single blind randomised controlled trial of GAME (Goals – Activity – Motor Enrichment) in infants at high risk of cerebral palsy. Research in developmental disabilities, 55, 256-267. See abstract
  6. Lowing, K., Bexelius, A., Brogen Carlberg, E. (2009). Activity focused and goal directed therapy for children with cerebral palsy – Do goals make a difference? Disability & Rehabilitation, 31(22), 1808-1816. See abstract
  7. Ketelaar, M., Vermeer, A., Hart, H., Beek, E., & Helders, P. (2001). Effects of a functional therapy program on motor abilities of children with cerebral palsy. Physical Therapy, 81(9), 1534-1545.
  8. Lowing, K., Bexelius, A., & Brogen Carlberg, E. (2010). Goal-directed functional therapy: A longitudinal study on gross motor function in children with cerebral palsy. Disability & Rehabilitation, 32(11), 908-916. See abstract
  9. Ekstrom, L., Johansson, E., Granat, T., & Brogen Carlberg, E. (2005). Functional therapy for children with cerebral palsy: An ecological approach. Developmental Medicine and Child Neurology, 47(9), 613–619.
  10. Sorsdahl, A., Moe-Nilssen, R., Kaale, H., Rieber, J., & Strand, L. (2010). Change in basic motor abilities, quality of movement and everyday activities following intensive, goal directed, activity focused physiotherapy in a group setting for children with cerebral palsy. BMC Paediatrics, 10(26).
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