Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20

How children with cerebral palsy master bimanual

activities from a parental perspective

Git Lidman, Kate Himmelmann, Gunilla Gosman-Hedström & Marie Peny-

Dahlstrand

To cite this article: Git Lidman, Kate Himmelmann, Gunilla Gosman-Hedström & Marie
Peny-Dahlstrand (2017): How children with cerebral palsy master bimanual activities
from a parental perspective, Scandinavian Journal of Occupational Therapy, DOI:
10.1080/11038128.2017.1337807

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Published online: 09 Jun 2017.

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY, 2017
https://doi.org/10.1080/11038128.2017.1337807

ORIGINAL ARTICLE

How children with cerebral palsy master bimanual activities from a parental
perspective
€ma and Marie Peny-Dahlstranda,b
Git Lidmana,b, Kate Himmelmannb,c, Gunilla Gosman-Hedstro
a
Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
b
Regional Rehabilitation Centre, Queen Silvia’s Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; cDepartment
of Pediatrics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

ABSTRACT ARTICLE HISTORY

Background: During childhood, children learn the daily life activities they want and need to do. Received 19 October 2015
Children with unilateral spastic cerebral palsy often have difficulties performing activities requir- Revised 19 May 2017
ing two hands. Accepted 26 May 2017
Aim: To describe parental reasoning on how children with unilateral spastic cerebral palsy learn
to master the performance of bimanual activities in everyday life. KEYWORDS
Material and methods: Sixteen parents participated in focus groups, a qualitative research Activity performance;
approach with its own methodological criteria and research methods. bimanual; hand;
Results: One overall theme emerged from the analysis: ‘Finding harmony between pleasure occupational therapy;
and effort is the key to learning’. This overall theme arose as a synthesis of four themes: parent; learning; qualitative
‘awakening of the inner drive’, ‘trying on one’s own’, ‘enabling things to work’ and ‘it must be research method; upper
worth the effort. The parents described when an activity woke their childrens inner drive to per- limb; cerebral palsy
form. Their children also strived to develop their own way to perform an activity, sometimes
with the support of others, still, some activities were not possible to learn.
Conclusions: Occupational therapists and others in the children’s environment have an import-
ant mission to support the children to find their own harmony between pleasure and effort and
their individual key to success in learning bimanual everyday activities.

Introduction This is not always the case in children with a neuro-

Children learn new activities during childhood
through play and by participating in Activities of
Daily Living (ADL) [1]. The acquisition of occupa-
tional skills has been described from a dynamic sys-
tem perspective [2]. In this perspective, occupational
development occurs via a dynamic interaction
between multiple determinants within the person, the
task and the environment. Humphry [3] describes this
as a self-organized process when children participate
in shared activities. Skills are learned both by observ-
ing and doing things with others, but it is also neces-
sary to try to do things oneself. To enable learning
activities, it is furthermore essential to find activities
that stimulate children’s own interest and motivation
[4,5]. The role of the active child is emphasized in
most contemporary theories of development [6].
Typically developed children gradually learn to use
their hands and to handle objects by adjusting the use
of their hands in increasingly complex activities [7].
logical dysfunction.
Cerebral palsy (CP) is the most common motor
impairment in children and occurs in two per 1000
live births in western Sweden [8]. More than one
third of these have unilateral spastic CP (USCP), with
consequences such as impaired development of hand
function, increased muscle tone, and decreased
strength, speed, coordination and sensation affecting
one of the child’s two hands [7,9]. This implies diffi-
culties in performing activities with both hands coop-
erating in a smooth and coordinated manner. Islam
et al. [10] also indicate that, when the impaired hand
is used, there is often a negative effect for the non-
affected hand. This indicates that using both hands
does not necessarily improve performance, which can
explain why children with USCP sometimes choose
only one hand in typical bimanual activities and why
they may choose alternative approaches.
Children develop skills by carrying out various
activities independently [11]. This provides a sense of

CONTACT Git Lidman git.lidman@vgregion.se Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg,
Box 455, SE-405 30, G€oteborg, Sweden
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 G. LIDMAN ET AL.
who they are and what they can become. Enabling the
learning of different activities at an early age is there-
fore invaluable. Parents of children with USCP follow
their children’s development from their early years
and observe aspects of the learning process and how
they master new activities. The parents often have
experience of home programs associated with different
treatment methods such as botulinum toxin, hand
surgery, goal directed therapy or constraint induced
therapy [12,13]. Still, the ways in which young chil-
dren with USCP learn everyday activities that require
the use of both hands and how parents support this
learning has not been studied.
In this sense the new information that this study,
integrated with the existing knowledge, will generate
new understanding that can be used in occupational
therapy practice. The aim of this study was to describe
parental reasoning on how children with USCP learn
to master bimanual activities in everyday life.
Material and method
Focus group method
The focus group method is a specific type of qualita-
tive research with its own methodological criteria and
research methods [14]. The group process encourages
participants to clarify what they think and provides
opportunities to develop how and why they think a
certain way. The data in a focus group are generated
through the interaction in the group, and this distin-
guishes its form compared to other types of methods
[15]. The analysis combines many different elements
of qualitative research and includes the complexity of
group interaction [16]. The composition of the group
is important. It must in some sense be both homoge-
neous and heterogeneous. Homogeneity in a focus
group study means that participants have the topic
under study in common, which serves to stimulate
the discussions. Equally important is heterogeneity, in
the sense that the discussions should capture a certain
amount of variation regarding aspects of the topic.
Ethics
The study was approved by the Regional Ethical
Review Board at the University of Gothenburg,
Sweden (Reg. No. 665-12).
Participants
Parents of 20 children with USCP were invited to par-
ticipate in this study, a convenient sample of parents
known from an earlier study [13]. Both parents of
each child were given the opportunity to participate.
Seventeen parents of 12 children accepted, and one
canceled on the day that the group was scheduled.
Thus 16 parents, five men and 11 women, participated
in the study. The median age of their children was
nine years (range 6–12 years). All children attended
mainstream schools, with the exception of one child
who attended a special education class. One child had
an additional neuropsychiatric diagnosis. The children
were classified from levels I–III according to the
Manual Ability Classification System (MACS) [17].
Procedure
The families received an invitation letter with infor-
mation about the study. Written consent was
obtained. Focus group discussions were conducted in
2013 at the Regional Rehabilitation Center in
Gothenburg, Sweden. The participants were familiar
with the clinical context. Each group met on one
occasion and the discussions were recorded on audio-
tape and lasted 1.5 to 2 hours. The groups were com-
posed with the aim to achieve a broad representation.
Four focus groups were formed, consisting of three to
five parents who were homogeneous in the sense that
all had children with USCP. At the same time, the
groups were heterogeneous as there was a spread in
their children’s ages and MACS level [17]. The five
men participated in three of the four groups.
The main author was the moderator and the coau-
thors were present one at a time, making notes in the
group discussions. The moderator began by clarifying
the purpose of the study, and the participants were
reminded that all information would be treated as con-
fidential. The participants briefly presented themselves
and their children. The moderator guided the discus-
sion, in which the participants opinions were treated
respectfully. The participants were asked gently to
express their experiences about the subject as freely as
possible.
The five key questions were: What are your experi-
ences of what has been important when your child
learned new bimanual activities? How would you
describe the various factors that are important for the
learning process? How would you describe how the
child is able to increase skills in a familiar activity?
What possible obstacles have you experienced when
your child was learning bimanual activities?
Data analysis
The audio-taped sessions were transcribed verbatim.
The transcript was analyzed with a method

developed for focus group discussions described by
Krueger et al. [14,16]. In the first step the main
author (GL) listened to the audio recordings, and
all authors read the transcript numerous times. To
become familiar with and to understand the mean-
ing of the material, it was necessary to study the
data in context, which meant that the raw data
were used as long as possible. All quotes in the raw
data relevant to the research purpose were identified
and sorted into different themes by the four authors
separately. The level of agreement was very high,
which indicated good trustworthiness of the results
[18]. Disagreement was resolved by consensus dis-
cussions leading to the final outcome. In the second
step the main (GL) and the last (MPD) author, did
a systematization of the raw data in the themes
into categories based on condensed meaning and
illustrated with quotations selected from the raw
data. In the third and final step all the authors
summarized the categorized data in combination
with an interpretative phase that aimed to provide
understanding, resulting in the overall theme. The
English translation of the quotations was carried out
by a native English speaker after completion of the
interpretation.
Results
The analysis of the discussions in the focus groups
resulted in four themes of parental reasoning for
learning: ‘awakening of the inner drive’, ‘trying on
one’s own’, ‘enabling things to work’ and ‘it must be
worth the effort’. Each theme contained two or three
categories.
Awakening of the inner drive
The parents described situations in which their child-
ren’s own inner drive stimulated activity performance
and made it possible to conduct activities with a high
degree of difficulty. The theme ‘Awakening of the
inner drive’ resulted in three categories: ‘kindles
the inner drive’, ‘being inspired by others’ and ‘want to
fit in’.
The activity kindles the inner drive
The children’s own interest in testing new activities is
an important stimulus and can in itself ‘work won-
ders’. The activity itself captures them because it is
such fun, thus initiating and spurring the children’s
inner drive to do it. They repeat the activity over and
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 3
over again, which results in increasingly efficient
performance.
P1 It must be interesting things, like playing
computer games. That’s very interesting. My son
loves that, and then he can ‘double-hop’ with that
hand, just because it’s such fun. He thinks that is so
super cool, he has to use both hands for that. You
can’t get them to cut out just anything, but you have
to find an interesting thing to cut out.
P2 Yes, that’s right.
P1 Because nobody wants to practise just cutting out,
do they?
P3 My daughter loves to keep busy, ‘scrap-booking’,
she loves cutting out and pasting, that’s what she
thinks is fun. (Group 1)
Being inspired by watching others
Looking at others doing activities creates a desire
and inspiration to do things. This give the children
the stimulus to try to overcome challenges necessary
to learn new activities. They want to manage things
that others do because it looks so appealing to
them.
Want to fit in
The parents noticed that the activity in itself is not
always the most important thing, but it was embar-
rassing for their children if they could not perform
the activities like other children. They want to fit in
and not be different from other children. This driving
force is so strong that they overcame difficulties by
training and obstinacy and finally performed the
activity on their own, even if the activity itself was
not so appealing.
The parents described that learning took place
when the activity itself aroused their children’s
interest or when they saw playmates or siblings
doing activities. A desire not to differ from others
or anxiety over not fitting in could also prompt the
children.
Trying on one’s own
The parents reasoned that they have to provide space
for self-development for their children and give them
the opportunity to find their own solutions to prob-
lems. Sometimes the children also needed to be left
alone, without anyone seeing them practice. ‘Trying
on one’s own’ resulted in two categories: ‘their own
way’ and ‘time to oneself’.
4 G. LIDMAN ET AL.
Their own way
The parents described how the children find their own
strategies, their own solutions to how the activity can
be performed, which was encouraged by the parents.
P1 And it’s the same with jackets, she finds a way … .
it looks very unusual and I would never do it like that,
but she has found her own way. So when I tried to
help her, to hold the jacket, it was no help at all. Then
her own way was much faster and more effective.
P2 He found a way of dressing himself, especially
with the foot that he has problems with. He places it
behind, like this … (Group 2)
Time to oneself
Opportunities arose when the parents endorsed the
children’s chances to learn things without their pres-
ence. The children were left to be by themselves and the
activity was allowed to take the time it took without
anyone observing the child and avoiding a stressful
situation.
P2 No, but I thought, because I’ve devoted very, very,
very much time to training, training, training so he
was very tired of me, and I was very tired as well,
and then he got a little brother, and then I didn’t
have time any longer … I’ve not noticed whether it’s
that he’s been left in peace to fix things himself, if it’s
maybe that that has done it …
P1 We talked about swimming before, didn’t we,
when I was not there, then she learns more, and later
we were actually at horse riding lessons – sometimes
then – she’s allowed to ride by herself. Then it
sounds a bit like this: ‘Oh how clever she is! ‘When I
walk beside her she can’t do anything, but when she
rides by herself, then she can. It’s a bit … .
P2 … .and then when they get to practise it
themselves in peace and quiet, it goes better. I don’t
know …
P3 I know, when he was smaller, he had easy clothes
and we lay them on the bed, at weekends, then he
wanted to put them on himself and then he went in
and we did not understand how he did it, but he had
the clothes on when he came out. (Group 3)
Parents’ experience shows that children often had
their own way of learning an activity; they still often
used both hands, but the solutions differed from the
solutions the parents would have chosen. They gave
their children the opportunity to try, and they trusted
their child’s ability. Sometimes the children were left
in peace to practice an activity and, even if it some-
times took a long time, they learned to do it. The
children were able to learn on their own since the
parents created space and time.
Enabling things to work
The parents discussed their children needing their
parents’ support in different circumstances. Sometimes
it was enough to give the children encouragement and
praise. In other situations, when the aim was to develop
new skills, the parents also exposed the children to
activities that gave rise to an appropriate challenge for
them. A third alternative that the parents described was
to simplify the activity so that it was feasible or that the
children got help with all or part of the activity.
The theme Enabling things to work contains
three categories describing parental strategies:
‘encouragement and praise’, ‘challenges and someone
who urges them onandactivities are adjusted.
Encouragement and praise
The parents described how they gave the children
reassurance to do activities. They let the children try
different activities even though they could turn out to
be difficult. They noticed that the children gained
self-confidence and dared to test more activities.
P3 And lots of encouragement!
P1 Yes, that happens a lot, you encourage them so
they think they are world champions …
P2 Yes.
P1 … but it’s good as long as he believes it, I feel …
yes, then they dare to go on.
P2 Yes, that’s it. My son still believes that he will play
with Zlatan, so. (Group 1)
well-known Swedish football player
Challenges and someone who urges them on
The parents described how they tried to take advan-
tage of situations arising in everyday life. They pro-
vided appropriate challenges in activities that their
children otherwise preferred assistance with, activities
reasonable to expect the children to manage
themselves.
P1 He rides, getting the horse to turn right is easy,
but turning left is a bit harder, then you have to do
something with your left hand and he can do that
There was no other way, it certainly works, but we
didn’t talk about any other way, but ‘Take out your

left hand and the horse will turn’, so there was no
other alternative.
P2 Then it worked, otherwise the horse went in
another direction?
P1 Exactly. So, I’ve noticed that quite a lot, if you
have to, then it can work, if you don’t have to, then
it doesn’t happen, hmm … (Group 3)
Activities are adjusted
The parents tried to adapt demanding activities with
respect to the degree of difficulty, the time spent and
how much energy and cognitive stress the activities
required of the children. They should fit into other daily
activities, and various types of compromises occur, but
repeating the same activities in the same order facili-
tated learning and could provide opportunities to grad-
ually increase the difficulty of some activities.
P1 That they do the same thing all the time gives you
feeling of security I suppose. It’s like a monotonous
job, well, you can do it see, then you do without
… thinking. It’s perhaps the same thing if you do the
same things.
P2 That’s how it is, when they are learning something
anyway, that’s how it is probably. a necessity. But
then you can probably build on it … .
Moderator Then you can be more flexible?
P2 Then you can be more flexible, when you’ve sort
of gotten used to it.
P3 Only the last two years have been quite different.
It’s just a matter of getting up in the morning, you
get up and you get dressed. He has been … like
routine … . (Group 4)
The parents performed activities together with their
children and talked about having an awareness of or a
kind of intuitive feeling to enable things to work for
them in everyday life. They tried to stimulate the
child’s desire to learn activities by giving them
encouragement or appropriate challenges to do things
they would otherwise hesitate to perform. Complex
activities were adjusted to match the children’s ability
and to gradually make it possible for these to be per-
formed automatically.
It must be worth the effort
The parents described that some of the activities were
too demanding and took too much energy and time in
relation to the children’s efforts. The activities must
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 5
be worth the effort; otherwise the children would not
take part. The theme ‘It must be worth the effort’
holds three different categories: ‘the degree of difficulty
must be reasonable’, ‘their energy has to last’ and it
must take a reasonable amount of time.
The degree of difficulty must be reasonable
The parents felt that the right degree of difficulty was
important. The children did not want to take part or
did not think the activities were fun when the degree
of difficulty was too high.
P3 My son also did that actually, he was very good
on the violin, and it’s a difficult instrument too, and
he took the hand that was already bad and should do
this (shows) and it went very well, to a certain level,
but then we couldn’t put pressure on him, it gets too
difficult then, he had to give it up, but it works to a
certain limit otherwise it has to be something that
you think is such fun, otherwise they will give up.
P2 Yes, that’s how it is.
P3 And you have to accept that.
P4 It’s a bit like that with my son, he’s clever at
skating and playing indoor bandy, but he finds it very
difficult to put his socks on, then it’s awfully difficult.
(Group 1)
Their energy has to last
The parents described a tiredness in their children that
they believe depends on the fact that more energy is
demanded of them in performing activities as compared
with other children. The amount of energy required for
the activity must be worth the result achieved.
P2 She gets tired very quickly, whatever she’s
doing … With clothes and everything, then she’s
completely finished when she has to jump into the
car and get to school. It’s obvious that they …
P5 That they have to spend more energy when they
have to do something.
P1 Yes.
P3 Yes. (Group 1)
It must take a reasonable amount of time
The parents reasoned that the children were able to
manage certain activities, but that it took a long time.
The time factor could mean limitations.
P4 Putting on clothes – he’s probably the last or
nearly the last from the gym hall or at breaks … …
6 G. LIDMAN ET AL.
or doesn’t bother to button up and then he freezes, of
course, it takes a longer time, everything takes longer.
P1 You show her how to tie shoe-laces and she tries,
you show her and she tries and tries, but it does not
work, there’s a little limit of course to how often and
how long you do this. We all have children of school
age. Or if we have to be off somewhere, she can go
on for 20 minutes, but in the end we have to, we
have to get on, it’s like that unfortunately. (Group 3)
The parents described obstacles that are difficult to
overcome and, for those reasons, the children had to
abandon demanding activities or were given assistance
in doing them.
The analysis of the discussions in the focus groups
resulted in one overall theme, Finding harmony
between pleasure and effort is the key to learning.
This overall theme arose as a synthesis of the four
themes describing how the parents strive to balance
different aspects in the multifaceted learning of
bimanual activities.
Discussion
This study resulted in one overall theme,Finding har-
mony between pleasure and effort is the key to
learning. The results summarize parents’ experiences
of what may promote learning of bimanual activities
in children with USCP. The parents describe the
learning of bimanual activities as demanding and
complex. The results showed that the children learned
many of the activities they had to do and wanted to
do, but that this required a daily amount of effort
from them and furthermore consideration from their
parents. The four themes describe the parents’ reason-
ing about how the children mastered the learning of
new activities. The results describe whether the child-
ren’s interest was piqued and that the activity itself
then started the child’s inner drive to learn.
Sometimes they wanted to develop their own way of
carrying out an activity and at other times they
needed support from their parents. However, accord-
ing to the parents, there were some activities that
were not possible to learn, or were consciously omit-
ted, because they were too difficult to integrate into
the child’s everyday life.
The parents described activities that the children
enjoyed and that were initiated by the children them-
selves, and repetition of these activities resulted in
more skilled performance in their children. An activ-
ity must arouse interest and give the child the reward
of pleasure from doing it; the child would then repeat
the activity by her- or himself. Meaning and value are
important aspects in human activities has also been
described by Persson et al. [5]. Many of the activities
mentioned by the parents were play activities, for
example computer games. Play includes many dimen-
sions according to Blanche [19], such as being arous-
ing, motivating and making it possible to dream away
from reality for a while. Parallels can be drawn from
the parents’ reasoning to the concept of ‘flow’, which
describes an experience that arises where the individ-
ual forgets himself, time and space and where the per-
formance and performer come together to form one
unit [20]. Bimanual activities often require a great
deal of effort in a child with USCP and according to
the parents they seemed to be easier to perform if
they fulfilled the concept of play or flow [19,20].
Persons in the children’s context provided inspiration,
and the children made an effort not to stand out as
being different. They wanted to do the same things as
others do, achieve a sense of belonging or a sense that
occurred when the children were part of a group of
others in close relationship with each other. This feel-
ing is similar to the description of H€annik€ainen called
‘togetherness’ [21]. This importance of the socially
interactive dimension of learning is described by the
parents and is well known in occupational therapy; it
is emphasized in a study by Lawlor [22] as helping
children to develop as occupational beings [3].The
children in our study were often dependent on their
parents to give them support or guidance to refine
their performance and introduce them to other chal-
lenging activities. The parents discussed that they had
developed a way of sharing activities, shaped by hav-
ing a child with a disability, i.e. a readiness to take a
step back or give support. This is earlier described in
the literature as a capacity of co-occupation with
others [23,24]. The parents know when the support is
needed in different circumstances, but also when their
children are ready to manage by themselves. When
the children tried on their own, solutions emerged
that the parents had not considered before, and it was
evident that the children had adapted their perform-
ance to suit their own abilities and limitations. This
was often discovered accidentally by the parents, but
through this experience they started to promote their
children’s own problem-solving skills. Similar to this
description is the therapeutic approach developed by
Polatajko et al. [25] where the importance of giving
children the opportunity to develop their own strat-
egies is emphasized and thus strengthens the findings
in the present study.
The result of this study may facilitate a develop-
ment of intervention programs appropriate for

children with USCP. Hopefully it may give rise to
new aspects how these programs can be adapted to
challenges in home and school environment. This is
especially important, as many intervention programs
require a considerable commitment on the part of
parents to implement training programs with their
children. The results have given us knowledge about
how children interact in the everyday environment,
including both the opportunities and the requirements
that arise there.
In the clinical setting, occupational therapists need
to expose children to activities that can promote their
internal motivation, prompt them to discover new
activities on their own and help them to become their
own problem-solvers. Co-occupation is equally
important, as described by Price, ‘a synchronous dance
back and forth between the occupational experiences of
the individuals involved, the action of one closely shap-
ing the action of the other’ (24, p 180). The occupa-
tional therapist should encourage children to find
their own solutions in performing bimanual activities;
according to the parents’ experience, the children
often found a different and better solution. They fre-
quently used both their hands and took their own
specific reduced ability into account. There must also
be an understanding that some activities takes an
unreasonable amount of time or can be too demand-
ing: avoiding them could sometimes instead be
described as energy- and time-saving. The parents
describe those activities as not being worth the effort
for the children to perform. This suggests that, when
children with USCP are learning new activities, it is
important to strive for reasonable demands in relation
to the effort and pleasure they bring to the child. The
occupational therapist, parents and other persons in
the children’s environment have a challenging and
important mission to strengthen the children’s own
inner drive, enabling their own solution, but they
must also be there to give them support or challenges,
and they must also be understanding when an activity
becomes too demanding.
Methodological strengths and limitations
The focus group methodology was highly suitable for
the aim of this study. Our intention in employing this
methodology [14,26] was to use group interaction as a
tool to capture a subject that is not always easy to
verbalize, where parents of children with USCP had
great experience and where their expertise was crucial
for the results. The focus group discussions enabled
the parents to verbalize these experiences, feeling con-
fident in their being with other parents in a similar
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 7
situation. The discussions became lively and genuine
and there was a confident atmosphere in the groups.
The trustworthiness of the results in reflecting the
parents experiences was assured by the separate ana-
lyzes by the four authors and through the implemen-
tation of the three steps in the method [14,16,18].
One limitation of this study is the absence of the
children’s own experience of learning activities that
require two hands and is hence an important subject
for future research.
Conclusions
Emerging from the parents reasoning, important
aspects of the learning process in performing every-
day activities among children with USCP became evi-
dent. The activity itself could awaken the children’s
internal motivation to perform activities. The chil-
dren could become problem-solvers by finding their
own ways to pursue activities. The assistance of the
parents was important for the children, but it was
also important to continue to expose them to chal-
lenging activities. Still, it must be acknowledged that
this learning process includes a cost for the children,
and there are activities that are too demanding for
them to perform in relation to the effort they
require.
We conclude that the occupational therapist and
others in the children’s environment have an import-
ant mission to support the children to find their own
harmony between pleasure and effort and their own
key to success with each individual’s unique process
of learning to master bimanual everyday activities.
Acknowledgements
We would like to sincerely thank all the parents who par-
ticipated in this study, and Marika Persson, occupational
therapist, who assisted with the children during the focus
group discussions.
Disclosure statement
The authors report no conflict of interest.
Funding
This study was financially supported by the Petter
Silfverski€
old Memorial Fund, the Swedish National
Association for Disabled Children and Young People: the
RBU Research Foundation, the Linnea and Josef Carlsson
Fund, the Swedish Association of Occupational Therapists
Scholarship Fund and the Fund Samariten.
8 G. LIDMAN ET AL.
ORCID
Marie Peny-Dahlstrand http://orcid.org/0000-0002-6026-
1136
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