Children with special needs

19th October 2009

Possible causes of disability

Hereditary factors Prenatal, birth and postnatal problems Childcare and parenting factors Sometimes it is not possible to identify

a clear cause

Recognising special needs

At birth Through child health promotion and

surveillance programmes By follow-up to a parent’s observation and

concern By professional observation home/school Prenatally e.g. amniocentesis, scans etc. Following an accident or serious illness

Some possible causes of special needs

Hereditary factors Genetic inheritance e.g. Cystic fibrosis, sickle

cell and thalassemia conditions, phenylketonuria etc.

Chromosonal inheritance e.g. Down syndrome, Fragile X syndrome

Sex- linked inheritance e.g. Haemophilia, Duchenne Muscular Dystrophy

Inherited disorders are passed on from parents to their children and are always present at birth even if not immediately identifiable

Prenatal factors

Substances e.g. drugs, tobacco, alcohol

Maternal infections e.g. rubella, toxoplasmosis, cytomegalovirus, listeriosis, HIV and some sexually transmitted diseases

Threatened miscarriage

At birth

Anoxia (lack of oxygen) Prematurity Postmaturity Low birth weight Difficult delivery Some examples are Cerebral Palsy,

development delay, Erb’s palsy

Postnatal factors

Infections – bacterial meningitis, measles

Accidents/injuries – brain and spine Childhood cancers – leukaemia,

retinoblastoma Child abuse of any kind Allergic reactions e.g. eczema and

asthma

Childcare and parenting factors

Frequent changes in primary carer in early years

Emotional deprivation Family stress Difficulties with parenting

Sometimes it is not possible to identify a clear cause for a special need

Key points to remember

Conditions present at birth are said to be congenital

Congenital conditions are not necessarily hereditary e.g. congenital heart disease, congenital dislocation of the hip

Special needs may not become obvious until a baby grows and develops, hence the importance of health promotion and developmental assessments

Feelings/attitudes to a diagnosis of disability

Class discussion Holland story

Cerebral palsy

Introduction What happens? Types Diagnosis Management Approaches Implications/additional developments

Introduction

It is not a disease but a complex physical condition affecting a child’s posture and movement

It is caused by damage or failure of the brain to develop in the specific area that controls movement

May cause hearing impairment and perceptual difficulties but not learning difficulties

Introduction continued

Not usually inherited and can occur in any family irrespective of race, social b’ground

One in every 400 children It usually occurs at or immediately after birth, but

also after brain infections The range of the effects of the condition is

enormous – very mild to severely disabled Associated difficulties can include; epilepsy, hearing

impairment, visual impairment (especially squints), speech problems, perceptual difficulties and possible learning delay

What happens?

Before birth Infections e.g. toxoplasmosis, rubella Failure of the placenta to develop or function effectively

Around birth Prolonged or very difficulty labour Prematurity infections

After birth Head injuries Infections e.g. meningitis Brain tumours

Types of Cerebral Palsy

Whatever the reason for the damage to the brain, it does not get worse; however it does not recover either

3 main types; Spastic cerebral palsy Athetoid cerebral palsy Ataxic cerebral palsy

Spastic cerebral palsy

Affects 50-60% of all children with CP Damage occurs to the cortex of the brain Results in abnormally strong tension in certain

groups of muscles and sometimes pain Areas affected are;

Arms – often pressed against the body, fists clenched

Legs – may be less involved, may only affect walking (legs wide apart, arms outstretched). May be poor balance, slow laboured movement. Severe involvement may result in ‘scissoring’ of legs

Athetoid cerebral palsy Occurs in 20-25% of children with CP It results from damage to the basal ganglia which

results in involuntary, uncoordinated and uncontrolled movements of muscle groups

Thought to be made worse by emotional stress All limbs may be involved. Movement is uncontrolled,

jerky and irregular, accompanied by twisting movements in the hands, involving the fingers and wrists

If legs are involved then the child may walk in a writhing, lurching, stumbling manner with arms moving in an uncoordinated way

Speech may be difficult to understand as the child’s tongue and vocal cords are affected.

The likelihood of hearing impairment is increased

Ataxic cerebral palsy

Occurs in 1-10% of cases It results from damage to the cerebellum which is

concerned with balance Child typically finds difficulty in balancing and co-

ordinating movements Often gross and fine control is affected Child may walk with a high stepping motion Often nystagmus is present – rapid eye movementIn addition to the 3 types of CP, around 15-40% of

all children have a combination of effects

Other terms used to describe the affects of CP

QUADRIPLEGIA – this is the most severe form of CP, all four limbs are affected

HEMIPLEGIA – one side of the body is affected

PARAPLEGIA – only the legs are affected

Diagnosis

Early signs Asymmetry in movement or contour –

creases in the groin and the axillae may be different on each side of the body. One hand or limb moves more freely than the other

Listlessness or irritability Feeding difficulties – poor sucking or

swallowing Excessive or feeble cry Long thin baby who is slow to gain weight

Diagnosis

Later signs Failure to follow normal patterns of motor

development Persistence of primitive reflexes Weakness Early hand preference shown (often before

12-14 months of age) Abnormal postures Delayed or impaired speech

Good practice notes

Parents anxieties about the progress of their child must always be acknowledged and investigated

Knowledge of the norms of development are essential

A child who is suspected of having CP will have a full developmental history taken and neurological examination by a paediatrician. An accurate assessment of a child’s abilities will be made in conjunction with a variety of professionals and in partnership with parents

Management Early diagnosis allows for the following; The development of a programme of care, specific to

a child’s total individual needs and the identification of particular strengths

Help to limit or prevent limb contractures (fixed abnormal limb positions)

The development of maximum mobility, preventing restricted movement and faulty posture

The identification and planning for any associated needs involving hearing, vision, speech and any learning disability

A parent may be supported by a variety of professionals depending on the specific needs of the individual child

Ensuring physical comfort and developing mobility

Handle affected limbs with care Try to maintain good body alignment Avoid situations that cause tension and stress for the

child If a spasm occurs – don’t try and control it by force but

gently rock the affected part instead Ensure you know how to lift correctly to prevent

putting strain on your own back When helping the child to stand, place yourself in front

to help balance. Ensure the child’s feet are firm to the floor with a wide base, check the body is leaning slightly forward and encourage to take their own weight

Working with the physiotherapist

The PT will develop a programme using exercises and aids specific to the needs of the individual child

The PT will also teach you how to lift a child to ensure the child has the correct safe support. This will help you to limit associated muscle tension and spasms which are different for each child

Your role is to understand this and how to implement the care plan

Managing feeding Initially some babies need to be tube fed and

this may lead to difficulties learning to suck A baby with CP may have fixed body positions

or develop spasms. Consider this when supporting them at meal times

In an older child, swallowing may be difficult – place food far back and to the side if the child cannot manage alone

Aim to promote independence even if it is initially messier and takes longer

Mealtimes should be sociable, friendly times with opportunities to interact and learn – e.g. taste, smell, tactile and language opportunities

Physical care Aim to promote independence in dressing Hygiene – non-slip bath mat; dental care

particularly important; adaptations may be necessary as child gets older

Toileting may be delayed because muscle tension affects ability to gain bladder and bowel control

Sleeping – a special sleep position may be recommended

The importance of play!!

General tips

The child may take longer to learn a game The child may tire more easily Always praise and encourage effort A child with CP has the same needs as

other children for love security, stimulation and protection. Always apply routine rules and discipline as with any child

Treat the child as a unique and individual with their own personality, likes and dislikes – this is especially important if the child has a communication difficulty

Various approaches

CONDUCTIVE EDUCATION Intensive teaching and learning system Specially trained ‘conductors’ provide the child

with a fully integrated day, without disruptions, from different professionals

The conductors role is to be aware of and develop all aspects of a child through the establishment of a strong relationship with the child

Parents and carers play an important part in the programme – skills learned in the programme should be applied and reinforced in every day life

Various approachesTHE BOBATH CONCEPT

Designed to help the child move more easily It is integral to a child’s daily routine and uses

play rather than ‘exercises’ It aims to improve posture, reduce stiffness,

increase muscle control and limit random muscle movements

Correct positioning and handling at all times is considered to be the key to enhanced movement

Involvement of parents and carers is essential

Persistence and effort is vital

Various approachesBOTULINUM TOXIN

This drug lasts up to 16 weeks and is injected deep into the muscle either by local or general anaesthetic

It works by blocking the signal that the nerves are trying to pass to the muscles

For some children it allows for reduction of muscle tightness and freer movements

It is thought that the drug enables the muscles to stretch and so may reduce the risk of permanent contractures

It is used in conjunction with physiotherapy

Various approachesPATTERNING

This aims to help the child’s mobility through a series of exercises that ‘teach’ the undamaged part of the brain to take over the functions of the damaged part

Involves intensive, frequent and repetitive rhythmic stimulation (patterning) to their limbs for up to 8 hours a day

The therapy is controversial and can exhaust and distress the child

Requires huge time commitment

Implications/additional developments

The range of disability in CP is enormous

Drug therapy to control epilepsy Assistive technology

Switches Communication aids