- Email: [email protected]
The spastic child and its problems
PUBLIC HEALTH,
9o
March, ~953
Educationally Sub-Normal
THE SPASTIC CHILD AND ITS PROBLEMS
A b o u t 1.2% o~ the school p o p u l a t i o n n e e d e d education in special schools. A s c e r t a i n m e n t m u s t pay regard to e m o t i o n a l a n d physical h a n d i c a p s ; maladjustment and partial deafness were often difficult to detect. T h e r e was also t h e n e e d for social e d u c a t i o n a n d t r a i n i n g of coordination, e.g., s p e e c h - t h e r a p y a n d physical training.
Physician-Superintendent, Queen Mary's Hospital for Children, Carshalton
Maladjusted W h i l e it w o u l d take some t i m e before the M i n i s t r y of E d u c a t i o n C o m m i t t e e could be expected to report, there were several points t h a t could well be reiterated. (1) T h e co-operation of p a r e n t s was essential. (2) W i t h admission to a suitable school the work had only b e g u n ; t h e family m u s t b e p r e p a r e d for the child's e v e n t u a l r e t u r n a n d a psychiatric social worker was invaluable. Failing her, the p h y s i c i a n a n d school n u r s e / h e a l t h visitor m u s t be p r e p a r e d to try. (3) D a y classes for t h e maladjusted, as developed in Leicester, L o n d o n , a n d o t h e r towns, h a d a great, if limited, SUCCESS.
Epileptics T h e r i g h t place for an epileptic child was in t h e o r d i n a r y school, b u t efficient t r e a t m e n t was needed. T e a c h e r s a n d p a r e n t s m u s t be e d u c a t e d in t h e needs of t h e epileptic child a n d t i m e m u s t b e s p e n t i n m a k i n g an assessment of the child's needs,
Physically Handicapped I n t h e past social a n d medical c o n d i t i o n s h a d m a d e
necessary a h i g h e r scale of provision t h a n w o u l d n o w b e t h o u g h t necessary. I n Switzerland, t h e provision was m i n i m a l because t h e o r d i n a r y school expected to take a p r o p o r t i o n of h a n d i c a p p e d children.
I n d i v i d u a l T u i t i o n in H o m e a n d Hospital T h o u g h p r o v i d e d u n d e r a different section of the E d u c a tion Act, p e r m i s s i v e n o t m a n d a t o r y , t h e t h e r a p e u t i c result of t h e provision of this tuition was m o s t i m p o r t a n t . I n addition, it could p r e v e n t the educational r e t a r d a t i o n t h a t was a n additional h a n d i c a p to c h i l d r e n already afflicted. I n t h e h o u s e it was i m p o r t a n t and, moreover, it gave the entrge to t h e school physician a n d the chance to develop good medico-social work.
After S c h o o l T h e r e c e n t M . R . C . r e p o r t o n t h e e m p l o y m e n t of c h i l d r e n leaving special schools in G l a s g o w was m o s t illuminating. T h e work of t h e physician c o n t i n u e d after t h e child h a d left school. N o one else was in a b e t t e r position to help the Y o u t h E m p l o y m e n t Officer, b u t to do so t h e physicia n m u s t k n o w s o m e t h i n g of the processes in local industries. T h e local a u t h o r i t y ' s welfare s c h e m e for t h e care of h a n d i c a p p e d persons was of i m p o r t a n c e to the school physician a n d he s h o u l d k n o w of its scope and be ready to advise t h e Welfare Officer o n the n e e d s of particular children.
N a t i o n a l Organisatlons T h e r e were several organisations t h a t were c o n c e r n e d w i t h t h e care of h a n d i c a p p e d c h i l d r e n , for instance, the S h a f t e s b u r y Society, N a t i o n a l Association for M e n t a l H e a l t h , British Epilepsy Association, N a t i o n a l Council for t h e Welfare of Spastics. O f t e n these organisations could help w h e r e a local a u t h o r i t y was u n a b l e to act. Finally, t h e r e was n o aspect of school health work t h a t f u r t h e r e d so i m m e d i a t e an e m o t i o n a l satisfaction, b u t n o n e t h e l e s s this was truly p r e v e n t i v e work, T h e importan~ t h i n g always to r e m e m b e r was t h a t this essentially was n o t a n organisational p r o b l e m b u t was the individual p r o b l e m of a child a n d his relationship w i t h his family, his school, a n d his c o m m u n i V ' . E a c h h a n d i c a p p e d child p r e s e n t e d a specific p r o b l e m t h a t h a d to b e faced and solved.
By C. D. S. ACASSlZ, M.C., M.D., F.R.C.P., D.P.tt.,
T o appreciate o u r p r o b l e m s in dealing w i t h the cerebral palsied child, a n d the p r o b l e m s t h a t c o n f r o n t the child, we s h o u l d have a clear idea as to w h a t we m e a n b y the t e r m cerebral palsy. I p r e f e r this t e r m to the t e r m spastic, as t h e spastic child is o n e w h o is suffering f r o m only one f o r m of cerebral palsy, namely, spasticity. T h e sense in w h i c h I a m c o n s i d e r i n g this p a r t i c u l a r affection is confined to t h a t c o n d i t i o n in w h i c h the child's b r a i n receives damage e i t h e r before, d u r i n g or a f t e r b i r t h as a c o n s e q u e n c e of w h i c h the child has a disability of m o v e m e n t w h i c h is usually general b u t m a y be of v a r y i n g degree a n d not c o n f i n e d to one particular p a r t of t h e b o d y as, for example, a h e m i p l e g i a resulting f r o m cerebral haemorrhage. W h e n t h e r e is this b r a i n damage, t h e r e is a consequential interference w i t h n e r v o u s control of the muscles d e p e n d i n g on the p o r t i o n of b r a i n affected a n d t h e type of disability varies w i t h the site of t h e lesion in t h e b r a i n : (i) I n t h e case of cortical lesion we find spasticity. (ii) A lesion in the basal .ganglia p r o d u c e s athetosis. (iii) A lesion in t h e sub-cortical areas p r o d u c e s rigidity w h i c h is often m i s t a k e n for spacticity. (iv) A lesion in t h e c e r e b e l l u m p r o d u c e s ataxia. (v) I n certain types of lesion one finds tremors. T h e r e are t h u s , broadly, these five types of cerebral palsy a n d the m e t h o d of h a n d l i n g each type is different a n d in each case the m e t h o d of dealing w i t h t h e child is individual. I n order to get successful results, therefore, we m u s t always bear in m i n d t h e s e t h r e e essential points : - (1) T h a t the lesion is a neurological one a n d not o r t h o paedic, t h o u g h d i s t u r b a n c e s of m o v e m e n t result f r o m the neurological lesion. T h e muscles a n d joints are n o r m a l a n d therefore it is useless to p r e s c r i b e massage, electrical t r e a t m e n t or p h y s i o t h e r a p y as a r o u t i n e unless you have a clear idea of w h a t you are p r e s c r i b i n g it for a n d why. (2) A n d , secondly, t h a t every case varies a n d t h e t r e a t m e n t p r e s c r i b e d m u s t b e individual. N o set s c h e m e of exercises or p h y s i o t h e r a p y can therefore be set out. T h e case of cerebral palsy m a y b e slight or severe a n d obviously t h e slight case is n o t g o i n g to require t h e same s u p e r v i s i o n or s c h e m e of t r a i n i n g as t h e severe case, n o r is the s c h e m e o f t r e a t m e n t at t h e b e g i n n i n g t h e same as t h a t r e q u i r e d w h e n the child has progressed. (3) A n d , ~hirdly, one has to b e a r in m i n d t h a t w h e r e t h e r e is a cerebral lesion it m a y be slight or severe and, w h e r e it is severe, t h e r e is m o r e likely to he damage to the intellectual faculties. I n m a n y of these cases, therefore, t h e r e m a y be p r o d u c e d variations in m e n t a l power apart f r o m t h a t r e t a r d a t i o n of m e n t a l activity t h a t always results w h e r e t h e r e is limitation of m o v e m e n t . T o get satisfactory results the child m u s t be m e n t a l l y n o r m a l or potentially n o r m a l a n d the assessment of this m e n t a l power is one of o u r m o s t difficult p r o b l e m s . I n order, therefore, to have a clear c o n c e p t i o n of w h a t f o r m s our t r e a t m e n t of these c h i l d r e n s h o u l d take we m u s t constantly bear in m i n d w h a t is t h e d e v e l o p m e n t of a n o r m a l b a b y . At b i r t h a n d for some t i m e afterwards all m o v e m e n t is i n v o l u n t a r y or leflex. As the child's n e r v o u s s y s t e m grows a n d the n e r v e s b e c o m e m y e l i n a t e d the b a b y b e g i n s to show v o l u n t a r y m o v e m e n t a n d his p o w e r of m o v e m e n t and m e n t a l pictures of m o v e m e n t s develop f r o m the s t i m u l i he receives f r o m outside a n d within. H e c o m m e n c e s to lift his head, to lift his arms, to be attracted b y b r i g h t o h j e c t s a n d to try to grasp t h e m a n d so on until he reaches t h e stage of t r y i n g to s t a n d a n d walk. A t first his m o v e m e n t s are f u m b l i n g a n d irregular a n d incoordinated, b u t slowly t h e y improve. W h e n t h e r e is damage to t h e b r a i n so as to interfere w i t h the d e v e l o p m e n t of the n e r v o u s control, t h e child is u n a b l e to lift his h e a d or take m u c h i n t e r e s t in his s u r r o u n d i n g s a n d as a c o n s e q u e n c e t h e
PUBLIC ItEALTH, March, I953 stimuli he receives are relatively few a n d as a c o n s e q u e n c e his picture of m o v e m e n t a n d p o w e r of m o v e m e n t are poor. Such a child if left alone will develop some m o v e m e n t b u t it will be slow a n d relatively ineffective. I f t h i s c h i l d is t o develop a n approximately n o r m a l m o v e m e n t he m u s t b e p r o v i d e d w i t h selected stimuli so t h a t h e can develop his o w n p i c t u r e a n d power of m o v e m e n t . W e c a n n o t develop his n e r v o u s control b u t we can provide those stimuli b y w h i c h he will, p r o v i d e d h e has t h e m e n t a l capacity, develop his own control of m o v e m e n t . If I m a y give a simple e x a m p l e - - a spastic child t e n d s to keep his legs straight a n d his back also, so t h a t if p u t to sit in a chair he t e n d s to sit on his coccyx. If allowed to do this his m e n t a l picture of sitting will be one of sitting on his coccyx. If you try sitting o n your coccyx you will find it m u c h more difficult to use y o u r arms or h a n d s in f r q n t of you a n d if it is difficult for you h o w m u c h m o r e difficult it m u s t be for t h e spastic child. If h e sits in the r i g h t position a n d always sits in t h a t position his idea of sitting will be a correct a n d a n easy one a n d he is placed i n the easiest position for h i m to m o v e his arms. I t r u s t I n e e d n o t l a b o u r this idea f u r t h e r b u t one or two t h i n g s follow f r o m it. First, it is obvious t h a t t h e use of calipers, braces a n d o t h e r appliances is n o t going to assist the child as the picture of m o v e m e n t the child will o b t a i n will b e one of being supported by them. Secondly, w h e r e a c h i l d has n o t b e e n given any treatm e n t a n d has developed some sort of m o v e m e n t , he will have to forget w h a t h e has l e a r n t a n d try to s u b s t i t u t e s o m e t h i n g else for i t - - a n extraordinarily difficult t h i n g to do. T h i r d l y , if we are going to get t h e best results we m u s t get h o l d of t h e s e c h i l d r e n before they have developed any v o l u n t a r y m o v e m e n t themselves, t h a t is, we m u s t get t h e m as babies a n d t h e earlier the better. T h e early diagnosis of such cases, therefore, is essential a n d it is in t h e m a t e r n i t y a n d child welfare clinics a n d p o s t natal clinics t h a t these cases s h o u l d b e picked up. I do n o t say t h a t they s h o u l d be diagnosed there, b u t w h e n a c h i l d is slow in developing he s h o u l d b e referred to s o m e o n e w i t h a special knowledge of cerebral palsy. Diagnosis at this early stage is, in m y opinion, very difficult, a n d it is only b y c o n c e n t r a t i n g o n these y o u n g infants t h a t we are going to make progress in early diagnosis. W h e n we have reached t h e stage of diagnosing all these cases in infancy t h e n will we b e in a position to treat t h e m as soon as they are discover,*.d a n d ultimately reduce t h e n u m b e r for w h o m special provision will have to b e m a d e at a later stage in t h e i r lives.
D i a g n o s i s o f Variations I n relation to t r e a t m e n t t h e r e are a n u m b e r of p r o b l e m s t h a t arise n o t only in the s t r a i g h t f o r w a r d case b u t in t h e variations t h a t occur. W e are apt to forget t h a t as the c o n dition is primarily a neurological one, the limitation or a b e r r a t i o n s of m o v e m e n t of the limbs, t h o u g h the m o s t obvious are n o t necessarily the only or even the chief p a r t s affected. Being a central lesion, t h e whole m u s c u l a t u r e is i n v o l v e d so t h a t one finds difficulties in swallowing, h e n c e d r i b b l i n g , i n c o n t i n e n c e of u r i n e a n d faeces, irregular respiration, a n d so on. F u r t h e r , there m a y b e obvious eye defects s u c h as strabismus, b u t also less obvious defects s u c h as difficulty in focusing or in co-ordination. I n the same way t h e r e m a y be defects of h e a r i n g or even severe deafness, either of w h i c h still f u r t h e r h a n d i c a p s the child b o t h physically a n d by c u t t i n g off stimuli necessary for his physical a n d m e n t a l d e v e l o p m e n t . W h e r e any of these defects exist they p r o v i d e a f u r t h e r p r o b l e m in t r e a t m e n t b u t also, as has b e e n so well p o i n t e d out b y Miss D u r i s t o n in h e r book on the " E d u c a b i l i t y of the C e r e b r a l Palsied C h i l d , " in the e d u c a t i o n of the c h i l d - - a p o i n t w h i c h has not b e e n sufficiently recognised in t h e past. So long as these p r o b l e m s are recognised t h e y will b e looked for, b u t m y experience has led m e to believe t h a t they are n o t always recognised. N o t i n f r e q u e n t l y we see c h i l d r e n who have b e e n referred to us w h o are deaf or partially so,
9x or blind, partially b l i n d or w i t h defective vision of o n e k i n d or a n o t h e r , w h i c h defect has n o t b e e n p I e v i o u s l y recognised. O n l y recently we h a d a boy w h o h a d b e e n i n a residential school for h a n d i c a p p e d c h i l d r e n , w h o m we f o u n d to be partially d e a f - - h i s teacher a n d those w h o dealt w i t h h i m were unaware of his partial deafness, however. H e was treated, p r o v i d e d with a h e a r i n g aid, a n d is n o w a t t e n d i n g an o r d i n a r y school. All these c h i l d r e n p r e s e n t p r o b l e m s in the e d u c a t i o n a l m e t h o d s t h a t s h o u l d be a d o p t e d for t h e m , b u t the diff• culty varies according to the type a n d e x t e n t of the disability. I n slight cases the c h i l d r e n m a y be able to a t t e n d an o r d i n a r y school, b u t the teacher, a n d those w h o deal w i t h the child, s h o u l d be aware of his disability a n d be i n s t r u c t e d in the best m e t h o d s of dealing w i t h him. N o n - r e c o g n i t i o n of the fact t h a t the child has some disability m a y lead to difficulties w i t h the child a n d an a c c e n t u a t i o n of his s h o r t comings w i t h a c o n s e q u e n t adverse psychological effect a n d resultant setback in the child's p h y s i c a l a n d m e n t a l progress.
P r o b l e m s for the T e a c h e r F o r c h i l d r e n w h o are m o r e severely affected special m e t h o d s m u s t b e a d o p t e d either in classes for the physically h a n d i c a p p e d or even in special schools for cerebral palsy cases such as those already set u p in B i r m i n g h a m , at I v y b r i d g e a n d elsewhere. I n dealing w i t h this latter class of case the teacher s h o u l d recognise a n d be i n s t r u c t e d t h a t : (1) T h e r e m a y be defects of vision, or hearing, in a d d i t i o n to the child's o t h e r defects. If these defects are n o t reeognised, the m e t h o d s of teaching m a y accentuate t h e c h i l d ' s difficulties, and, instead of progressing, t h e child will n o t only retrogress b u t his physical progress outside the classr o o m m a y also b e i n t e r f e r e d with. F u r t h e r , n o n - r e c o g n i t i o n of these defects m a y lead to a conclusion t h a t t h e c h i l d ' s m e n t a l c o n d i t i o n is worse t h a n it really is, a n d as a c o n s e quence the s t a n d a r d of work set m a y b e below t h e child's m e n t a l ability w i t h a c o n s e q u e n t adverse psychological effect, w h i c h it s h o u l d be o u r a i m to avoid. (2) H a v i n g recognised these difficulties, the t e a c h e r has also to a d a p t h e r m e t h o d s of t e a c h i n g to suit t h e i n d i v i d u a l child, a n d this requires considerable care, o b s e r v a t i o n of the child, a n d a t t e n t i o n to its particular needs. It is u s e less, for instance, to expect a child w h o has severe a t h e t o i d m o v e m e n t s of the fingers a n d h a n d s to h o l d a p e n a n d att e m p t to v, rite, b u t s u c h a child m a y be able to h o l d w o o d e n blocks w i t h letters o n t h e m a n d so spell words to b e g i n w i t h and, later, b y a p p r o p r i a t e a d a p t a t i o n of t e a c h i n g m e t h o d s , can be t a u g h t to read, write, do s u m s a n d o t h e r t h i n g s . As t h e i r physical c o n d i t i o n i m p r o v e s so the m e t h o d of t e a c h i n g requires modifying. N o t only m u s t t h e t e a c h e r a d a p t her m e t h o d s for t h e individual child b u t in o r d e r to do this she m u s t recognise t h a t t h e h a n d l i n g of t h e different varieties of cerebral palsy is different. The h a n d l i n g of a spastic child is different f r o m t h a t necessary for an athetoid. T o do this she m u s t have a k n o w l e d g e of t h e u n d e r l y i n g cause. T h e r e r e m a i n a n u m b e r of c h i l d r e n w h o are so severely h a n d i c a p p e d t h a t t h e y c a n n o t a t t e n d one of these special schools, a n d for these, h o m e t u i t i o n is necessary. S u c h cases s h o u l d be k e p t to a m i n i m u m as t h e child misses t h e contacts he s h o u l d have w i t h o t h e r c h i l d r e n w h i c h help in his rehabilitation. It will be obvious f r o m w h a t I have said t h a t all those dealing w i t h the child, i n c l u d i n g the teachers c o n c e r n e d , s h o u l d have a period of i n s t r u c t i o n in a cerebral palsy u n i t before taking o n a class of these children. P r o b l e m s F a c i n g the Child H a v i n g dealt w i t h t h e t e a c h e r ' s p r o b l e m , before I c o n t i n u e o n the educational aspects, m a y I say a few w o r d s u p o n the p r o b l e m s w h i c h face the child ? W e are apt to forget t h a t t h o u g h such c h i l d r e n m a y have a b n o r m a l m o v e m e n t s or severe h a n d i c a p s their outlook o n life is t h a t they themselves are like o r d i n a r y c h i l d r e n b u t , u n f o r t u n a t e l y , h a n d i c a p p e d in carrying o u t certain activities.
92 T h e fact that t h e i r activities are restricted does not m e a n t h a t t h e i r b r a i n s are therefore defective, n o r does it m a k e t h e m feel t h a t they are a n y t h i n g b u t normal, a n d o u r a p p r o a c h s h o u l d be to encourage this outlook and, so far as possible, m a k e t h e m m i x w i t h n o r m a l children. U n f o r tunately, t h e child c a n n o t explain all this to us, a n d t h e r e fore it behoves us to try to f a t h o m t h e i r desires a n d help t h e child give expression to t h e m . T h e fact of t h e i r m e n t a l outlook has b e e n b r o u g h t h o m e to m e o n m a n y Occasions. I n p h o t o g r a p h s of these c h i l d r e n on a d m i s s i o n I h~ve b e e n s t r u c k b y the f r e q u e n c y w i t h w h i c h the child's expression is o n e of f r u s t r a t i o n a n d u n h a p p i n e s s , an expression w h i c h is quickly replaced b y a more n o r m a l expression once the child is p r o p e r l y h a n d l e d . Again, o n one occasion, I f o u n d t h e c h i l d r e n in o u r c e r e b r a l palsy u n i t d o i n g a little play in t h e d a y - r o o m in t h e same way t h a t healthy c h i l d r e n do. T h e fact t h a t few of t h e m c o u l d walk, a n d one or two o n l y speak indistinctly, d i d n o t d e t e r or even b o t h e r t h e m I t h e y were b e h a v i n g as t h e y k n e w n o r m a l c h i l d r e n do, a n d t h e i r imaginations filled in a n y little gaps or lapses there m a y have been. T h i s attitude was well expressed b y one a t h e t o i d girl, w h o s h o w e d a finger p a i n t i n g to one of the doctors w i t h t h e r e m a r k , " I t m a y n o t be m u c h , b u t if you only k n e w w h a t f u n it was after n o t b e i n g able to do a n y t h i n g . " T h e p a i n t i n g , t h o u g h r o u g h , as it was b o u n d to be, s h o w e d a w o n d e r f u l sense of design a n d cotour w h i c h m a d e it e v i d e n t t h a t h e r b r a i n was quite bright. All s u c h activities, t h e n , s h o u l d b e encouraged, a n d these c h i l d r e n s h o u l d have as m a n y varieties of experience as o t h e r c h i l d r e n have, if it is possible. W e s e n d these c h i l d r e n to concerts a n d plays w i t h the others, a n d one has only to w a t c h t h e m to realise t h a t they take it all in, a n d such stimuli are helpful in t h e i r development.
T h e A f t e r m a t h to Hospital T r a i n i n g O f t h e o t h e r p r o b l e m s t h a t face us I suppose the chief is w h a t is to h a p p e n to s u c h a child w h e n h e leaves the unit, if he has b e e n in one. I n all this i n s t r u c t i o n a n d h a n d l i n g we s h o u l d bear in m i n d t h a t if the child has to go into a u n i t it can only b e for a limited period. Once h e is set o n the r i g h t lines he can be discharged, b u t he will retrogress unless he is supervised. T h i s s u p e r v i s i o n m u s t go on for years, a n d it is particularly the m o t h e r w h o m u s t exercise s u p e r v i s i o n and, therefore, she above all others requires i n s t r u c t i o n in h o w to h a n d l e h e r child. Once she has received this i n s t r u c t i o n , preferably for as long as she can spare t h e time, she can b r i n g the child to the clinic periodically. I n the less severe cases she can be given i n s t r u c t i o n a n d b e kept u n d e r m o r e f r e q u e n t supervision. T h e n t h e r e comes the p r o b l e m of t h e child's schooling at h o m e . Some of these children, t h o u g h fit for an o r d i n a r y school intellectually, have difficulty in o b t a i n i n g admission because of some a b n o r m a l i t y of m o v e m e n t . H e a d mistresses a n d teachers should be i n s t r u c t e d r e g a r d i n g s u c h c h i l d r e n a n d n o t b e e m p o w e r e d to refuse admission. A s o m e w h a t similar difficulty m a y b e e n c o u n t e r e d if t h e child is r e c o m m e n d e d for a special school for physically h a n d i c a p p e d children. I feel s t r o n g l y that, generally speaking, the solution of this p r o b l e m is to train t h e teachers in these special schools h o w to deal w i t h the h a n d i c a p of cerebral palsy r a t h e r t h a n t r y to set u p special schools for cerebral palsied c h i l d r e n . E x c e p t in very large industrial areas t h e n u m b e r s of s u c h c h i l d e r n are n o t sufficient to w a r r a n t s u c h special schools b u t w h e r e they are set u p t h e y s h o u l d b e u s e d as a t r a i n i n g - g r o u n d t h r o u g h w h i c h the c h i l d r e n pass to t h e special or o r d i n a r y schools. T h e fact t h a t a child w h o is u n a b l e to walk is therefore e x c l u d e d f r o m a special school does n o t seem to m e an intelligent m e t h o d of dealing w i t h the e d u c a t i o n of s u c h children. I have at t h e m o m e n t a spastic child who, a l t h o u g h deaf a n d d u m b , is quite e v i d e n t l y intelligent, b u t because she c a n n o t walk upstairs c a n n o t b e a d m i t t e d to a deaf a n d d u m b school,
PUBI.IC HEALTH,
March, z953
Once the child has passed the school age, w h a t is to be done with h i m ? T h e p r o b l e m of o b t a i n i n g some t r a i n i n g for such c h i l d r e n is one that we are constantly faced with. T h e r e are m a n y i n s t i t u t i o n s w h e r e physically h a n d i c a p p e d c h i l d r e n are t r a i n e d for some occupation, b u t usually such children are selected r a t h e r carefully for such traini~ag. F o r economic reasons such selection m a y be necessary, b u t if we take t h e long view it is surely desirable that we should e n c o u r a g e in every way the d e v e l o p m e n t of special t r a i n i n g centres, or even homes, w h e r e cases of cerebral palsy of the m o r e severe type can be t r a i n e d to carry out some occupation w h i c h would c o n t r i b u t e s o m e t h i n g towards the cost of t h e i r m a i n t e n a n c e . I f the p a t i e n t can only be trained to use his arms a n d h a n d s while sitting a n d is u n a b l e to use his legs he m a y u n d e r t a k e useful a n d r e m u n e r a t i v e work w h i c h w o u l d n o t only lmlp h i m financially a n d reduce the b u r d e n he m i g h t otherwise be on the St/rte, b u t would also effect t h e even m o r e i m p o r t a n t object of b u i l d i n g up a sense of self-respect a n d responsibility a n d a feeling t h a t his life a n d work are not only of value to h i m self b u t a c o n t r i b u t i o n towards the c o m m u n i t y of w h i c h he would t h e n feel h i m s e l f a responsible m e m b e r .
A CEREBRAL PALSY UNIT WITHIN A DAY SCHOOL FOR P H Y S I C A L L Y H A N D I C A P P E D C H I L D R E N By T . MORRISON CLAYTON, M.D., B.S., B.HY., I).P.H.,
Medical Q~cer of Health and School Medical Officer, Coventry " W h a t sculpture is to a block of m a r b l e , education is to t h e h u m a n SOUl."--ADDISON. T h e r e is ever~r justification in these p r e s u m a b l y m o r e e n l i g h t e n e d days for us to accept t h e fact t h a t c h i l d r e n suffering f r o m t h e effects of cerebral palsy are also h a n d i capped in the t r u e sense a n d t h a t if t a k e n sufficiently early. m o s t sufferers can be assisted to o v e r c o m e t h e i r disabilities to a greater or lesser extent. T h i s in itself is an a d m i s s i o n w h i c h s h o u l d b e a p p l a u d e d for, in spite of D r . Little's original description of t h e condition over 100 years ago, it constitutes a clear a d v a n c e m e n t in t h o u g h t even over fairly r e c e n t times : it is only a very few years since palsied c h i l d r e n were to all i n t e n t s a n d p u r p o s e s f o r g o t t e n save b y a few. T h e greater p r o p o r t i o n of those " few " n a t u r a l l y c o n s t i t u t e d t h e i m m e d i a t e a n d responsible relatives, a n d w h i c h of us can n o w gainsay t h a t their b u r d e n a n d p r e o c c u p a t i o n w i t h t h e i r p r o b l e m s was oppressive ? M a n y of these p a r e n t s have for long h a d grave misgivings a n d i n d e e d e x t r e m e depression as to w h a t the f u t u r e held in store for t h e i r h a n d i c a p p e d offsprings and, n o t u n n a t u r a l l y at times, for t h e i r o w n place a n d f u t u r e in society also. I n the past we as a c o m m u n i t y have been too ready to regard these c h i l d r e n as b e i n g so m e n t a l l y incapable a n d physically u n a b l e of d e r i v i n g benefit i n the spheres of e d u c a t i o n a n d r e h a b i l i t a t i o n t h a t we have t e n d e d to allow this acute h u m a n p r o b l e m to go b y default. T h i s , as has b e e n stated o n o t h e r occasions, is n o d o u b t one of t h e reasons w h y a p r o p o r t i o n of these u n f o r t u n a t e s has b e c o m e e n t a n g l e d in m e n t a l deficiency institutions, h a v i n g b e e n placed t h e r e in error, or, if you prefer, because of e r r o n e o u s diagnoses. W h i l e such a confession m a y a p p e a r deplorable to t h e u n i n f o r m e d lay m i n d it is, I feel in effect, n o t so m u c h a m a t t e r of negligence u p o n the p a r t of o u r profession b u t r a t h e r a defect in o u r t e a c h i n g a n d c o n s e q u e n t lack of detailed knowledge u p o n this p r o b l e m w h i c h n o w conf r o n t s us. 'Judging, however, b y t h e n u m e r o u s lectures a r r a n g e d in refresher courses for School Medical Officers d u r i n g this last few years it is v e r y e v i d e n t that this section of o u r profession has t h e subject m u c h at heart a n d is alive to t h e implications. D u r i n g these past few years we have all h e a r d a n d read m u c h a b o u t D r . C a r l s o n - - h i m s e l f a severe case of diplegia
9o
March, ~953
Educationally Sub-Normal
THE SPASTIC CHILD AND ITS PROBLEMS
A b o u t 1.2% o~ the school p o p u l a t i o n n e e d e d education in special schools. A s c e r t a i n m e n t m u s t pay regard to e m o t i o n a l a n d physical h a n d i c a p s ; maladjustment and partial deafness were often difficult to detect. T h e r e was also t h e n e e d for social e d u c a t i o n a n d t r a i n i n g of coordination, e.g., s p e e c h - t h e r a p y a n d physical training.
Physician-Superintendent, Queen Mary's Hospital for Children, Carshalton
Maladjusted W h i l e it w o u l d take some t i m e before the M i n i s t r y of E d u c a t i o n C o m m i t t e e could be expected to report, there were several points t h a t could well be reiterated. (1) T h e co-operation of p a r e n t s was essential. (2) W i t h admission to a suitable school the work had only b e g u n ; t h e family m u s t b e p r e p a r e d for the child's e v e n t u a l r e t u r n a n d a psychiatric social worker was invaluable. Failing her, the p h y s i c i a n a n d school n u r s e / h e a l t h visitor m u s t be p r e p a r e d to try. (3) D a y classes for t h e maladjusted, as developed in Leicester, L o n d o n , a n d o t h e r towns, h a d a great, if limited, SUCCESS.
Epileptics T h e r i g h t place for an epileptic child was in t h e o r d i n a r y school, b u t efficient t r e a t m e n t was needed. T e a c h e r s a n d p a r e n t s m u s t be e d u c a t e d in t h e needs of t h e epileptic child a n d t i m e m u s t b e s p e n t i n m a k i n g an assessment of the child's needs,
Physically Handicapped I n t h e past social a n d medical c o n d i t i o n s h a d m a d e
necessary a h i g h e r scale of provision t h a n w o u l d n o w b e t h o u g h t necessary. I n Switzerland, t h e provision was m i n i m a l because t h e o r d i n a r y school expected to take a p r o p o r t i o n of h a n d i c a p p e d children.
I n d i v i d u a l T u i t i o n in H o m e a n d Hospital T h o u g h p r o v i d e d u n d e r a different section of the E d u c a tion Act, p e r m i s s i v e n o t m a n d a t o r y , t h e t h e r a p e u t i c result of t h e provision of this tuition was m o s t i m p o r t a n t . I n addition, it could p r e v e n t the educational r e t a r d a t i o n t h a t was a n additional h a n d i c a p to c h i l d r e n already afflicted. I n t h e h o u s e it was i m p o r t a n t and, moreover, it gave the entrge to t h e school physician a n d the chance to develop good medico-social work.
After S c h o o l T h e r e c e n t M . R . C . r e p o r t o n t h e e m p l o y m e n t of c h i l d r e n leaving special schools in G l a s g o w was m o s t illuminating. T h e work of t h e physician c o n t i n u e d after t h e child h a d left school. N o one else was in a b e t t e r position to help the Y o u t h E m p l o y m e n t Officer, b u t to do so t h e physicia n m u s t k n o w s o m e t h i n g of the processes in local industries. T h e local a u t h o r i t y ' s welfare s c h e m e for t h e care of h a n d i c a p p e d persons was of i m p o r t a n c e to the school physician a n d he s h o u l d k n o w of its scope and be ready to advise t h e Welfare Officer o n the n e e d s of particular children.
N a t i o n a l Organisatlons T h e r e were several organisations t h a t were c o n c e r n e d w i t h t h e care of h a n d i c a p p e d c h i l d r e n , for instance, the S h a f t e s b u r y Society, N a t i o n a l Association for M e n t a l H e a l t h , British Epilepsy Association, N a t i o n a l Council for t h e Welfare of Spastics. O f t e n these organisations could help w h e r e a local a u t h o r i t y was u n a b l e to act. Finally, t h e r e was n o aspect of school health work t h a t f u r t h e r e d so i m m e d i a t e an e m o t i o n a l satisfaction, b u t n o n e t h e l e s s this was truly p r e v e n t i v e work, T h e importan~ t h i n g always to r e m e m b e r was t h a t this essentially was n o t a n organisational p r o b l e m b u t was the individual p r o b l e m of a child a n d his relationship w i t h his family, his school, a n d his c o m m u n i V ' . E a c h h a n d i c a p p e d child p r e s e n t e d a specific p r o b l e m t h a t h a d to b e faced and solved.
By C. D. S. ACASSlZ, M.C., M.D., F.R.C.P., D.P.tt.,
T o appreciate o u r p r o b l e m s in dealing w i t h the cerebral palsied child, a n d the p r o b l e m s t h a t c o n f r o n t the child, we s h o u l d have a clear idea as to w h a t we m e a n b y the t e r m cerebral palsy. I p r e f e r this t e r m to the t e r m spastic, as t h e spastic child is o n e w h o is suffering f r o m only one f o r m of cerebral palsy, namely, spasticity. T h e sense in w h i c h I a m c o n s i d e r i n g this p a r t i c u l a r affection is confined to t h a t c o n d i t i o n in w h i c h the child's b r a i n receives damage e i t h e r before, d u r i n g or a f t e r b i r t h as a c o n s e q u e n c e of w h i c h the child has a disability of m o v e m e n t w h i c h is usually general b u t m a y be of v a r y i n g degree a n d not c o n f i n e d to one particular p a r t of t h e b o d y as, for example, a h e m i p l e g i a resulting f r o m cerebral haemorrhage. W h e n t h e r e is this b r a i n damage, t h e r e is a consequential interference w i t h n e r v o u s control of the muscles d e p e n d i n g on the p o r t i o n of b r a i n affected a n d t h e type of disability varies w i t h the site of t h e lesion in t h e b r a i n : (i) I n t h e case of cortical lesion we find spasticity. (ii) A lesion in the basal .ganglia p r o d u c e s athetosis. (iii) A lesion in t h e sub-cortical areas p r o d u c e s rigidity w h i c h is often m i s t a k e n for spacticity. (iv) A lesion in t h e c e r e b e l l u m p r o d u c e s ataxia. (v) I n certain types of lesion one finds tremors. T h e r e are t h u s , broadly, these five types of cerebral palsy a n d the m e t h o d of h a n d l i n g each type is different a n d in each case the m e t h o d of dealing w i t h t h e child is individual. I n order to get successful results, therefore, we m u s t always bear in m i n d t h e s e t h r e e essential points : - (1) T h a t the lesion is a neurological one a n d not o r t h o paedic, t h o u g h d i s t u r b a n c e s of m o v e m e n t result f r o m the neurological lesion. T h e muscles a n d joints are n o r m a l a n d therefore it is useless to p r e s c r i b e massage, electrical t r e a t m e n t or p h y s i o t h e r a p y as a r o u t i n e unless you have a clear idea of w h a t you are p r e s c r i b i n g it for a n d why. (2) A n d , secondly, t h a t every case varies a n d t h e t r e a t m e n t p r e s c r i b e d m u s t b e individual. N o set s c h e m e of exercises or p h y s i o t h e r a p y can therefore be set out. T h e case of cerebral palsy m a y b e slight or severe a n d obviously t h e slight case is n o t g o i n g to require t h e same s u p e r v i s i o n or s c h e m e of t r a i n i n g as t h e severe case, n o r is the s c h e m e o f t r e a t m e n t at t h e b e g i n n i n g t h e same as t h a t r e q u i r e d w h e n the child has progressed. (3) A n d , ~hirdly, one has to b e a r in m i n d t h a t w h e r e t h e r e is a cerebral lesion it m a y be slight or severe and, w h e r e it is severe, t h e r e is m o r e likely to he damage to the intellectual faculties. I n m a n y of these cases, therefore, t h e r e m a y be p r o d u c e d variations in m e n t a l power apart f r o m t h a t r e t a r d a t i o n of m e n t a l activity t h a t always results w h e r e t h e r e is limitation of m o v e m e n t . T o get satisfactory results the child m u s t be m e n t a l l y n o r m a l or potentially n o r m a l a n d the assessment of this m e n t a l power is one of o u r m o s t difficult p r o b l e m s . I n order, therefore, to have a clear c o n c e p t i o n of w h a t f o r m s our t r e a t m e n t of these c h i l d r e n s h o u l d take we m u s t constantly bear in m i n d w h a t is t h e d e v e l o p m e n t of a n o r m a l b a b y . At b i r t h a n d for some t i m e afterwards all m o v e m e n t is i n v o l u n t a r y or leflex. As the child's n e r v o u s s y s t e m grows a n d the n e r v e s b e c o m e m y e l i n a t e d the b a b y b e g i n s to show v o l u n t a r y m o v e m e n t a n d his p o w e r of m o v e m e n t and m e n t a l pictures of m o v e m e n t s develop f r o m the s t i m u l i he receives f r o m outside a n d within. H e c o m m e n c e s to lift his head, to lift his arms, to be attracted b y b r i g h t o h j e c t s a n d to try to grasp t h e m a n d so on until he reaches t h e stage of t r y i n g to s t a n d a n d walk. A t first his m o v e m e n t s are f u m b l i n g a n d irregular a n d incoordinated, b u t slowly t h e y improve. W h e n t h e r e is damage to t h e b r a i n so as to interfere w i t h the d e v e l o p m e n t of the n e r v o u s control, t h e child is u n a b l e to lift his h e a d or take m u c h i n t e r e s t in his s u r r o u n d i n g s a n d as a c o n s e q u e n c e t h e
PUBLIC ItEALTH, March, I953 stimuli he receives are relatively few a n d as a c o n s e q u e n c e his picture of m o v e m e n t a n d p o w e r of m o v e m e n t are poor. Such a child if left alone will develop some m o v e m e n t b u t it will be slow a n d relatively ineffective. I f t h i s c h i l d is t o develop a n approximately n o r m a l m o v e m e n t he m u s t b e p r o v i d e d w i t h selected stimuli so t h a t h e can develop his o w n p i c t u r e a n d power of m o v e m e n t . W e c a n n o t develop his n e r v o u s control b u t we can provide those stimuli b y w h i c h he will, p r o v i d e d h e has t h e m e n t a l capacity, develop his own control of m o v e m e n t . If I m a y give a simple e x a m p l e - - a spastic child t e n d s to keep his legs straight a n d his back also, so t h a t if p u t to sit in a chair he t e n d s to sit on his coccyx. If allowed to do this his m e n t a l picture of sitting will be one of sitting on his coccyx. If you try sitting o n your coccyx you will find it m u c h more difficult to use y o u r arms or h a n d s in f r q n t of you a n d if it is difficult for you h o w m u c h m o r e difficult it m u s t be for t h e spastic child. If h e sits in the r i g h t position a n d always sits in t h a t position his idea of sitting will be a correct a n d a n easy one a n d he is placed i n the easiest position for h i m to m o v e his arms. I t r u s t I n e e d n o t l a b o u r this idea f u r t h e r b u t one or two t h i n g s follow f r o m it. First, it is obvious t h a t t h e use of calipers, braces a n d o t h e r appliances is n o t going to assist the child as the picture of m o v e m e n t the child will o b t a i n will b e one of being supported by them. Secondly, w h e r e a c h i l d has n o t b e e n given any treatm e n t a n d has developed some sort of m o v e m e n t , he will have to forget w h a t h e has l e a r n t a n d try to s u b s t i t u t e s o m e t h i n g else for i t - - a n extraordinarily difficult t h i n g to do. T h i r d l y , if we are going to get t h e best results we m u s t get h o l d of t h e s e c h i l d r e n before they have developed any v o l u n t a r y m o v e m e n t themselves, t h a t is, we m u s t get t h e m as babies a n d t h e earlier the better. T h e early diagnosis of such cases, therefore, is essential a n d it is in t h e m a t e r n i t y a n d child welfare clinics a n d p o s t natal clinics t h a t these cases s h o u l d b e picked up. I do n o t say t h a t they s h o u l d be diagnosed there, b u t w h e n a c h i l d is slow in developing he s h o u l d b e referred to s o m e o n e w i t h a special knowledge of cerebral palsy. Diagnosis at this early stage is, in m y opinion, very difficult, a n d it is only b y c o n c e n t r a t i n g o n these y o u n g infants t h a t we are going to make progress in early diagnosis. W h e n we have reached t h e stage of diagnosing all these cases in infancy t h e n will we b e in a position to treat t h e m as soon as they are discover,*.d a n d ultimately reduce t h e n u m b e r for w h o m special provision will have to b e m a d e at a later stage in t h e i r lives.
D i a g n o s i s o f Variations I n relation to t r e a t m e n t t h e r e are a n u m b e r of p r o b l e m s t h a t arise n o t only in the s t r a i g h t f o r w a r d case b u t in t h e variations t h a t occur. W e are apt to forget t h a t as the c o n dition is primarily a neurological one, the limitation or a b e r r a t i o n s of m o v e m e n t of the limbs, t h o u g h the m o s t obvious are n o t necessarily the only or even the chief p a r t s affected. Being a central lesion, t h e whole m u s c u l a t u r e is i n v o l v e d so t h a t one finds difficulties in swallowing, h e n c e d r i b b l i n g , i n c o n t i n e n c e of u r i n e a n d faeces, irregular respiration, a n d so on. F u r t h e r , there m a y b e obvious eye defects s u c h as strabismus, b u t also less obvious defects s u c h as difficulty in focusing or in co-ordination. I n the same way t h e r e m a y be defects of h e a r i n g or even severe deafness, either of w h i c h still f u r t h e r h a n d i c a p s the child b o t h physically a n d by c u t t i n g off stimuli necessary for his physical a n d m e n t a l d e v e l o p m e n t . W h e r e any of these defects exist they p r o v i d e a f u r t h e r p r o b l e m in t r e a t m e n t b u t also, as has b e e n so well p o i n t e d out b y Miss D u r i s t o n in h e r book on the " E d u c a b i l i t y of the C e r e b r a l Palsied C h i l d , " in the e d u c a t i o n of the c h i l d - - a p o i n t w h i c h has not b e e n sufficiently recognised in t h e past. So long as these p r o b l e m s are recognised t h e y will b e looked for, b u t m y experience has led m e to believe t h a t they are n o t always recognised. N o t i n f r e q u e n t l y we see c h i l d r e n who have b e e n referred to us w h o are deaf or partially so,
9x or blind, partially b l i n d or w i t h defective vision of o n e k i n d or a n o t h e r , w h i c h defect has n o t b e e n p I e v i o u s l y recognised. O n l y recently we h a d a boy w h o h a d b e e n i n a residential school for h a n d i c a p p e d c h i l d r e n , w h o m we f o u n d to be partially d e a f - - h i s teacher a n d those w h o dealt w i t h h i m were unaware of his partial deafness, however. H e was treated, p r o v i d e d with a h e a r i n g aid, a n d is n o w a t t e n d i n g an o r d i n a r y school. All these c h i l d r e n p r e s e n t p r o b l e m s in the e d u c a t i o n a l m e t h o d s t h a t s h o u l d be a d o p t e d for t h e m , b u t the diff• culty varies according to the type a n d e x t e n t of the disability. I n slight cases the c h i l d r e n m a y be able to a t t e n d an o r d i n a r y school, b u t the teacher, a n d those w h o deal w i t h the child, s h o u l d be aware of his disability a n d be i n s t r u c t e d in the best m e t h o d s of dealing w i t h him. N o n - r e c o g n i t i o n of the fact t h a t the child has some disability m a y lead to difficulties w i t h the child a n d an a c c e n t u a t i o n of his s h o r t comings w i t h a c o n s e q u e n t adverse psychological effect a n d resultant setback in the child's p h y s i c a l a n d m e n t a l progress.
P r o b l e m s for the T e a c h e r F o r c h i l d r e n w h o are m o r e severely affected special m e t h o d s m u s t b e a d o p t e d either in classes for the physically h a n d i c a p p e d or even in special schools for cerebral palsy cases such as those already set u p in B i r m i n g h a m , at I v y b r i d g e a n d elsewhere. I n dealing w i t h this latter class of case the teacher s h o u l d recognise a n d be i n s t r u c t e d t h a t : (1) T h e r e m a y be defects of vision, or hearing, in a d d i t i o n to the child's o t h e r defects. If these defects are n o t reeognised, the m e t h o d s of teaching m a y accentuate t h e c h i l d ' s difficulties, and, instead of progressing, t h e child will n o t only retrogress b u t his physical progress outside the classr o o m m a y also b e i n t e r f e r e d with. F u r t h e r , n o n - r e c o g n i t i o n of these defects m a y lead to a conclusion t h a t t h e c h i l d ' s m e n t a l c o n d i t i o n is worse t h a n it really is, a n d as a c o n s e quence the s t a n d a r d of work set m a y b e below t h e child's m e n t a l ability w i t h a c o n s e q u e n t adverse psychological effect, w h i c h it s h o u l d be o u r a i m to avoid. (2) H a v i n g recognised these difficulties, the t e a c h e r has also to a d a p t h e r m e t h o d s of t e a c h i n g to suit t h e i n d i v i d u a l child, a n d this requires considerable care, o b s e r v a t i o n of the child, a n d a t t e n t i o n to its particular needs. It is u s e less, for instance, to expect a child w h o has severe a t h e t o i d m o v e m e n t s of the fingers a n d h a n d s to h o l d a p e n a n d att e m p t to v, rite, b u t s u c h a child m a y be able to h o l d w o o d e n blocks w i t h letters o n t h e m a n d so spell words to b e g i n w i t h and, later, b y a p p r o p r i a t e a d a p t a t i o n of t e a c h i n g m e t h o d s , can be t a u g h t to read, write, do s u m s a n d o t h e r t h i n g s . As t h e i r physical c o n d i t i o n i m p r o v e s so the m e t h o d of t e a c h i n g requires modifying. N o t only m u s t t h e t e a c h e r a d a p t her m e t h o d s for t h e individual child b u t in o r d e r to do this she m u s t recognise t h a t t h e h a n d l i n g of t h e different varieties of cerebral palsy is different. The h a n d l i n g of a spastic child is different f r o m t h a t necessary for an athetoid. T o do this she m u s t have a k n o w l e d g e of t h e u n d e r l y i n g cause. T h e r e r e m a i n a n u m b e r of c h i l d r e n w h o are so severely h a n d i c a p p e d t h a t t h e y c a n n o t a t t e n d one of these special schools, a n d for these, h o m e t u i t i o n is necessary. S u c h cases s h o u l d be k e p t to a m i n i m u m as t h e child misses t h e contacts he s h o u l d have w i t h o t h e r c h i l d r e n w h i c h help in his rehabilitation. It will be obvious f r o m w h a t I have said t h a t all those dealing w i t h the child, i n c l u d i n g the teachers c o n c e r n e d , s h o u l d have a period of i n s t r u c t i o n in a cerebral palsy u n i t before taking o n a class of these children. P r o b l e m s F a c i n g the Child H a v i n g dealt w i t h t h e t e a c h e r ' s p r o b l e m , before I c o n t i n u e o n the educational aspects, m a y I say a few w o r d s u p o n the p r o b l e m s w h i c h face the child ? W e are apt to forget t h a t t h o u g h such c h i l d r e n m a y have a b n o r m a l m o v e m e n t s or severe h a n d i c a p s their outlook o n life is t h a t they themselves are like o r d i n a r y c h i l d r e n b u t , u n f o r t u n a t e l y , h a n d i c a p p e d in carrying o u t certain activities.
92 T h e fact that t h e i r activities are restricted does not m e a n t h a t t h e i r b r a i n s are therefore defective, n o r does it m a k e t h e m feel t h a t they are a n y t h i n g b u t normal, a n d o u r a p p r o a c h s h o u l d be to encourage this outlook and, so far as possible, m a k e t h e m m i x w i t h n o r m a l children. U n f o r tunately, t h e child c a n n o t explain all this to us, a n d t h e r e fore it behoves us to try to f a t h o m t h e i r desires a n d help t h e child give expression to t h e m . T h e fact of t h e i r m e n t a l outlook has b e e n b r o u g h t h o m e to m e o n m a n y Occasions. I n p h o t o g r a p h s of these c h i l d r e n on a d m i s s i o n I h~ve b e e n s t r u c k b y the f r e q u e n c y w i t h w h i c h the child's expression is o n e of f r u s t r a t i o n a n d u n h a p p i n e s s , an expression w h i c h is quickly replaced b y a more n o r m a l expression once the child is p r o p e r l y h a n d l e d . Again, o n one occasion, I f o u n d t h e c h i l d r e n in o u r c e r e b r a l palsy u n i t d o i n g a little play in t h e d a y - r o o m in t h e same way t h a t healthy c h i l d r e n do. T h e fact t h a t few of t h e m c o u l d walk, a n d one or two o n l y speak indistinctly, d i d n o t d e t e r or even b o t h e r t h e m I t h e y were b e h a v i n g as t h e y k n e w n o r m a l c h i l d r e n do, a n d t h e i r imaginations filled in a n y little gaps or lapses there m a y have been. T h i s attitude was well expressed b y one a t h e t o i d girl, w h o s h o w e d a finger p a i n t i n g to one of the doctors w i t h t h e r e m a r k , " I t m a y n o t be m u c h , b u t if you only k n e w w h a t f u n it was after n o t b e i n g able to do a n y t h i n g . " T h e p a i n t i n g , t h o u g h r o u g h , as it was b o u n d to be, s h o w e d a w o n d e r f u l sense of design a n d cotour w h i c h m a d e it e v i d e n t t h a t h e r b r a i n was quite bright. All s u c h activities, t h e n , s h o u l d b e encouraged, a n d these c h i l d r e n s h o u l d have as m a n y varieties of experience as o t h e r c h i l d r e n have, if it is possible. W e s e n d these c h i l d r e n to concerts a n d plays w i t h the others, a n d one has only to w a t c h t h e m to realise t h a t they take it all in, a n d such stimuli are helpful in t h e i r development.
T h e A f t e r m a t h to Hospital T r a i n i n g O f t h e o t h e r p r o b l e m s t h a t face us I suppose the chief is w h a t is to h a p p e n to s u c h a child w h e n h e leaves the unit, if he has b e e n in one. I n all this i n s t r u c t i o n a n d h a n d l i n g we s h o u l d bear in m i n d t h a t if the child has to go into a u n i t it can only b e for a limited period. Once h e is set o n the r i g h t lines he can be discharged, b u t he will retrogress unless he is supervised. T h i s s u p e r v i s i o n m u s t go on for years, a n d it is particularly the m o t h e r w h o m u s t exercise s u p e r v i s i o n and, therefore, she above all others requires i n s t r u c t i o n in h o w to h a n d l e h e r child. Once she has received this i n s t r u c t i o n , preferably for as long as she can spare t h e time, she can b r i n g the child to the clinic periodically. I n the less severe cases she can be given i n s t r u c t i o n a n d b e kept u n d e r m o r e f r e q u e n t supervision. T h e n t h e r e comes the p r o b l e m of t h e child's schooling at h o m e . Some of these children, t h o u g h fit for an o r d i n a r y school intellectually, have difficulty in o b t a i n i n g admission because of some a b n o r m a l i t y of m o v e m e n t . H e a d mistresses a n d teachers should be i n s t r u c t e d r e g a r d i n g s u c h c h i l d r e n a n d n o t b e e m p o w e r e d to refuse admission. A s o m e w h a t similar difficulty m a y b e e n c o u n t e r e d if t h e child is r e c o m m e n d e d for a special school for physically h a n d i c a p p e d children. I feel s t r o n g l y that, generally speaking, the solution of this p r o b l e m is to train t h e teachers in these special schools h o w to deal w i t h the h a n d i c a p of cerebral palsy r a t h e r t h a n t r y to set u p special schools for cerebral palsied c h i l d r e n . E x c e p t in very large industrial areas t h e n u m b e r s of s u c h c h i l d e r n are n o t sufficient to w a r r a n t s u c h special schools b u t w h e r e they are set u p t h e y s h o u l d b e u s e d as a t r a i n i n g - g r o u n d t h r o u g h w h i c h the c h i l d r e n pass to t h e special or o r d i n a r y schools. T h e fact t h a t a child w h o is u n a b l e to walk is therefore e x c l u d e d f r o m a special school does n o t seem to m e an intelligent m e t h o d of dealing w i t h the e d u c a t i o n of s u c h children. I have at t h e m o m e n t a spastic child who, a l t h o u g h deaf a n d d u m b , is quite e v i d e n t l y intelligent, b u t because she c a n n o t walk upstairs c a n n o t b e a d m i t t e d to a deaf a n d d u m b school,
PUBI.IC HEALTH,
March, z953
Once the child has passed the school age, w h a t is to be done with h i m ? T h e p r o b l e m of o b t a i n i n g some t r a i n i n g for such c h i l d r e n is one that we are constantly faced with. T h e r e are m a n y i n s t i t u t i o n s w h e r e physically h a n d i c a p p e d c h i l d r e n are t r a i n e d for some occupation, b u t usually such children are selected r a t h e r carefully for such traini~ag. F o r economic reasons such selection m a y be necessary, b u t if we take t h e long view it is surely desirable that we should e n c o u r a g e in every way the d e v e l o p m e n t of special t r a i n i n g centres, or even homes, w h e r e cases of cerebral palsy of the m o r e severe type can be t r a i n e d to carry out some occupation w h i c h would c o n t r i b u t e s o m e t h i n g towards the cost of t h e i r m a i n t e n a n c e . I f the p a t i e n t can only be trained to use his arms a n d h a n d s while sitting a n d is u n a b l e to use his legs he m a y u n d e r t a k e useful a n d r e m u n e r a t i v e work w h i c h w o u l d n o t only lmlp h i m financially a n d reduce the b u r d e n he m i g h t otherwise be on the St/rte, b u t would also effect t h e even m o r e i m p o r t a n t object of b u i l d i n g up a sense of self-respect a n d responsibility a n d a feeling t h a t his life a n d work are not only of value to h i m self b u t a c o n t r i b u t i o n towards the c o m m u n i t y of w h i c h he would t h e n feel h i m s e l f a responsible m e m b e r .
A CEREBRAL PALSY UNIT WITHIN A DAY SCHOOL FOR P H Y S I C A L L Y H A N D I C A P P E D C H I L D R E N By T . MORRISON CLAYTON, M.D., B.S., B.HY., I).P.H.,
Medical Q~cer of Health and School Medical Officer, Coventry " W h a t sculpture is to a block of m a r b l e , education is to t h e h u m a n SOUl."--ADDISON. T h e r e is ever~r justification in these p r e s u m a b l y m o r e e n l i g h t e n e d days for us to accept t h e fact t h a t c h i l d r e n suffering f r o m t h e effects of cerebral palsy are also h a n d i capped in the t r u e sense a n d t h a t if t a k e n sufficiently early. m o s t sufferers can be assisted to o v e r c o m e t h e i r disabilities to a greater or lesser extent. T h i s in itself is an a d m i s s i o n w h i c h s h o u l d b e a p p l a u d e d for, in spite of D r . Little's original description of t h e condition over 100 years ago, it constitutes a clear a d v a n c e m e n t in t h o u g h t even over fairly r e c e n t times : it is only a very few years since palsied c h i l d r e n were to all i n t e n t s a n d p u r p o s e s f o r g o t t e n save b y a few. T h e greater p r o p o r t i o n of those " few " n a t u r a l l y c o n s t i t u t e d t h e i m m e d i a t e a n d responsible relatives, a n d w h i c h of us can n o w gainsay t h a t their b u r d e n a n d p r e o c c u p a t i o n w i t h t h e i r p r o b l e m s was oppressive ? M a n y of these p a r e n t s have for long h a d grave misgivings a n d i n d e e d e x t r e m e depression as to w h a t the f u t u r e held in store for t h e i r h a n d i c a p p e d offsprings and, n o t u n n a t u r a l l y at times, for t h e i r o w n place a n d f u t u r e in society also. I n the past we as a c o m m u n i t y have been too ready to regard these c h i l d r e n as b e i n g so m e n t a l l y incapable a n d physically u n a b l e of d e r i v i n g benefit i n the spheres of e d u c a t i o n a n d r e h a b i l i t a t i o n t h a t we have t e n d e d to allow this acute h u m a n p r o b l e m to go b y default. T h i s , as has b e e n stated o n o t h e r occasions, is n o d o u b t one of t h e reasons w h y a p r o p o r t i o n of these u n f o r t u n a t e s has b e c o m e e n t a n g l e d in m e n t a l deficiency institutions, h a v i n g b e e n placed t h e r e in error, or, if you prefer, because of e r r o n e o u s diagnoses. W h i l e such a confession m a y a p p e a r deplorable to t h e u n i n f o r m e d lay m i n d it is, I feel in effect, n o t so m u c h a m a t t e r of negligence u p o n the p a r t of o u r profession b u t r a t h e r a defect in o u r t e a c h i n g a n d c o n s e q u e n t lack of detailed knowledge u p o n this p r o b l e m w h i c h n o w conf r o n t s us. 'Judging, however, b y t h e n u m e r o u s lectures a r r a n g e d in refresher courses for School Medical Officers d u r i n g this last few years it is v e r y e v i d e n t that this section of o u r profession has t h e subject m u c h at heart a n d is alive to t h e implications. D u r i n g these past few years we have all h e a r d a n d read m u c h a b o u t D r . C a r l s o n - - h i m s e l f a severe case of diplegia