Infant Behavior and Development 54 (2019) 133–139

Contents lists available at ScienceDirect

Infant Behavior and Development

journal homepage: www.elsevier.com/locate/inbede

Review

Are sensorimotor experiences the key for successful early

T
intervention in infants with congenital brain lesion?
⁎
Anina Ritterband-Rosenbauma,b, , Mikkel Damgaard Justinianob,c, Jens Bo Nielsena,b,
Mark Schram Christensena,c
a
Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
b
Elsass Institute, Elsass Foundation, Charlottenlund, Denmark
c
DTU Compute, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark

A R T IC LE I N F O ABS TRA CT

Keywords: Living with a congenital brain lesion may have detrimental effects on the ability to do everyday
Predictive coding activities, but contrary to acquired brain lesions, people and in particular children, with con-
Embodied cognition genital brain lesions may have limited or no experience of how their bodies work. This absence of
Sense of agency experience gives rise to challenges for habilitation of sensorimotor abilities and derived cognitive
Infants
abilities. How can motor and cognitive abilities be achieved and trained in an individual with no
Nervous system
Early brain lesion
experience of potential abilities? In this article, we aim to review the existing knowledge about
the development of sensorimotor integration. Further, we will discuss this knowledge in the light
of two neurocognitive theories: embodied cognition and predictive coding. Moreover, using
developmental knowledge and theory in combination, we will argue that early sensorimotor
development serves as a foundation for later cognitive development. Finally, we try to use these
elements in a strategy to make interventions as early as possible, with the purpose of improving
sensorimotor and cognitive abilities in children with congenital brain lesions.

1. Introduction - The problem

Controlling one’s own movements is an inherent ability that is mostly taken for granted. For infants with a congenital brain lesion
such as cerebral palsy (CP), abilities such as precise movement control and appropriate integration of sensory information during
movements may be severely impaired. CP is a sensorimotor development impairment which affects movements, sensory processing
and the perception and experience of the world in a different way that is seen in typically developing peers (Rosenbaum, 2017). Older
children and adults, who suffer a brain lesion have already experienced the ability to control their body prior to the lesion. They may
therefore have the ability to set clear goals for their efforts to regain functional abilities. They possess a memory of how it feels to
move a specific limb, they have an awareness of the impaired body part as part of their body (unless they suffer from neglect
syndrome), and they may have a voluntary, deliberate, desire to move that body part. In contrast, children with CP who are born with
a brain lesion that affects the sensory-motor system will have no prior awareness of the existence of the impaired body part, and they
may have no specific desire to make purposeful movement of the impaired body part. They are therefore impaired in gaining
experience of the body part and how it moves and may consequently never develop the motor abilities that would develop with the

Abbreviations: EC, embodied cognition; FM, fidgety movements; CP, cerebral palsy; MRI, magnetic resonance imaging
⁎
Corresponding author at: Department of Neuroscience, University of Copenhagen, Panum Institute 33.3, Blegdamsvej 3, 2200, Copenhagen N,
Denmark.
E-mail address: arr@elsassfonden.dk (A. Ritterband-Rosenbaum).

https://doi.org/10.1016/j.infbeh.2019.02.001
Received 3 April 2018; Received in revised form 1 February 2019; Accepted 4 February 2019
0163-6383/ © 2019 Elsevier Inc. All rights reserved.
A. Ritterband-Rosenbaum, et al. Infant Behavior and Development 54 (2019) 133–139

repeated use of the limb. This fundamental problem highlights a tough challenge, which parents, therapists, clinicians, relatives and
teachers interacting with children with cerebral palsy are faced with daily. How do you ask a child to move a body part over which
the child has never had any experience of movement control? This situation points to another challenge, one that may have even
greater importance for future quality of life in children with cerebral palsy: If you have never experienced that your movements have
an impact on the surroundings, how can you ever learn that you are the agent of your own actions, and that you can impact the
world?

1.1. Outline of the paper

To try to answer these questions, we will give a brief overview of the different developmental stages in sensorimotor development,
both in terms of results from behavioral studies in infants as well as studies of structural changes in neural tissue. We will then
introduce two theoretical frameworks that can be used in order to understand how sensorimotor development may influence later
cognitive development. We will then identify the critical areas of research where it is possible to establish a relationship between
development of sensorimotor integration and later cognitive development. Finally, we will discuss how early intervention in neu-
rodevelopmental disorders such as CP may benefit by focusing on the ability to develop predictive skills based on predictive coding
principles.

2. Theoretical framework for sensorimotor development

Understanding the different stages of sensorimotor development is of paramount importance if we want to improve quality of life
for children with congenital brain lesions. Action and perception seem to be context-related even at a very early stage in development
(von Hofsten, 2004). This means that to act appropriately, infants need to be able to comprehend a given situation and to modify their
motor response accordingly. However, the age of the child corresponding to the developmental stages in healthy typical developing
infants is not the only requirement for successful acquisition of sensorimotor skills and cognitive skills. One also has to understand the
neurobiological mechanisms that are involved in learning new skills. Here we will take advantage of the theoretical framework of
predictive coding (Rao & Ballard, 1999) and Bayesian integration, which has proven extremely useful in understanding the ability to
acquire new skills (Kording & Wolpert, 2004) and perceive sensory stimuli. A fundamental feature of predictive coding is that the
brain makes sense of the world by constantly making predictions about the incoming information (for an overview with additional
discussion, see Clark, 2013) it receives and tests whether these predictions are in accordance with the incoming information (see e.g.
Friston, Samothrakis, & Montague, 2012). If the information is not in accordance, the predictions may be updated, or sensory stimuli
can be obtained in a different environment through exploration (Kaplan & Friston, 2018). Henceforth, learning takes place either
through a change in prediction or through active exploration in a different environment.
This principle is a powerful explanatory model because it allows both so-called model-based learning and model-free learning
through exploration. Predictive coding is fundamentally hierarchical (Friston, 2008) in terms of how the brain implements in-
formation. This means that the brain can gradually build skills upon skills, and that low-level functions serve as the foundation for
higher level functions. This suggests that predictions are fundamental for the brain and that low-level sensorimotor integration skills
may have profound impact on later development of higher order cognitive skills.
A fundamental aspect of sensorimotor development and sensorimotor learning is that it involves predictions of sensory con-
sequences of actions (Friston et al., 2012; Haggard, 2017). These predictions can arise through forward models (Kawato, Furukawa, &
Suzuki, 1987) which use copies of motor command signals, also termed efference copies (Holst & Mittelstaedt, 1950), to make a
prediction of the sensory outcome of the action. An alternative theoretical standpoint is that motor command signals are in fact not
command signals, but sensory prediction signals that are compared with sensory feedback signals, which then generate prediction
errors (Adams, Shipp, & Friston, 2013). Thenceforth, self-produced voluntary movements suppress sensory prediction errors.
The idea that active exploration and interaction with the environment provide building blocks for higher-order functions is
perhaps best elaborated in the idea of embodied cognition. Embodied cognition designates a theory in current cognitive science,
which suggests that human cognition is dependent upon, or strongly influenced by, our bodily experience and presence in an en-
vironment (Chemero, 2009; Clark, 1997; Gallagher, 2000; Varela, Thompson, & Rosch, 1991; Wilson, 2002). The notion ‘embodi-
ment’ refers to aspects of the body and the environment that go beyond the brain itself. Varela et al. describe the notion as follows:
“first that cognition depends upon the kinds of experience that comes from having a body with various sensorimotor capacities, and
second, that these individual sensorimotor capacities are themselves embedded in a more encompassing biological, psychological and
cultural context” (Varela et al., 1991, p. 171–172). Embodied cognition is typically related to the idea that cognition is enactive,
which means that cognition and knowledge of the world is dependent on an experiencing subject and something that the subject
enacts (Hurley, 1998; Nöe, 2004; Thompson, 2007, 2014; Varela et al., 1991), and it is embedded within the relation of the subject to
the natural and social environment (Clark, 1997; Haugeland, 1998; Hurley, 1998).

2.1. How to operationalize studies in cognitive development

One experimental approach to study the interaction between movement and cognition is to study sense of agency. One definition
of sense of agency is that it is the experience of being in control of one’s movements and the effects they exert in the environment (for
a comprehensive review of the definitions of sense of agency, see Christensen and Grunbaum (2017) and Christensen and Grunbaum
(2018). Sense of agency is believed to rely on the ability to make predictions about the sensory consequences of movements. In order

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to probe whether you have an experience of control of your movements, you have to rely on subjective reports of the experience of
control. Alternatively, indirect measures like the phenomenon of intentional binding phenomenon (Haggard, Clark, & Kalogeras,
2002), where an action and a consequence seem attracted to each other in time, which also relies on subjective report of when actions
and their subsequent consequences take place, could be used. These approaches are not an option when we want to study predictive
mechanisms in infants. We are clearly in a situation where mainly indirect measures of cognitive abilities have to be considered due
to lack of abilities in very young infants to solve complex tasks or communicate in a clear verbal fashion. We will therefore use a
combination of sensorimotor developmental processes, such as studies on structural development of specific sensorimotor neural
networks, as well as direct and indirect predictive mechanisms derived from behavioral experiments. These comprise studies of
sucking, eye-gaze, and other indirect indications of sensorimotor development, which have in common an element of skill learning or
prediction. Finally, for the purpose of designing appropriate intervention strategies, we have to adopt the types of processes employed
in the studies of sensorimotor development that can improve sensorimotor and cognitive abilities in children with cerebral palsy.

3. Development of neural circuitries

The question is: What are the fundamental building blocks in a normal functional nervous system that support control of actions,
sensorimotor integration, and experiences of the consequences of the actions? Furthermore, when do these building blocks start to
develop? In this section, we briefly describe the development of the central nervous system, with an emphasis on the necessities that
describes the sensorimotor integration.
The nervous system begins development around day 17 after conception, but it is not until week five that myotomes begin to
differentiate and develop into muscles (Musumeci et al., 2015). Very soon after this (in week seven) the first movements of the fetus
may be detected in ultrasound examinations (de Vries & Fong, 2006). This coincides very well with the migration of radial neurons
and rapid growth of the nervous system (Sidman & Rakic, 1973). Magnetic resonance imaging (MRI) studies have shown that the
cortical growth, which develops with an exponential component during the second trimester, slows down at the third trimester
(Zhang et al., 2010). At this time, a few immature long range corticocortical connections emerge, but do not provide strong brain
connectivity (Takahashi, Folkerth, Galaburda, & Grant, 2012). During the third trimester the brain’s connectivity is characterized by
a high number of short-range corticocortical fiber pathways (Takahashi et al., 2012). In parallel with this, increased complexity of
movements of the fetus, such as opening of the mouth prior to movement of the hand towards the mouth, is observed (de Vries &
Fong, 2006; Myowa-Yamakoshi & Takeshita, 2006). This is evidence of coordinated activity of neural circuits that involve both the
spinal cord and the brain stem, with little cortical involvement, since at this time the cerebral cortex has not yet developed significant
connections to the spinal cord. Corticospinal connections are not established until shortly before birth at the earliest (Eyre, 2003), and
they undergo significant postnatal development and re-organization (Clowry, 2007; Dubois et al., 2009; Martin, Friel, Salimi, &
Chakrabarty, 2007).
Since control of the extremities is very limited in the first months after birth (D’Souza, Cowie, Karmiloff-Smith, & Bremner, 2017)
studies in newborns have focused on other motor abilities such as eye movements, rooting reflexes or sucking reflexes, in order to
evaluate the prerequisites that underlie the ability to make predictions about sensory consequences of movements. Newborns show
different rooting reflexes whether their chin is touched by an external agent or as part of their own movements (Rochat & Hespos,
1997). This behavior may indicate an early ability of neural circuitries to distinguish sensory stimuli generated by an internal
command (re-afference) from purely external stimuli (ex-afference), and thereby could be interpreted as an ability to make pre-
dictions about consequences of movement (Kawato & Wolpert, 1998) as well as implicitly making the self-other distinction
(Jeannerod, 2006).
Soon after birth infants also appear to be able to detect discrepancies between their experience of the external world and their
own bodily sensation (Filippetti, Johnson, Lloyd-Fox, Dragovic, & Farroni, 2013). Filippetti et al. found that healthy term-born
infants would maintain a longer looking time in situations where they observed a face being stroked synchronously by a touch
delivered to their own face, in comparison to when visual and tactile strokes were asynchronous. The prolonged looking time in
newborns can also be interpreted as a response to familiar objects based on tactile habituation. In another study, newborn infants
were habituated to a specific object form by letting the infants hold it in their hands. After habituation the infants were visually
presented with the familiar and unfamiliar objects, resulting in longer looking time for the familiar objects compared with the
unfamiliar (Sann & Streri, 2007). This indicates that the neural circuitries for detecting connections between different sensory
modalities, are important abilities for development of predictive abilities, are present at birth which. However, whereas two month
old infants modulate their sucking pressure on a dummy pacifier depending on whether an auditory click is presented contingent with
their sucking pressure or in random (Rochat & Striano, 1999), the same behavior appears not to be present in newborns (Rochat &
Hespos, 1997). It is unclear whether this difference is related to the sensory modalities (vision versus hearing) or due to the beha-
vioral responses (eye fixation time versus sucking pressure) investigated in the studies. Two month old infants also maintain visual
fixation for a longer time when a video recording of themselves showed head movements that were congruent rather than incon-
gruent with their own actual head movements (Reddy, Chisholm, Forrester, Conforti, & Maniatopoulou, 2007). Literature on infants’
preference of contingent or non-contingent stimuli indicate that developmental stage, age and exposure to the environment are
important factors (Bahrick & Watson, 1985). However, there seems to be consensus that at around two months of age, infants appear
to have the ability to link events in the external world with sensations related to their own body.

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4. A link between corticospinal control of extremities and prediction

Newborn infants initially make uncoordinated or functionally diffuse movements of the extremities (D’Souza et al., 2017), but
within the first couple of months they will grasp objects placed in their hands, and they may perform bilateral grasp of objects placed
centrally in their visual field (Wallace & Whishaw, 2003). However, it is not until around five months of age that they become capable
of performing goal directed reaching movements towards objects, which they may grasp using independent finger movements and
precision grip (Wallace & Whishaw, 2003). Furthermore, it seems that at a later age, inappropriate accompanied movements during
unimanual reaching (e.g. activation of the other arm, legs, toe wriggling) fade out and are replaced by more efficient goal-directed
actions (D’Souza et al., 2017). At a similar time, infants also greatly improve their ability to make coordinated goal-directed kicking
movements (Thelen & Fisher, 1983). These abilities follow a period where so-called fidgety movements (FM) are observed (Hadders-
Algra, 2007). FM have been linked to re-organization of corticospinal connections (Ritterband-Rosenbaum et al., 2017). It is tempting
to speculate that the appearance of FMs in 3–5-month-old human infants marks a period of activity-dependent corticospinal re-
organization that leads to significant improvements in the skilled control of the extremities. The observation that cortex and muscle
show enhanced coupled activity in this period is consistent with this hypothesis (Ritterband-Rosenbaum et al., 2017). In fact, it has
been shown in cats that synapses of corticospinal neurons undergo substantial activity-dependent re-organization during a sensitive
period shortly after birth (Martin et al., 2007). During this period, the animal shows significant improvements in skilled forelimb
reaching and a concomitant differentiation of corticospinal projections to the involved spinal motor neurons (Martin et al., 2007).
The ability to perform coordinated goal-directed reaching and kicking movements involves elements of sensorimotor integration and
the capacity to adjust their own motor activity, based on the feedback from the environment is an ability that supports motor skill
learning. Developing these motor skills based on feedback from the environment indicates the presence of a so-called forward model
that predicts the sensory feedback of a movement.

4.1. Motor activity influences development of prediction

Understanding the actions of others derives from a translation of one’s own motor repertoire (Cannon & Woodward, 2012; Daum,
Prinz, & Aschersleben, 2011; Gredeback & Kochukhova, 2010; Southgate, Johnson, Osborne, & Csibra, 2009). This is supported by
the study by Kanakogi and Itakura (2011), who suggest that the ability of 10-month old infants to anticipate the goal of others is
associated with their own ability to perform that specific action. Similar findings have been reported by Stapel, Hunnius, and
Bekkering (2015), van Hof, van der Kamp, and Savelsbergh (2008). In contrast to this suggestion, four month old infants were unable
to anticipate the goal of the action, and were also unable to perform the action themselves (Kanakogi & Itakura, 2011). This implies
that development of predictive abilities may be tightly linked to the capacity to comprehend the effect of an action as illustrated by
5–6-months old infants, who crawl and reach purposefully for a desired object (Wallace & Whishaw, 2003). Some experimental
evidence has also been provided by Thelen and Fisher (1983), who observed that children at the age of 5–6 months would perform
more leg kicks when the movement of a mobile was controlled by their kicks rather than by an experimenter (Thelen & Fisher, 1983).
Under the assumption that more leg kicks are interpreted as increased sensorimotor comprehension, this suggests that they under-
stand the consequences of their own movements. A study of even younger infants between three-five months of age describes that
infants of that age show systematic visual and proprioceptive self-exploration providing early evidence of sensorimotor awareness in
typical developing infants. Their results indicated that infants showed spatial preferences; when the infants felt their legs where
kicking in a specific direction, they expected the real-time video feedback to provide the similar direction based on their looking time
(Rochat & Morgan, 1995). These results could indicate that around three to five months of age a more conscious multimodal sensory
integration is developed through a systematic self-exploration of the environment. More recently, Wang et al. (2012) used eye-
tracking to demonstrate that six-month-old infants were able to control the occurrence of a visual image on a computer screen. The
appearance of the image was made dependent on how long the infants fixed their gaze on a specific point on a computer screen. The
results demonstrate that the infants fixed their gaze for an increasingly longer time in order to make the image appear (Wang et al.,
2012), if longer gaze correctly can be interpreted as increased comprehension of sensorimotor consequences. The study included sub-
experiments which allowed Wang and colleagues to argue that the infants’ behavior was not merely based on only lower level sensory
information (reflex level or visual evoked potential to the occurrence of light); rather, they adjusted their eye movements according
to the learned consequence of their behavior, i.e. they must have been able to predict the consequences of their movements.

5. Sense of agency and prediction in infants with brain lesion

We have very little knowledge of sense of agency in infants and children with neurodevelopmental disorders. The test used by
Ritterband-Rosenbaum et al. (2011) to evaluate sense of agency in children is not applicable to younger children and infants, since it
requires verbal reporting and understanding of the task involved. It is therefore not possible to determine whether younger children
and infants with CP would also show a difference in the experience of their own movements with respect to typically developing
children. Therefore, we must rely on other indirect measures of the ability to predict consequences of movements.
Infants with CP show abnormal movements and lack of normal movements (Hadders-Algra, 2007; Prechtl et al., 1997). Fur-
thermore, it has been documented that very premature infants, a group at high risk of developing CP, have a different visual tracking
behavior from that of typically developing term infants. This is a behavior which can predict the sensorimotor development at a later
stage in the infants’ lives (Kaul et al., 2016). While it is very likely that sensorimotor development is accompanied by an altered sense
of agency, it is more difficult to determine whether abnormal development of sense of agency plays a role for the abnormal behavioral

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development in infants with CP, or the other way around. However, the studies described in the previous sections indicate that the
ability to make predictions about consequences of movements is gradually established early during development through interaction
with the environment, once the basic structural connections in the nervous system are in place. If it is correct that development of the
ability to make predictions about consequences of movements involves a gradually more precise prediction of sensory consequences of
actions through experience in typically developed infants, it must be assumed that these abilities in children with CP are delayed and
likely also altered due to affected motor and sensory signaling in the nervous system as well as the reduced interaction with the
environment, all of which may lead to a failure to establish an adequate predictive forward model (Haggard, 2017; Kawato &
Wolpert, 1998). We believe that this is a key element in the understanding of the symptomatology of children between the sensing
agent of the child and the external environment within the first months following birth. In all likelihood, predictive models have great
impact on the further cognitive and motor development of the infant. In this scenario it is not possible to separate the role prediction,
the connectivity in specific neural networks in the nervous system and the acquisition of motor skills of the child, since all are
strongly interdependent.

6. What can we do? Interventions to strengthen the ability to make predictions about consequences of movements in early
infancy

Prediction of the sensory consequences of movement lies at the heart of improved motor performance through practice (Haggard,
2017; Kawato & Wolpert, 1998; Kimberly, Novak, Boyd, Fowler, & Larsen, 2016; Ritterband-Rosenbaum, Christensen, & Nielsen,
2012). Although there is consensus that early intervention is essential to facilitate motor and cognitive development in children with
early brain lesion, we have very little knowledge of what kind of interventions are effective and when they should be initiated in
order to be most efficient. Establishment of new neural connections and re-organization of existing connections is the biological basis
for plasticity within cognitive and behavioral changes (Hebb, 1949; Martin et al., 2007). A review by Campos and colleagues ex-
ploring locomotion progress in infants, a process which causes a heavy load on sensorimotor integration in general, highlights
locomotion as an important factor in developmental changes such as socioemotional development and other cognitive components,
due to a whole new perspective for infants in observing the world (from crawling to upright position) (Campos et al., 2000). This
illustrates very well how motor processes potentially give rise to cognitive developmental changes. It demonstrates the brain´s
activity-dependent synaptic plasticity as the neural network can adapt and change depending on external stimuli. This point is
extremely important when applying intervention for infants with a neurological deficit, as it could enhance beneficial plastic changes
in the nervous system (new wiring of the neural networks) when training sensorimotor integration.
The considerations that we have here regarding development of abilities to make predictions therefore also relates directly to the
neuroplastic changes underlying improved motor performance through practice and development. The ability to make predictions is
consequently also an important factor to consider for early interventions that aim to facilitate motor and cognitive development in
children with CP. First, it appears likely that the development of corticospinal pathways and other descending motor pathways in the
nervous system undergo a period of re-organization after birth, similar to that which has been described in rodents and cats (Martin
et al., 2007). We propose that this period in humans may be approximately within the first six months after birth, corresponding to
the period where FM are seen which can be supported by a changed neural activity within that period (Ritterband-Rosenbaum et al.,
2017) and where important new motor skills are acquired in parallel with development of predictive abilities. Second, if estab-
lishment of the ability to make predictions about consequences of movements is important for acquisition of motor skills and de-
velopment of connections in the nervous system, it is necessary that the intervention involves attempts at getting the infant to interact
with the environment. New motor skills might initiate a cascade of effects, which have a direct impact on cognitive skills. One
example of this approach is the feedback system developed by Linda Fetters and colleagues. The system is an advanced training
module based on the experimental design by Rovee and Rovee (1969) and later Thelen and Fisher (1983). The system requires infants
to lift their leg above a threshold set by a photo-beam in order to play a music recording and make a mobile move. Infants as young as
3 months were able to understand the idea of this system and were found to lift their leg higher and higher for each acquisition period
in order to make the mobile move and hear the music (Sargent, Reimann, Kubo, & Fetters, 2015). Passive stimulation and passive
movement are unlikely to be sufficient in this respect because they do not involve the updating of a forward model or a predictive
mechanism. It is therefore a key for successful intervention at this time that the therapist or the parents find ways of encouraging the
child to make movements towards goals and provide sensory feedback that can be used as an estimate of success when the goal is
reached.
There is good reason to believe that enriched environment is a good approach for stimulating the nervous system, especially as
early in development as possible, as task-specific actions appear from spontaneous movements during infancy when they explore and
learn about their environment. Training systems that stimulate and encourage movement of infants from very early after birth may be
developed. A few randomized controlled (pilot) studies have also investigated the effects of goal-oriented activity-based motor
enriched environment (Morgan, Novak, Dale, & Badawi, 2015; Sgandurra et al., 2016) for infants between 3–9 months of corrected
age who were at risk of developing CP to improve their motor and cognitive functions. Needham and colleagues used an enriched
environment approach in their studies of typically developing pre-reaching infants (around three months of age) to address how a
skill such as ‘reaching’ early in development influences motor and cognitive abilities later in life, due to early self-exploration of their
environment. Each infant was equipped with a mitten of Velcro to facilitate successful reaching/grasping of toys. Results showed that
by reinforcing the action and consequence of the infants’ own movement, i.e. successful grasping a toy, has an impact on their
immediate response towards more engagement in play (Needham, Barrett, & Peterman, 2002), and a follow-up test indicated cor-
relational evidence that infants who have had sticky-mitten-training around three months of age had an improved attentional and

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spatial skills compared to non-trained peers at 15 months of age. These training studies in infants build on the action-reward/
prediction system which encourages the infants to take active part in discovering the consequences of their own movements. The
studies have documented successful motor outcomes of the interventions. We find it very likely that the reason for improved motor
function is related to the infants’ own initiative to participate in the continuous play/training by moving their own bodies in the
environment through continuous sensorimotor integration. Devices that similarly use motivational incentives to enhance movements
that are barely present, albeit possible to detect, may provide an opportunity to promote development of motor skills that would
otherwise potentially be lost. If congenital brain lesions give rise to uncertainty in terms of both motor output and sensory feedback
from the body, we advise that any type of explicit feedback provided to the children should be made as clear and concise as possible.
We recognize the fact that, due to uncertainties of the sensorimotor system caused by the lesion, reproducibility of outcomes might be
less reliable. Therefore, we support continuous self-exploration arising from the infants themselves in the form of producing
movements with the addition of experimental strategies that can reduce the variability of the feedback. This could happen either
through explicit motivational encouragements provided to the movements conducted with limited variability or artificial means of
providing sensory feedback without restricting self-exploration. Furthermore, considerations for how specific interventions should be
designed are also needed. If we accept that Bayesian integration lies at the core of sensorimotor skill acquisition, clear feedback
combined with simple tasks initially to reduce noise would benefit fast learning. Later, more complex tasks and feedback can be
introduced to match the developing motor control skills of the infants.

7. Conclusion

Development of the ability to comprehend the consequences of one’s own movements occurs parallel to the activity-dependent
progress of skilled control of the extremities in the first few months after birth. We argue that this early establishment of an un-
derstanding of one´s own motor abilities through repeated practice and interaction with the environment has an important impact on
later motor and cognitive development. It follows that early identification of neurodevelopmental disorders is essential to instigate
efficient interventions, which promote normal cognitive and motor development. We argue that an essential component of such
interventions is the establishment of the ability to make predictions about consequences of movements of affected body parts by the
means of self-propelled, intentional repeated movements. The possibility of making these predictions should be incorporated through
motivating feedback-reward training of the infants.

Funding

This research received funding from The Elsass Foundation.

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