When surveyed, most people rate childhood as the most happy and valuable part of their life. Childhood has intrinsic value, it is not a time to be sacrificed in preparation for adult life. The childhood of children with CP is often placed at risk because it is squeezed out by treatments. Health care professionals have an enormous influence on the life of the child and the family. Management principles help keep a balance between medical interventions and preserving childhood. Over the past four decades we have
found these twelve principles useful in maintaining this balance.

1. Consider the natural history of the disorder.
The problem is a neurological lesion. The effects of this lesion include motor, sensory and integration difficulties. Tertiary problems include dynamic deformities of the musculoskeletal system that tend to become fixed with time. Fixed contractures cause altered loading of joint cartilage, disturbed growth and bony deformity. These deformities limit function and mobility, and eventually cause degenerative arthritis and pain. Understanding this sequence is important in planning management and preventing adverse outcome. A knowledge of natural history helps us differentiate the effect of our treatment from that of growth and maturation of the child.

2. Appreciate the significance of sensation and perceptive
disabilities.
The child with cerebral palsy has a loss of sensation that is not often appreciated. A diagnosis of spastic diplegia does not acknowledge the existence of any sensory component. In the child with hemiplegia hand function may be more limited by the sensory loss than the deformity and muscle weakness. The child with arthrogryposis with severe deformity still functions well because of intact sensation. Skin ulcers are common in children with myelodysplasia.

3. Recognize the limitations of treatments.
Our treatments do not correct the primary neurological lesion. Our inability to cure the disease means we manage symptoms or deformity. Acknowledging these limitations is important in developing a treatment plan that balances time for treatment and time for being a child.

4. Be cautious with comparisons.
Our objective is to give the child the best possible life-not to make the child normal. Be cautious about using normal values to assess children with cerebral palsy. Becoming too focused on making limbs straight or gait lab curves normal may be counterproductive.

5. Focus on appearance, function and comfort, not on
deformity.
Focus management to the individual’s needs. Base management principles on severity of the problems.

6. Provide functional mobility.
Provide functional mobility to promote intellectual and social development. Functional mobility must be practical, effective and energy efficient. Walking is only one method of mobility. If necessary, provide mobility aids early to increase independence.  Children do not become addicted to these aids. Make time for exploration.

7. Establish appropriate priorities.
Adults with CP rank communication and socialization above mobility in importance. Frequently the family’s major concern is whether or not their child will walk. Walking is important but not essential. Our goal is to help family understand that the most important objectives are independence, social integration and mobilitynot necessarily walking. During each visit attempt to keep the focus on these long term objectives. Help the family accept the limitations caused by the neurological lesion and the reality that
this cannot be corrected. Avoid becoming focused on minor problems that consume energy and resources without long-term value. Make time for friendships with other children.

8. Focus on the child’s assets.
Like other children, children with disability have talents that need to be identified and developed. Take every opportunity to compliment the child and the parents. Time spent developing the child’s assets is usually more productive than time spent attempting to overcome the child’s disability. Make time for creativity.

9. Shift priorities with age.
In early childhood focus on mobility and self care. In mid childhood focus on socialization and education. In late childhood focus on vocational preparation. Make time for just fooling around.

10. Maintain family health.
Protect the health and well being of the marriage and the family. Help the family and support groups to provide information, perspective, support and friendship. Recognize that all treatments have a cost to the child and the family. Avoid overwhelming the family. Make time for family fun. The family is like a computer. If too many programs are opened at once it will crash.
Monitor the family’s stress and avoid overloads.

11. Avoid management fads.
History of medical management includes a vast number of treatments that were either harmful or ineffective. Children are vulnerable, adults would never tolerate what has been done to children. Steer the family away from interventions that are unproven or unrealistic. Such treatments drain the resources of the family and lead to eventual disappointment for the child. Extensive bracing, misguided operations and exhaustive therapies are examples of treatments once in vogue but later abandoned. Often management methods are like waves, a rise and fall followed a new wave of some new treatment. We cannot cure these disorders but we can care for the child and the family. Most important- care not cure.

12. Protect the child’s play experience.
The objective is a child who meets his potential both emotionally and physically. Play is the occupation of the child. The child with a disability needs to play just as other children, perhaps more. Preserve time and energy for this experience. The individual is a child only once. Special Olympics and wheelchair basketball are examples of appropriate team sports. Spontaneous play is best. Let the child discover the joy of childhood. Monitor the child’s time and preserve time for play.

Summary
The relationship with the health care provider is very important in the child’s life. Monitor and preserve the health of the family. Avoid excessive stresses by too many programs. Help the family accept the child’s problem. Compliment and affirm the child and the family whenever possible. Focus on the child’s assets. Provide a time for childhood with play.