THE HISTORY OF ATTITUDES TO DISABLED PEOPLE

The ‘traditional model’

Traditionally, in many cultures around the world, people with physical, sensory or mental impairments were thought of as under the spell of witchcraft, possessed by demons, or as penitent sinners, being punished by God for wrong-doing by themselves or their parents.

A medieval woodcut of witches.

The ‘medical model’

With the Age of Enlightenment in the 18th century, came a more scientific understanding of the causes of impairment and, with it, a sense of confidence in medical science’s ability to cure, or at least rehabilitate, disabled people. Some disabled people (often for social or political reasons) were deemed incurable and placed in long-stay institutions and special schools (or, today, in day-care centres). A notion of ‘normality’ was invested with great pseudo-scientific significance. It was based on assessments of impairments from a deficit point of view against normality: what one cannot do, instead of what one can do. This has been called ‘medical model’ (or ‘individual model’) thinking by the Disabled People’s Movement over the last 30 years. This is not to deny the very necessary role of medical science in keeping many disabled people alive, and reducing their pain and discomfort, but it is to argue that disabled people should not be reduced to just their impairments.

The ‘medical model’ sees disabled people as the problem. They need to be adapted to fit into the world as it is. If this isn’t possible, then they should be shut away in a specialised institution or isolated at home, where only their most basic needs are met. The emphasis is on dependence, backed up by the stereotypes of disability that bring out pity, fear and patronising attitudes. Usually, the impairment is focused on, rather than the needs of the person. The power to change disabled people seems to lie with the medical and associated professions, with their talk of cures, normalisation and science. Often, disabled people’s lives are handed over to these professionals. Their decisions affect where disabled people go to school; what support they get; where they live; what benefits they are entitled to; whether they can work; and even, at times, whether they are born at all, or allowed to have children themselves.

In addition, the Disability Movement points out how the built environment imposes further limitations on disabled people. Medical model thinking would say these problems are due to the disabled person’s lack of rehabilitation. The Disability Movement perceives the difficulties disabled people experience as the barriers that disable them and curtail their life chances. These difficulties include in school and higher education, in finding work and suitable work environments, accessing leisure and entertainment facilities, using private and public transport, obtaining suitable housing, or in their personal, family and social life.

Diagram showing the effects of medical model thinking.

Powerful and pervasive medical model views are reinforced in the media, books, films, comics, art and language. Many disabled people internalise negative views of themselves and develop feelings of low self-esteem and underachievement, which reinforce non-disabled people’s assessments of their worth. The medical model, plus the built environment and social attitudes it creates, lead to a cycle of dependency and exclusion which is difficult to break.

This thinking predominates in filmmaking, leisure, work and education. In schools, for instance, special educational needs are considered the problem of the individual, who is seen as different, faulty and needing to be assessed and made as ‘normal’ as possible.

Increasingly, today, the medical model is being rejected. Many people feel strongly that treating disabled people as needing to be adapted to existing circumstances or, if this is not possible, caring for them in specialised institutions, is wrong.

The ‘social model’

In recent years, the disability movement has advocated a different way of looking at disability, which they call the ‘social model’. This starts from the standpoint of all disabled adults’ and children’s right to belong to and be valued in their local community. Using this model, you start by looking at the strengths of the person with the impairment and at the physical and social barriers that obstruct them, whether at school, college, home or work. The ‘social model’ defines ‘impairment’ and ‘disability’ as very different things:

Disabled people rally together to demonstrate for their rights.

“Impairment is the loss or limitation of physical, mental or sensory function on a long-term or permanent basis.

Disablement is the loss or limitation of opportunities to take part in the normal life of the community on an equal level with others due to physical and social barriers.” Disabled People’s International 1981

Impairment and chronic illness exist and sometimes pose real difficulties. Supporters of the disability movement believe that the discrimination against disabled people is socially created and has little to do with their impairments, and that, regardless of the type or severity of their impairments, disabled people are subjected to a common oppression by the non-disabled world. Disabled people are often made to feel it’s their own fault that they are different. If some part, or parts, of your body or mind are limited in their functioning, this is simply an impairment. It doesn’t make you any less human. But most people have not been brought up to accept all people as they are; in other words, to value difference. Through fear, ignorance and prejudice, barriers and discrimination develop which disable some people. These are often reinforced by images in the media. Understanding this process allows disabled people to feel good about themselves and empowers them to fight for their human rights.

Diagram showing the problems as perceived by ‘social model’ thinking.

The ‘social model’ approach suggests disabled people’s disadvantage is due to a complex form of institutional discrimination, as fundamental to society as sexism, racism or heterosexism. The disability movement believes the ‘cure’ to the problem of disability lies in changing society. Unlike medically-based cures, this is an achievable goal and benefits everyone.

The obsession with finding medically-based cures also distracts people from looking at the causes of impairment or disablement. In a worldwide sense, most impairments are created by wars, hunger, lack of clean water, exploitation of labour, lack of safety, and child abuse and these should be addressed more robustly, rather than just responding to the injuries and impairments that result from them.

Challenging prejudice

Chart comparing the attitudes of medical model and social model thinking.

Social model thinking has important implications for the education system, and particularly primary and secondary schools. Prejudiced attitudes toward disabled people and all minority groups are not innate. They are learned through contact with the prejudice and ignorance of others.

Therefore, it is appropriate that the challenge to discrimination against disabled people should begin in schools. The fight for the inclusion of all disabled people, however severe their impairments, in one mainstream social system, will not make sense unless people understand the difference between the social and medical models of disability.

The social model has now been adopted by the World Health Organisation.

Who is disabled?

People who have an impairment and experience some form of social exclusion as a result are disabled people. Many people have impairments, such as those who use glasses or contact lenses. They are not usually discriminated against. Whereas, people who are deaf and use hearing aids are usually discriminated against by barriers in communication. Therefore, disabled people includes people with:

• Physical impairments;
• Sensory impairments (deaf people, blind people);
• Chronic illness or health issues, including HIV and AIDS;
• All degrees of learning difficulties;
• Emotional, mental health and behavioural problems.

The definition also includes people with hidden impairments, such as:

• Epilepsy;
• Diabetes;
• Sickle cell anaemia;
• Specific learning difficulties, such as dyslexia;
• Speech and language impairments;
• Children labelled as ‘delicate’;
• People who identify as ‘disfigured’;
• People of diminutive stature;
• People with mental distress.

Children of a Lesser God (1986, Randa Haines, USA)

Disabled people fight for equality

In the last 30 years, disabled people have campaigned for and won a human rights-based approach to disability. It is beginning to be accepted that disability discrimination, prejudice, negative attitudes and stereotypes are not acceptable. The struggles of disabled people to gain civil rights have led to legislation in the USA (The Americans with Disabilities Act 1990); in the UK (The Disability Discrimination Act 1995); and many other countries, including South Africa, India and Australia. The United Nations adopted the UN Standard Rules on Equalisation in 1992.

In all these measures, the onus is on eliminating discrimination by bringing in enforceable civil rights legislation, based on the idea that adjustments need to be made to services, buildings, transport, workplaces, environments, communications and equipment to allow disabled people access. Prejudicial attitudes and practices are outlawed and institutional discrimination, in the form of organisations which exclude disabled people, is being challenged.

However, negative attitudes, stereotypes and distorted portrayals of disabled people’s lives still predominate in commercial films. The increasing capacity of the world media system to recycle moving image media means that, despite worthy legislation, negative views are continually reinforced through film.

Check out the Disability Rights Commission website for guidance and a Code of Practice.

 

PUBLISHED IN:  ‘MEDICAL MODEL’ VS ‘SOCIAL MODEL’ ON FEBRUARY 27, 2007 AT 4:59 PM

 

Learning Disability – what is it?

From Wikipedia, the free encyclopedia

Learning disability (sometimes called a learning disorder^[1] or learning difficulty), is a classification including several disorders in which a person has difficulty learning in a typical manner, usually caused by an unknown factor or factors. The unknown factor is the disorder that affects the brain‘s ability to receive and process information. This disorder can make it problematic for a person to learn as quickly or in the same way as someone who isn’t affected by a learning disability. Learning disability is not indicative of intelligence level. Rather, people with a learning disability have trouble performing specific types of skills or completing tasks if left to figure things out by themselves or if taught in conventional ways.

Learning disability
Classification and external resources
ICD–10	F81.9
ICD–9	315.0–315.3
DiseasesDB	4509
eMedicine	article/1835801article/1835883article/915176
MeSH	D007859

A learning disability cannot be cured or fixed. With the right support and intervention, however, people with learning disabilities can succeed in school and go on to be successful later in life.

Contents [hide] 1 Definitions 2 Types of learning disabilities 2.1 By stage of information processing 2.2 By function impaired 2.2.1 Reading disorder (ICD-10 and DSM-IV codes: F81.0/315.00) 2.2.2 Writing disorder (ICD-10 and DSM-IV codes F81.1/315.2) 2.2.3 Math disability (ICD-10 and DSM-IV codes F81.2-3/315.1) 2.2.4 Non ICD-10/DSM 3 Diagnosis 3.1 IQ-Achievement Discrepancy 3.2 Response to Intervention (RTI) 3.3 Assessment 4 Treatment and intervention 5 Causes and risk factors 6 Impact on affected individuals 7 Societal Factors In the USA 7.1 Welfare/Public assistance relating to educational development 7.2 Gender issues 7.3 Crime and prison population 8 Contrast with other conditions 9 Advocacy of the concept of learning disabilities 10 United States and Canada 10.1 USA Legislation related to learning difficulties 11 United Kingdom 12 See also 13 References 14 External links

[edit]Definitions

This section requires expansion.

In the 1980s, the National Joint Committee on Learning Disabilities (NJCLD) defines the term learning disability as:

a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual and presumed to be due to Central Nervous System Dysfunction. Even though a learning disability may occur concomitantly with other handicapping conditions (e.g. sensory impairment, mental retardation, social and emotional disturbance) or environmental influences (e.g. cultural differences, insufficient/inappropriate instruction, psychogenic factors) it is not the direct result of those conditions or influences.

The NJCLD used the term to indicate a discrepancy between a child’s apparent capacity to learn and his or her level of achievement.^[2]

The 2002 LD Roundtable produced the following definition:

“Concept of LD: Strong converging evidence supports the validity of the concept of specific learning disabilities (SLD). This evidence is particularly impressive because it converges across different indicators and methodologies. The central concept of SLD involves disorders of learning and cognition that are intrinsic to the individual. SLD are specific in the sense that these disorders each significantly affect a relatively narrow range of academic and performance outcomes. SLD may occur in combination with other disabling conditions, but they are not due primarily to other conditions, such as mental retardation, behavioral disturbance, lack of opportunities to learn, or primary sensory deficits.”^[3][4]

The term “learning disability” does not exist in DSM-IV, but it has been proposed that it be added to DSM-5, and incorporate the conditions learning disorder not otherwise specified anddisorder of written expression.^[5]

[edit]Types of learning disabilities

Learning disabilities can be categorized either by the type of information processing that is affected or by the specific difficulties caused by a processing deficit.

[edit]By stage of information processing

Learning disabilities fall into broad categories based on the four stages of information processing used in learning: input, integration, storage, and output.^[6]

• Input: This is the information perceived through the senses, such as visual and auditory perception. Difficulties with visual perception can cause problems with recognizing the shape, position and size of items seen. There can be problems with sequencing, which can relate to deficits with processing time intervals or temporal perception. Difficulties with auditory perception can make it difficult to screen out competing sounds in order to focus on one of them, such as the sound of the teacher’s voice. Some children appear to be unable to process tactile input. For example, they may seem insensitive to pain or dislike being touched.

• Integration: This is the stage during which perceived input is interpreted, categorized, placed in a sequence, or related to previous learning. Students with problems in these areas may be unable to tell a story in the correct sequence, unable to memorize sequences of information such as the days of the week, able to understand a new concept but be unable to generalize it to other areas of learning, or able to learn facts but be unable to put the facts together to see the “big picture.” A poor vocabulary may contribute to problems with comprehension.

• Storage: Problems with memory can occur with short-term or working memory, or with long-term memory. Most memory difficulties occur in the area of short-term memory, which can make it difficult to learn new material without many more repetitions than is usual. Difficulties with visual memory can impede learning to spell.

• Output: Information comes out of the brain either through words, that is, language output, or through muscle activity, such as gesturing, writing or drawing. Difficulties with language output can create problems with spoken language, for example, answering a question on demand, in which one must retrieve information from storage, organize our thoughts, and put the thoughts into words before we speak. It can also cause trouble with written language for the same reasons. Difficulties with motor abilities can cause problems with gross and fine motor skills. People with gross motor difficulties may be clumsy, that is, they may be prone to stumbling, falling, or bumping into things. They may also have trouble running, climbing, or learning to ride a bicycle. People with fine motor difficulties may have trouble buttoning shirts, tying shoelaces, or with handwriting.

[edit]By function impaired

Deficits in any area of information processing can manifest in a variety of specific learning disabilities. It is possible for an individual to have more than one of these difficulties. This is referred to as comorbidity or co-occurrence of learning disabilities.^[7] In the UK, the term dual diagnosis is often used to refer to co-occurrence of learning difficulties.

[edit]Reading disorder (ICD-10 and DSM-IV codes: F81.0/315.00)

The most common learning disability. Of all students with specific learning disabilities, 70%-80% have deficits in reading. The term ” Developmental Dyslexia ” is often used as a synonym for reading disability; however, many researchers assert that there are different types of reading disabilities, of which dyslexia is one. A reading disability can affect any part of the reading process, including difficulty with accurate or fluent word recognition, or both, word decoding, reading rate, prosody (oral reading with expression), and reading comprehension. Before the term “dyslexia” came to prominence, this learning disability used to be known as “word blindness.”

Common indicators of reading disability include difficulty with phonemic awareness—the ability to break up words into their component sounds, and difficulty with matching letter combinations to specific sounds (sound-symbol correspondence).

[edit]Writing disorder (ICD-10 and DSM-IV codes F81.1/315.2)

Speech and language disorders can also be called Dysphasia/Aphasia (coded F80.0-F80.2/315.31 in ICD-10 and DSM-IV).

Impaired written language ability may include impairments in handwriting, spelling, organization of ideas, and composition. The term “dysgraphia” is often used as an overarching term for all disorders of written expression. Others, such as the International Dyslexia Association, use the term “dysgraphia” exclusively to refer to difficulties with handwriting.

[edit]Math disability (ICD-10 and DSM-IV codes F81.2-3/315.1)

Sometimes called dyscalculia, a math disability can cause such difficulties as learning math concepts (such as quantity, place value, and time), difficulty memorizing math facts, difficulty organizing numbers, and understanding how problems are organized on the page. Dyscalculics are often referred to as having poor “number sense”.^[8]

[edit]Non ICD-10/DSM

• Nonverbal learning disability: Nonverbal learning disabilities often manifest in motor clumsiness, poor visual-spatial skills, problematic social relationships, difficulty with math, and poor organizational skills. These individuals often have specific strengths in the verbal domains, including early speech, large vocabulary, early reading and spelling skills, excellent rote-memory and auditory retention, and eloquent self-expression.^[9]

• Disorders of speaking and listening: Difficulties that often co-occur with learning disabilities include difficulty with memory, social skills and executive functions (such as organizational skills and time management).

• Auditory processing disorder: Difficulties processing auditory information include difficulty comprehending more than one task at a time and a relatively stronger ability to learn visually.

[edit]Diagnosis

[edit]IQ-Achievement Discrepancy

Learning disablties are often identified by school psychologists, clinical psychologists, and neuropsychologists through a combination of intelligence testing, academic achievement testing, classroom performance, and social interaction and aptitude. Other areas of assessment may include perception, cognition, memory, attention, and language abilities. The resulting information is used to determine whether a child’s academic performance is commensurate with his or her cognitive ability. If a child’s cognitive ability is much higher than his or her academic performance, the student is often diagnosed with a learning disability. The DSM-IV and many school systems and government programs diagnose learning disabilities in this way (although the DSM-IV refers to them as Disorder and NOT as disabilities.)

Although the discrepancy model has dominated the school system for many years, there has been substantial criticism of this approach among researchers.^[10][11] Recent research has provided little evidence that a discrepancy between formally-measured IQ and achievement is a clear indicator of LD.^[12] Furthermore, diagnosing on the basis of a discrepancy does not predict the effectiveness of treatment. Low academic achievers who do not have a discrepancy with IQ (i.e. their IQ scores are also low) appear to benefit from treatment just as much as low academic achievers who do have a discrepancy with IQ (i.e. their IQ scores are higher).

[edit]Response to Intervention (RTI)

Much current research has focused on a treatment-oriented diagnostic process known as response to intervention (RTI). Researcher recommendations for implementing such a model include early screening for all students, placing those students who are having difficulty into research-based early intervention programs, rather than waiting until they meet diagnostic criterion. Their performance can be closely monitored to determine whether increasingly intense intervention results in adequate progress.^[12] Those who respond will not require further intervention. Those who do not respond adequately to regular classroom instruction (often called “Tier 1 instruction”) and a more intensive intervention (often called “Tier 2” intervention) are considered “nonresponders.” These students can then be referred for further assistance through special education, in which case they are often identified with a learning disability. Some models of RTI include a third tier of intervention before a child is identified as having a learning disability.

A primary benefit of such a model is that it would not be necessary to wait for a child to be sufficiently far behind to qualify for assistance.^[13] This may enable more children to receive assistance before experiencing significant failure, which may in turn result in fewer children who need intensive and expensive special education services. In the United States, the 2004 reauthorization of the Individuals with Disabilities Education Act permitted states and school districts to use RTI as a method of identifying students with learning disabilities. RTI is now the primary means of identification of learning disabilities in Florida.

The process does not take into account children’s individual neuropsychological factors such as phonological awareness and memory, that can help design instruction^[14]. Second, RTI by design takes considerably longer than established techniques, often many months to find an appropriate tier of intervention. Third, it requires a strong intervention program before students can be identified with a learning disability. Lastly, RTI is considered a regular education initiative and is not driven by psychologists, reading specialists, or special educators.

[edit]Assessment

Many normed assessments can be used in evaluating skills in the primary academic domains: reading, not including word recognition, fluency, and comprehension; mathematics, including computation and problem solving; and written expression, including handwriting, spelling and composition.

The most commonly used comprehensive achievement tests include the Woodcock-Johnson III (WJ III), Weschler Individual Achievement Test II (WIAT II), the Wide Range Achievement Test III (WRAT III), and the Stanford Achievement Test–10th edition. These tests include measures of many academic domains that are reliable in identifying areas of difficulty.^[12]

In the reading domain, there are also specialized tests that can be used to obtain details about specific reading deficits. Assessments that measure multiple domains of reading include Gray’s Diagnostic Reading Tests–2nd edition (GDRT II) and the Stanford Diagnostic Reading Assessment. Assessments that measure reading subskills include the Gray Oral Reading Test IV – Fourth Edition (GORT IV), Gray Silent Reading Test, Comprehensive Test of Phonological Processing (CTOPP), Tests of Oral Reading and Comprehension Skills (TORCS), Test of Reading Comprehension 3 (TORC-3), Test of Word Reading Efficiency (TOWRE), and the Test of Reading Fluency. A more comprehensive list of reading assessments may be obtained from the Southwest Educational Development Laboratory.^[15]

The purpose of assessment is to determine what is needed for intervention, which also requires consideration of contextual variables and whether there are comorbid disorders that must also be identified and treated, such as behavioral issues or language delays.^[12]

[edit]Treatment and intervention

This section includes a list of references or external links, but its sources remain unclear because it has insufficient inline citations. Please help to improve this article by introducing more precise citations where appropriate. (February 2008)

Interventions include:

• Mastery model:
  • Learners work at their own level of mastery.
  • Practice
  • Gain fundamental skills before moving onto the next level
    • Note: this approach is most likely to be used with adult learners or outside the mainstream school system.

• Direct Instruction:^[16]
  • Highly structured, intensive instruction
  • Emphasizes carefully planned lessons for small learning increments
  • Scripted lesson plans
  • Rapid-paced interaction between teacher and students
  • Correcting mistakes immediately
  • Achievement-based grouping
  • Frequent progress assessments

• Classroom adjustments:
  • Special seating assignments
  • Alternative or modified assignments
  • Modified testing procedures
  • Quiet environment

• Special equipment:
  • Word processors with spell checkers and dictionaries
  • Text-to-speech and speech-to-text programs
  • Talking calculators
  • Books on tape

• Classroom assistants:
  • Note-takers
  • Readers
  • Proofreaders
  • Scribes

• Special Education:
  • Prescribed hours in a resource room
  • Placement in a resource room^[17]
  • Enrollment in a special school for learning disabled students
  • Individual Education Plan (IEP)
  • Educational therapy

Sternberg^[18] has argued that early remediation can greatly reduce the number of children meeting diagnostic criteria for learning disabilities. He has also suggested that the focus on learning disabilities and the provision of accommodations in school fails to acknowledge that people have a range of strengths and weaknesses, and places undue emphasis on academic success by insisting that people should receive additional support in this arena but not in music or sports. Other research has pinpointed the use of resource rooms as an important—yet often politicized component of educating students with learning disabilities.^[19]

[edit]Causes and risk factors

This section includes a list of references, related reading or external links, but its sources remain unclear because it lacks inline citations. Please improve this article by introducing more precise citations where appropriate. (November 2009)

The causes for learning disabilities are not well understood, and sometimes there is no apparent cause for a learning disability. However, some causes of neurological impairments include:

• Heredity – Learning disabilities often run in the family.
• Problems during pregnancy and birth – Learning disabilities can result from anomalies in the developing brain, illness or injury, fetal exposure to alcohol or drugs, low birth weight, oxygen deprivation, or by premature or prolonged labor.
• Accidents after birth – Learning disabilities can also be caused by head injuries, malnutrition, or by toxic exposure (such as heavy metals or pesticides).
• Poverty- Learning disabilies can be the result of a lack of parental reinforcement of academics. Parents living in poverty who don’t read to their children at an early age, expose them to appropriate communication networks, feed them nutritious food and allow them to interact with intellectually stimulating environments can place their children at risk for moderate to severe learning disabilities.^[20]

[edit]Impact on affected individuals

This section requires expansion.

Neuropsychological differences can impact the accurate perception of social cues with peers ^[21].

[edit]Societal Factors In the USA

This section is in a list format that may be better presented using prose. You can help by converting this section to prose, ifappropriate. Editing help is available. (November 2009)

Society both impacts upon, and is impacted by, individuals with learning disabilities. Significant factors in this relationship include poverty (with its concomitant reliance on welfare/public assistance), gender, and crime/imprisonment.

[edit]Welfare/Public assistance relating to educational development

A 36 month study conducted by Taylor and Barusch^[22] included 284 welfare recipients, who were frequently interviewed, called, and visited with in their homes. In this study the average age was 34 and 97% of the participants were female. Of the welfare participants 22.9% were learning disabled and 32% had no high school diploma or GED. Findings from this study imply that long term learning disabled welfare recipients will not be able to support their family through employment.

A study conducted by Margai and Henry^[23] found that the laws of identifying special education children have been revised within the past years. Learning disabled children in public schools now make up 6% of all kids.

High risk neighborhoods and poor living conditions add to the factor of being more vulnerable to having a learning disability. A study was conducted exploring the areas of pollution and socioeconomic factors related to having a higher risk of a learning disability. Margai and Henry [10] used primary data and analyzed clusters of people in a distinct part of a community near a toxic waste place, living in poor neighborhoods and living in poverty). The results confirmed that a majority of the people with a learning disability came from some socio-economic indicator such as poverty, subdivided housing, and lower adult educational attainment. Individuals with a learning disability will rely more heavily on public assistance/welfare than individuals who do not because of their lack of knowledge

[edit]Gender issues

• Researchers believe that there are more boys in special education programs compared to girls. Coutinho and Oswald^[24] found that data was collected from the U.S. office of Civil Rights to view the underrepresentation of females in special education. Oswald [11] found that 73% of learning disabled individuals in special education programs were boys.

However, the ratio of boys to girls (having a learning disability) is equal. In dealing with learning disabilities no significant gender differences were found in a study of more than 400 children. Bandian^[25] found that if identified by research criteria there were no differences in gender, but if learning disabilities were identified by general education teachers and/or special education teachers, there was twice as many boys identified compared to girls. Alongside that, there was another statement said by Bandian [12] that supported the claim stated above “boys were twice as like[ly] to be identified by teachers as in need of a learning disability programs [sic] [compared to girls].”

• In a study 266 youths between the ages of 12-18 were voluntarily interviewed with 74 structured questions in a small classroom, question structure was based on “special education, juvenile justice, and child and adolescent development literature,” and then categorized into three parts: personal, home, and school. Based on the information the individuals provided to the interviewers the juvenile delinquents were put into a category, special education, or non-special education. Zabel and Nigro^[26] stated that
  

  “girls are less often viewed as disruptive and disturbing behavior patterns that often lead to special education.”

In contrast to that Zabel and Nigro [13] also found that the

“gender pattern was reversed for LD classification, with nearly 78.6% of females who had been in special education.”

[edit]Crime and prison population

• Individuals in a detention facility are more likely to have a learning disability, receive poor grades, and repeat a grade. Zabel and Nigro [13] conducted a study with 266 youths (currently in a detention facility), with the youths ages ranging from 12-18. The individuals were voluntarily interviewed with 74 structured questions. Based on the information provided from the individuals, the individuals were categorized into two groups, special education or non-special education. Zabel and Nigro [13] stated “a majority of participants had received failing grades, and many had repeated at least one grade.” The researchers also found that 88.6% of the youth had been suspended, and those in the SpEd group were more likely than those in the non-SpEd group to report their first instance of trouble in elementary school. This information provided relates to the factor of when most learning disabled individuals are identified is in elementary school thus proving that it would make sense that the individuals in the SpEd group had their first instance of trouble in elementary school and it is hard for LD individuals to complete the education system, thus resulting in having to rely on welfare and public assistance.

• Another statistic (calculated from the study stated above) found by Zabel and Nigro [13] was that 37.1% had been involved with special education, and classified having EBD and/or LD. Zabel also found that those individuals with a learning disability were at a higher risk that those with no special education experience (in the violent inmates, 17 of 30 were LD, and in the nonviolent, 13 of 30 were LD).

• Individuals in detention facilities may have a learning disability and more specifically have dyslexia (severe difficulty in recognizing and understanding written language, leading to spelling and writing problems). Gretchell, Pabreja, Neeld, and Carrio^[27] conducted a study that compared the difference of children with dyslexia and without. Twenty six individuals were dyslexic and 23 individuals were not. Individuals were tested with the Test of Gross Motor Development and Movement Assessment Battery for Children. Individuals with dyslexia performed significantly lower than the control group (individuals who aren’t dyslexic).

• Youth in a detention facility are more likely to have a special education problem, such as a learning disability, than not. Zabel and Nigro [13] found in their study that
  

  “about one half of SpEd participants and nearly 20% of the total sample reported their classification as learning disabilities.”

LD individuals make up a large portion of individuals in a detention facility which may have been a result from the LD individual not learning at a significant pace in the education system and also potentially not completing the education system. Zabel and Nigro’s study was made up of 266 youth between the ages of 12-18 who were currently in a detention facility.

[edit]Contrast with other conditions

People with an IQ lower than 70 are usually characterized as having mental retardation (MR), mental deficiency, or cognitive impairment and are not included under most definitions of learning disabilities, because their learning difficulties are considered to be related directly to their low IQ scores.

Attention-deficit hyperactivity disorder (ADHD) is often studied in connection with learning disabilities, but it is not actually included in the standard definitions of learning disabilities. An individual with ADHD may struggle with learning, but he or she can often learn adequately once successfully treated for the ADHD. A person can have ADHD but not learning disabilities or have learning disabilities without having ADHD. The conditions can co-occur

Some research is beginning to make a case for ADHD being included in the definition of LDs, since it is being shown to have a strong impact on “executive functions” required for learning. This has not as yet affected any official definitions.

[edit]Advocacy of the concept of learning disabilities

Rick Lavoie is an advocate, author, special education teacher, and writer of learning disabilities. He started a school in Massachusetts specifically targeted towards learning disabled children. Rick Lavoie has written several books on the subject of learning disabilities and their impact on children. The F.A.T. City Project (1989) was a documentary that created a mock environment where everyday people could experience the Frustration, Anxiety, and Tension of being a learning disabled child. ^[28]

[edit]United States and Canada

In the United States and Canada, the terms learning disability and learning disorder (LD) refer to a group of disorders that affect a broad range of academic and functional skills including the ability to speak, listen, read, write, spell, reason, organize information, and do math. A person’s IQ must be average or above to have a learning disability or learning disorder.

[edit]USA Legislation related to learning difficulties

The Section 504 of the Rehabilitation Act 1973 was taken in effect in May 1977, this American legislation guarantees certain rights to people with disabilities, especially in the cases of education and work, such being in schools, colleges and university settings.

The Individuals with Disabilities Education Act, formerly known as the Education for All Handicapped Children Act, is a United States federal law that governs how states and public agencies provide early intervention, special education and related services to children with disabilities. It addresses the educational needs of children with disabilities from birth to the age of 21.^[29] Considered as a civil rights law, states are not required to participate.

[edit]United Kingdom

In the UK, terms such as specific learning difficulty (SpLD), Developmental Dyslexia, dyspraxia and dyscalculia are used to cover the range of learning difficulties referred to in the United States as “learning disabilities”. In the UK, the term “learning disability” refers to a range of conditions that are almost invariably associated with more severe generalized cognitive impairment.

[edit]See also

• Language-based learning disability
• Learning Disability Coalition
• Rundle Academy
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Cerebral Palsy

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(Redirected from Celebral palsy)

This article is about cerebral palsy as an overall umbrella term. For the most common type of cerebral palsy worldwide, see the article on spastic diplegia. For specifics on other types of CP, see their corresponding articles.

Cerebral palsy
Classification and external resources
A child with cerebral palsy being examined.
ICD–10	G80.
ICD–9	343
OMIM	603513 605388
DiseasesDB	2232
eMedicine	neuro/533 pmr/24
MeSH	D002547

Disability
Disability in practice
Disability Theory · Ableism Models of disability (Medical · Social) Inclusion · Freak show Disabled sports (Special Olympics · Paralympics) Universal access Emotional and/or behavioral disability Disability-related terms with negative connotations
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Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive,^[1][2] non-contagious motor conditions that causephysical disability in human development, chiefly in the various areas of body movement.^[3]

Cerebral refers to the cerebrum, which is the affected area of the brain (although the disorder most likely involves connections between thecortex and other parts of the brain such as the cerebellum), and palsy refers to disorder of movement. Cerebral palsy is caused by damage to the motor control centers of the developing brain and can occur during pregnancy, during childbirth or after birth up to about age three.^[4][5]

Cerebral palsy describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behaviour, by epilepsy, and by secondary musculoskeletal problems.^[6]

Of the many types and subtypes of CP, none of them has a known cure. Usually, medical intervention is limited to the treatment and prevention of complications arising from CP’s effects.

A 2003 study put the economic cost for people with CP in the US at $921,000 per individual, including lost income.^[7]

In another study, the incidence in six countries surveyed was 2.12–2.45 per 1,000 live births,^[8] indicating a slight rise in recent years. Improvements in neonatal nursing have helped reduce the number of babies who develop cerebral palsy, but the survival of babies with very low birth weights has increased, and these babies are more likely to have cerebral palsy.^[9][10]

Contents [hide] 1 Classification 1.1 Spastic 1.2 Ataxic 1.3 Athetoid/dyskinetic 1.4 Hypotonic 2 Signs and symptoms 2.1 Skeleton 3 Causes 4 Diagnosis 5 Treatment 5.1 Nutritional/substance 5.2 Interpersonal therapy 5.2.1 Occupational Therapy 5.3 Pain and sleep disorders 5.4 Surgery and orthoses 5.5 Temperature regulation 6 Prognosis 6.1 Self-care 6.2 Productivity 6.3 Leisure 6.4 Participation and barriers 7 Epidemiology 8 History 9 Society and culture 9.1 Economic Impact Of Cerebral Palsy In Australia 9.2 Use of terms when referring to people with CP 9.3 Misconceptions 9.4 Media Representations and Documentaries 9.5 Notable cases 10 References 11 External links

[edit]Classification

CP is divided into four major classifications to describe different movement impairments. These classifications also reflect the areas of the brain that are damaged. The four major classifications are:

[edit]Spastic

For details on the most common form of cerebral palsy, see spastic diplegia.

Spastic cerebral palsy is by far the most common type, occurring in 70% to 80% of all cases. Moreover, spastic CP accompanies one of the other types in 30% of all cases. People with this type are hypertonic and have a neuromuscular condition stemming from damage to the corticospinal tract or the motor cortex that affects the nervous system’s ability to receivegamma amino butyric acid in the area(s) affected by the disability. Spastic CP is further classified by topography dependent on the region of the body affected; these include:

• Spastic hemiplegia (one side being affected). Generally, injury to muscle-nerves controlled by the brain’s left side will cause a right body deficit, and vice versa. Typically, people that have spastic hemiplegia are the most ambulatory, although they generally have dynamic equinus on the affected side and are primarily prescribed ankle-foot orthoses to prevent said equinus.^[11]
• Spastic diplegia (the lower extremities are affected with little to no upper-body spasticity). The most common form of the spastic forms. Most people with spastic diplegia are fully ambulatory and have a scissors gait. Flexed knees and hips to varying degrees are common. Hip problems, dislocations, and in three-quarters of spastic diplegics, also strabismus(crossed eyes), can be present as well. In addition, these individuals are often nearsighted. The intelligence of a person with spastic diplegia is unaffected by the condition.
• Spastic quadriplegia (all four limbs affected equally). People with spastic quadriplegia are the least likely to be able to walk, or if they can, to want to walk, because their muscles are too tight and it is too much effort to do so. Some children with quadriplegia also have hemiparetic tremors, an uncontrollable shaking that affects the limbs on one side of the body and impairs normal movement.

Occasionally, terms such as monoplegia, paraplegia, triplegia, and pentaplegia may also be used to refer to specific manifestations of the spasticity.

[edit]Ataxic

Ataxia (ICD-10 G80.4) type symptoms can be caused by damage to the cerebellum. The forms of ataxia are less common types of cerebral palsy, occurring in at most 10% of all cases. Some of these individuals have hypotonia and tremors. Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing.

[edit]Athetoid/dyskinetic

Athetoid or dyskinetic is mixed muscle tone — People with athetoid CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. For some people with athetoid CP, it takes a lot of work and concentration to get their hand to a certain spot (like scratching their nose or reaching for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects (such as a toothbrush or pencil). About one quarter of all people with CP have athetoid CP. The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia. It occurs in 10% to 20% of all cases.^[12] In newborn infants, high bilirubin levels in the blood, if left untreated, can lead to brain damage in certain areas (kernicterus). This may also lead to athetoid cerebral palsy.

[edit]Hypotonic

People with hypotonic CP appear limp and can move only a little or can’t move at all.

[edit]Signs and symptoms

All types of cerebral palsy are characterized by abnormal muscle tone (i.e. slouching over while sitting), reflexes, or motor development and coordination. There can be joint and bone deformities and contractures (permanently fixed, tight muscles and joints). The classical symptoms are spasticities, spasms, other involuntary movements (e.g. facial gestures), unsteady gait, problems with balance, and/or soft tissue findings consisting largely of decreased muscle mass. Scissor walking (where the knees come in and cross) and toe walking (which can contribute to a gait reminiscent of a marionette) are common among people with CP who are able to walk, but taken on the whole, CP symptomatology is very diverse. The effects of cerebral palsy fall on a continuum of motor dysfunction which may range from slight clumsiness at the mild end of the spectrum to impairments so severe that they render coordinated movement virtually impossible at the other end the spectrum.

Babies born with severe CP often have an irregular posture; their bodies may be either very floppy or very stiff. Birth defects, such as spinal curvature, a small jawbone, or a small head sometimes occur along with CP. Symptoms may appear or change as a child gets older. Some babies born with CP do not show obvious signs right away. Classically, CP becomes evident when the baby reaches the developmental stage at six and a half to 9 months and is starting to mobilise, where preferential use of limbs, asymmetry or gross motor developmental delay is seen.

Secondary conditions can include seizures, epilepsy, apraxia, dysarthria or other communication disorders, eating problems, sensory impairments, mental retardation, learning disabilities, and/or behavioral disorders.

Speech and language disorders are common in people with Cerebral Palsy. The incidence of dysarthria is estimated to range from 31% to 88%. Speech problems are associated with poor respiratory control, laryngeal and velopharyngeal dysfunction as well as oral articulation disorders that are due to restricted movement in the oral-facial muscles. There are three major types of dysarthria in cerebral palsy: spastic, dyskinetic (athetosis) and ataxic. Speech impairments in spastic dysarthria involves four major abnormalities of voluntary movement: spasticity, weakness, limited range of motion and slowness of movement. Speech mechanism impairment in athetosis involves a disorder in the regulation of breathing patterns, laryngeal dysfunction (monopitch, low, weak and breathy voice quality). It is also associated with articulatory dysfunction (large range of jaw movements), inappropriate positioning of the tongue, instability of velar elevation. Athetoid dysarthria is caused by disruption of the internal sensorimotor feedback system for appropriate motor commands, which leads to the generation of faulty movements that are perceived by others as involuntary. Ataxic dysarthria is uncommon in cerebral palsy. The speech characteristics are: imprecise consonants, irregular articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow rate, monopitch, monoloudness and harsh voice.^[13] Overall language delay is associated with problems of mental retardation, hearing impairment and learned helplessness.^[3] Children with cerebral palsy are at risk of learned helplessness and becoming passive communicators, initiating little communication.^[3] Early intervention with this clientele often targets situations in which children communicate with others, so that they learn that they can control people and objects in their environment through this communication, including making choices, decisions and mistakes.^[3]

[edit]Skeleton

In order for bones to attain their normal shape and size, they require the stresses from normal musculature. Osseous findings will therefore mirror the specific muscular deficits in a given person with CP. The shafts of the bones are often thin (gracile) and become thinner during growth. When compared to these thin shafts (diaphyses), the centers (metaphyses) often appear quite enlarged (ballooning). With lack of use, articular cartilage may atrophy, leading to narrowed joint spaces. Depending on the degree of spasticity, a person with CP may exhibit a variety of angular joint deformities. Because vertebral bodies need vertical gravitational loading forces to develop properly, spasticity and an abnormal gait can hinder proper and/or full bone and skeletal development. People with CP tend to be shorter in height than the average person because their bones are not allowed to grow to their full potential. Sometimes bones grow to different lengths, so the person may have one leg longer than the other.

[edit]Causes

While in certain cases there is no identifiable cause, other etiologies include problems in intrauterine development (e.g. exposure to radiation, infection), asphyxia before birth, hypoxia of the brain, and birth trauma during labor and delivery, and complications in the perinatal period or during childhood.^[3] CP is also more common in multiple births.

Studies at the University of Liverpool have led to the hypothesis that many cases of cerebral palsy, and other conditions that an infant has at birth, are caused by the death in very early pregnancy of an identical twin. This may occur when twins have a joint circulation through sharing the same placenta. Not all identical twins share the same blood supply (monochorionic twins), but if they do, the suggestion is that perturbations in blood flow between them can cause the death of one and damage to the development of the surviving fetus.^[14][15][16] It is common knowledge amongst obstetricians and midwives that a small dead fetus (fetus papyraceus) may sometimes be found attached to a placenta following birth. In the past, this has not been considered important and knowledge of the so called ‘vanishing twin’ has been suppressed to avoid triggering feelings of loss, grief, or guilt in mothers and especially the surviving twin. The pathological consequences depend on the severity and the stage of development of the fetus when the imbalances in blood flow between the fetuses occur. It has been proposed that such pathology could account, not just for cerebral palsy, but for developmental abnormalities of the eye, heart, and gut, and other specific brain abnormalities such as neuronal migration disorders e.g. lissencephaly and holoprosencephaly.

Between 40% and 50% of all children who develop cerebral palsy were born prematurely. Premature infants are vulnerable, in part because their organs are not fully developed, increasing the risk of hypoxic injury to the brain that may manifest as CP. A problem in interpreting this is the difficulty in differentiating between CP caused by damage to the brain that results from inadequate oxygenation and CP that arises from prenatal brain damage that then precipitates premature delivery.

Recent research has demonstrated that intrapartum asphyxia is not the most important cause, probably accounting for no more than 10 percent of all cases; rather, infections in the mother, even infections that are not easily detected, may triple the risk of the child developing the disorder, mainly as the result of the toxicity to the fetal brain of cytokines that are produced as part of the inflammatory response.^[17] Low birthweight is a risk factor for CP—and premature infants usually have low birth weights, less than 2.0 kg, but full-term infants can also have low birth weights. Multiple-birth infants are also more likely than single-birth infants to be born early or with a low birth weight.

After birth, other causes include toxins, severe jaundice, lead poisoning, physical brain injury, shaken baby syndrome, incidents involving hypoxia to the brain (such as near drowning), and encephalitis or meningitis. The three most common causes of asphyxia in the young child are: choking on foreign objects such as toys and pieces of food, poisoning, and near drowning.

Some structural brain anomalies such as lissencephaly may present with the clinical features of CP, although whether that could be considered CP is a matter of opinion (some people say CP must be due to brain damage, whereas people with these anomalies didn’t have a normal brain). Often this goes along with rare chromosome disorders and CP is not genetic or hereditary.

[edit]Diagnosis

The diagnosis of cerebral palsy has historically rested on the patient’s history and physical examination. Once diagnosed with cerebral palsy, further diagnostic tests are optional. TheAmerican Academy of Neurology published an article in 2004 reviewing the literature and evidence available on CT and MRI imaging. They suggested that neuroimaging with CT or MRI is warranted when the etiology of a patient’s cerebral palsy has not been established – an MRI is preferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus, porencephaly, arteriovenous malformation,subdural hematomas and hygromas, and a vermian tumor^[18] (which a few studies suggest are present 5 to 22%). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as epilepsy and mental retardation.^[19]

[edit]Treatment

There is no cure for CP, but various forms of therapy can help a person with the disorder to function and live more effectively. In general, the earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. The earliest proven intervention occurs during the infant’s recovery in the neonatal intensive care unit (NICU). Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepienes, baclofen and intrathecal phenol/baclofen); hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesizers. For instance, the use of a standing frame can help reduce spasticity and improve range of motion for people with CP who use wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Non-speaking people with CP are often successful availing themselves of augmentative and alternative communication systems such as Blissymbols.

[edit]Nutritional/substance

Early Nutritional Support In one cohort study of 490 premature infants discharged from the NICU, the rate of growth during hospital stay was related to neurological function at 18 and 22 months of age. The study found a significant decrease in the incidence of cerebral palsy in the group of premature infants with the highest growth velocity. This study suggests that adequate nutrition and growth play a protective role in the development of cerebral palsy.^[20]

Cord Blood Therapy: There are no published randomized controlled trials or meta-analysis of this treatment modality in cerebral palsy. In March 2008 a boy diagnosed with cerebral palsy appeared on the Today Show with his family.^[21] The parents noted that he could not walk on his own and appeared to be “swallowing his tongue” at times. He was eventually diagnosed with cerebral palsy and could only walk with the aid of a walker for a short time. Earlier that year he participated in a clinical trial involving his own cord blood that his parents had saved when he was born. His parents reported that within 5 days after the procedure he was walking on his own and talking, something his mother said he was not capable of on his own and it was doubtful he would ever be able to do on his own. They also reported that the doctors also told them that if his rate of progress continues uninterrupted until he is 7 he will be pronounced cured.

Hyperbaric oxygen therapy (HBOT), in which pressurized oxygen is inhaled inside a hyperbaric chamber, has been used to treat CP under the theory that improving oxygen availability to damaged brain cells can reactivate some of them to function normally. Its use to treat CP is controversial. A 2007 systematic review concluded that the effect of HBOT on CP is not significantly different from that of pressurized room air, and that some children undergoing HBOT will experience adverse events such as seizures and the need for ear pressure equalization tubes; due to poor quality of data assessment the review also concluded that estimates of the prevalence of adverse events are uncertain.^[22]

Nutritional counseling may help when dietary needs are not met because of problems with eating certain foods.

[edit]Interpersonal therapy

Physiotherapy (PT) programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Many experts believe that life-long physiotherapy is crucial to maintain muscle tone, bone structure, and prevent dislocation of the joints.

Occupational therapy helps adults and children maximise their function, adapt to their limitations and live as independently as possible.^[23][24]

Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.^[25]

Conductive education (CE) was developed in Hungary from 1945 based on the work of András Pető. It is a unified system of rehabilitation for people with neurological disorders including cerebral palsy, Parkinson’s disease and multiple sclerosis, amongst other conditions. It is theorised to improve mobility, self-esteem, stamina and independence as well as daily living skills and social skills. The conductor is the professional who delivers CE in partnership with parents and children. Skills learned during CE should be applied to everyday life and can help to develop age-appropriate cognitive, social and emotional skills. It is available at specialized centers.

Biofeedback is an alternative therapy in which people with CP learn how to control their affected muscles. Some people learn ways to reduce muscle tension with this technique. Biofeedback does not help everyone with CP.

Neuro-cognitive therapy. It is based upon two proven principles. (1) Neural Plasticity. The brain is capable of altering its own structure and functioning to meet the demands of any particular environment. Consequently if the child is provided with an appropriate neurological environment, he will have the best chance of making progress. (2) Learning can lead to development. As early as the early 1900s, this was being proven by a psychologist named Lev Vygotsky. He proposed that children’s learning is a social activity, which is achieved by interaction with more skilled members of society. There are many studies, which provide evidence for this claim. there are however, as yet no controlled studies on neuro-cognitive therapy.

Patterning is a controversial form of alternative therapy for people with CP. The method is promoted by The Institutes for the Achievement of Human Potential (IAHP), a Philadelphia nonprofit, but has been criticized by the American Academy of Pediatrics.^[26] The IAHP’s methods have been endorsed by Linus Pauling,^[27] as well as some parents of children treated with their methods.^[28][29][30]

Both massage therapy^[31] and hatha yoga^{[citation needed]} are designed to help relax tense muscles, strengthen muscles, and keep joints flexible. Hatha yoga breathing exercises are sometimes used to try to prevent lung infections. More research is needed to determine the health benefits of these therapies for people with CP.

[edit]Occupational Therapy

Main article: Occupational therapy in the management of cerebral palsy

Occupational Therapy (OT) enables individuals with CP to participate in activities of daily living that are meaningful to them. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child.^[32] Occupational therapists may address issues relating to sensory, cognitive, or motor impairments resulting from CP that affect the child’s participation in self-care, productivity, or leisure. Parent counselling is also an important aspect of occupational therapy treatment with regard to optimizing the parent’s skills in caring for and playing with their child to support improvement of their child’s abilities to do things.^[33][34] The occupational therapist typically assesses the child to identify abilities and difficulties, and environmental conditions, such as physical and cultural influences, that affect participation in daily activities.^[34] Occupational therapists may also recommend changes to the play space, changes to the structure of the room or building, and seating and positioning techniques to allow the child to play and learn effectively.^[34][35]

[edit]Pain and sleep disorders

Pain is a concern for many children diagnosed with Cerebral Palsy, which may result from the inherent deficits associated with the condition, along with the numerous procedures children with CP face regularly ^[36]. Children with CP also have a high likelihood of suffering from chronic sleep disorders associated with both physical and environmental factors ^[37].

[edit]Surgery and orthoses

Surgery for people with CP usually involves one or a combination of:

• Loosening tight muscles and releasing fixed joints, most often performed on the hips, knees, hamstrings, and ankles. In rare cases, this surgery may be used for people with stiffness of their elbows, wrists, hands, and fingers.

• The insertion of a Baclofen Pump usually during the stages while a patient is a young adult. This is usually placed in the left abdomen. It is a pump that is connected to the spinal cord, whereby it sends bits of Baclofen alleviating the continuous muscle flexion. Baclofen is a muscle relaxant and is often given PO to patients to help counter the effects of spasticity.

• Straightening abnormal twists of the leg bones, i.e. femur (termed femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary complication caused by the spastic muscles generating abnormal forces on the bones, and often results in intoeing (pigeon-toed gait). The surgery is called derotation osteotomy, in which the bone is broken (cut) and then set in the correct alignment.^[38]

• Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomy, “rhizo” meaning root and “tomy” meaning “a cutting of” from the Greek suffix ‘tomia’ reduces spasms and allows more flexibility and control of the affected limbs and joints.^[39]

• Botulinum Toxin A (Botox) injections into muscles that are either spastic or have contractures, the aim being to relieve the disability and pain produced by the inappropriately contracting muscle.^[40]

Orthotic devices such as ankle-foot orthoses (AFOs) are often prescribed to minimise gait irregularities. AFOs have been found to improve several measures of ambulation, including reducing energy expenditure^[41] and increasing speed and stride length.^[42]

[edit]Temperature regulation

A new study has found that cooling the bodies and blood of high-risk full-term babies shortly after birth may significantly reduce disability or death.^[43]

[edit]Prognosis

CP is not a progressive disorder (meaning the brain damage neither improves nor worsens), but the symptoms can become more severe over time due to subdural damage. A person with the disorder may improve somewhat during childhood if he or she receives extensive care from specialists, but once bones and musculature become more established, orthopedic surgery may be required for fundamental improvement. People who have CP tend to develop arthritis at a younger age than normal because of the pressure placed on joints by excessively toned and stiff muscles.

The full intellectual potential of a child born with CP will often not be known until the child starts school. People with CP are more likely to have some type of learning disability, but this is not related to a person’s intellect or IQ level. Intellectual level among people with CP varies from genius to mentally retarded, as it does in the general population, and experts have stated that it is important to not underestimate a person with CP’s capabilities and to give them every opportunity to learn.^[44]

The ability to live independently with CP varies widely depending on the severity of each case. Some individuals with CP will require personal assistant services for all activities of daily living. Others can lead semi-independent lives, needing support only for certain activities. Still others can live in complete independence. The need for personal assistance often changes with increasing age and associated functional decline. However, in most cases persons with CP can expect to have a normal life expectancy; survival has been shown to be associated with the ability to ambulate, roll, and self-feed.^[45] As the condition does not directly affect reproductive function, some persons with CP have children and parent successfully.

According to OMIM, only 2% of cases of CP are inherited (with glutamate decarboxylase-1 as one known enzyme involved.)^[46] There is no evidence of an increased chance of a person with CP having a child with CP.

The common signs and symptoms associated with CP can have a significant impact on participation in occupations. Occupation is a term used in occupational therapy that refers to all activities a person does throughout their day. These activities may be grouped into the categories of self-care, productivity and leisure activities. Impairments related to CP can impact these activities. For example, children with motor impairments may also experience difficulties moving around their home and community, such as transportation, moving from room to room or transferring from wheelchair to toilet.

[edit]Self-care

Self-care is any activity children do to care for themselves. For many children with CP, parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, grooming and eating, can be difficult for children with CP as self-care depends primarily on use of the upper limbs.^[47] For those living with CP, impaired upper limb function affects almost 50% of children and is considered the main factor contributing to decreased activity and participation.^[48] Since the hands are used for many self-care tasks, it is logical that sensory and motor impairments would impact daily self-care. The extent of the hand impairment depends on the location and degree of brain damage.^[49] Sensory impairments can make getting dressed and brushing teeth difficult. Along with sensory impairments, motor impairments of the hand are thought to be responsible for difficulties experienced in daily, self-care activities.^[50] However, motor impairments are more important than sensory impairments, with the most prevalent impairment being finger dexterity (ability to manipulate small objects).^[49]Finger dexterity is essential in fastening buttons, doing up zippers and tying shoelaces. With upper limb spasticity, it may be difficult to get dressed in the morning. If the individual with CP also has cognitive deficits, this may add an additional challenge to dressing and grooming.

Children with CP often have oral sensory disturbances meaning that they have too little or too much sensitivity around and in the mouth.^[51] An infant with CP may not be able to suck, swallow or chew and this can result in difficulty eating.^[51] As mentioned in the above paragraph, finger dexterity is the most prevalent motor impairment.^[49] Finger dexterity is essential for manipulating cutlery or bringing food to the mouth. Fine finger dexterity, like picking up a spoon, is more frequently impaired than gross manual dexterity, like spooning food onto a plate.^[49] Grip strength impairments are less common.^[49] Overall, children with CP may have difficulty chewing and swallowing food, holding utensils, and preparing food due to sensory and motor impairments.

[edit]Productivity

The effects of sensory, motor and cognitive impairments not only affect self-care occupations in children with CP, but also productivity occupations. Productivity can include, but is not limited to: school, work, household chores and contributing to the community.^[52] Play is also included as a productive occupation as it is often the primary activity for children.^[53]

Play is considered the main occupation for children.^[53] If play becomes difficult due to a disability, like CP, this can cause problems for the child.^[54] These difficulties can affect a child’s self-esteem and sense of self-value and worth.^[54] As well, the sensory and motor problems experienced by children with CP affect how the child interacts with his or her surroundings, including the environment and other people.^[54] Not only do physical limitations affect a child’s ability to play, the limitations perceived by the child’s caregivers and playmates also impact the child’s play activities.^[55] Typically, children with disabilities spend more time playing by themselves.^[56] When a disability prevents a child from playing, there may be social, emotional and psychological problems,^[57] which can lead to being more dependent on others, less motivation and poor social skills.^[58]

In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with CP have the capacity to learn and write in the school environment.^[59] However, students with CP may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read.^[59] In addition, writing may take longer and require greater effort on the student’s part.^[59] Factors linked to handwriting include: postural stability, sensory and perceptual abilities of the hand and writing tool pressure.^[59]

Also, speech impairments may be seen in children with CP depending on the severity of brain damage.^[60] Communication in a school setting is quite important because communicating with peers and teachers is very much a part of the “school experience” and enhances social interaction. Problems with language or motor dysfunction can lead to underestimating a student’s intelligence.^[61] In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally and interacting socially.

[edit]Leisure

Leisure occupations are any activities that are done for enjoyment. Enjoyable activities depend on the child’s personality and environment. Leisure activities can have several positive effects on physical health, mental health, life satisfaction and psychological growth for children with physical disabilities like CP.^[62] Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction.^[63] In addition, for children with CP, leisure appears to enhance adjustment to living with a disability.^[64]

Leisure can be divided into structured (formal) and unstructured (informal) activities.^[65] Studies show that children with disabilities, like CP, participate mainly in informal activities that are carried out in the family environment and are organized by adults.^[66] Typically, children with disabilities carry out leisure activities by themselves or with their parents rather than with friends. Therefore, children may experience limited diversity of activities and social engagements, as well as a more passive lifestyle than their peers.^[67] Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers.

[edit]Participation and barriers

Participation is considered involvement in life situations and everyday activities.^[68] Participation includes the domains of self-care, productivity and leisure. In fact, communication, mobility, education, home life, leisure and social relationships require participation and are indicators of the extent to which a child functions in his or her environment.^[69] Barriers can exist on three levels: micro, meso and macro.^[70] Firstly, the barriers at the micro level involve the person.^[71] Barriers at the micro level include the child’s physical limitations (motor, sensory and cognitive impairments) or their subjective feelings regarding their ability to participate.^[72] For example, the child may not participate in group activities due to lack of confidence. Secondly, the barriers at the meso level include the family and community.^[73] These may include negative attitudes of people towards disability or lack of support within the family or in the community.^[74] One of the main reasons for this limited support appears to be the result of a lack of awareness and knowledge regarding the child’s ability to engage in activities despite his or her disability.^[75] Thirdly, barriers at the macro level incorporate the systems and policies that are not in place or hinder children with CP. These may be environmental barriers to participation such as architectural barriers, lack of relevant assistive technology and transportation difficulties due to limited wheelchair or public transit that can accommodate the children with CP.^[76] For example, a building without an elevator may prevent the child from accessing higher floor levels.

[edit]Epidemiology

In the industrialized world, the incidence of cerebral palsy is about 2 per 1000 live births.^[77] The incidence is higher in males than in females; the Surveillance of Cerebral Palsy in Europe (SCPE) reports a M:F ratio of 1.33:1.^[78] Variances in reported rates of incidence across different geographical areas in industrialised countries are thought to be caused primarily by discrepancies in the criteria used for inclusion and exclusion. When such discrepancies are taken into account in comparing two or more registers of patients with cerebral palsy (for example, the extent to which children with mild cerebral palsy are included), the incidence rates converge toward the average rate of 2:1000.

In the United States, approximately 10,000 infants and babies are diagnosed with CP each year, and 1200–1500 are diagnosed at preschool age.^[79]

Overall, advances in care of pregnant mothers and their babies has not resulted in a noticeable decrease in CP. This is generally attributed to medical advances in areas related to the care of premature babies (which results in a greater survival rate). Only the introduction of quality medical care to locations with less-than-adequate medical care has shown any decreases. The incidence of CP increases with premature or very low-weight babies regardless of the quality of care.^{[citation needed]}

Prevalence of cerebral palsy is best calculated around the school entry age of about six years, the prevalence in the U.S. is estimated to be 2.4 out of 1000 children^[80]

The SCPE reported the following incidence of comorbidities in children with CP (the data are from 1980–1990 and included over 4,500 children over age 4 whose CP was acquired during the prenatal or neonatal period):

• Mental disadvantage (IQ < 50): 31%
• Active seizures: 21%
• Mental disadvantage (IQ < 50) and not walking: 20%
• Blindness: 11%^[78]

The SCPE noted that the incidence of comorbidities is difficult to measure accurately, particularly across centers. For example, the actual rate of mental retardation may be difficult to determine, as the physical and communicational limitations of people with CP would likely lower their scores on an IQ test if they were not given a correctly modified version.

Apgar scores have sometimes been used as one factor to predict whether or not an individual will develop CP.^[81]

[edit]History

CP, formerly known as “Cerebral Paralysis,” was first identified by English surgeon William Little in 1860. Little raised the possibility of asphyxia during birth as a chief cause of the disorder. It was not until 1897 that Sigmund Freud, then a neurologist, suggested that a difficult birth was not the cause but rather only a symptom of other effects on fetal development.^[82] Research conducted during the 1980s by the National Institute of Neurological Disorders and Stroke (NINDS) suggested that only a small number of cases of CP are caused by lack of oxygen during birth.^[83]

[edit]Society and culture

[edit]Economic Impact Of Cerebral Palsy In Australia

Access Economics has released a report on the economic impact of cerebral palsy in Australia. Launched by the Hon. Bill Shorten, MP, the report found that, in 2007, the financial cost of cerebral palsy (CP) in Australia was $1.47 billion or 0.14% of GDP. When the value of lost well-being (disability and premature death) was added, the cost rose a further $2.4 billion.^[84]

In 2007, the financial cost of CP was $1.47 billion (0.14% of GDP). Of this:

• 1.03 billion (69.9%) was productivity lost due to lower employment, absenteeism and premature death of Australians with CP;

• 141 million (9.6%) was the DWL from transfers including welfare payments and taxation forgone;

• 131 million (9.0%) was other indirect costs such as direct program services, aides and home modifications and the bringing-forward of funeral costs;

• 129 million (8.8%) was the value of the informal care for people with CP; and

• 40 million (2.8%) was direct health system expenditure.

Additionally, the value of the lost well-being (disability and premature death) was a further $2.4 billion.

In per capita terms, this amounts to a financial cost of $43,431 per person with CP per annum. Including the value of lost well-being, the cost is over $115,000 per person per annum.

Individuals with CP bear 37% of the financial costs, and their families and friends bear a further 6%. Federal government bears around one third (33%) of the financial costs (mainly through taxation revenues forgone and welfare payments). State governments bear under 1% of the costs, while employers bear 5% and the rest of society bears the remaining 19%. If the burden of disease (lost well-being) is included, individuals bear 76% of the costs.

[edit]Use of terms when referring to people with CP

Many people would rather be referred to as a person with a disability instead of handicapped. “Cerebral Palsy: A Guide for Care” at the University of Delaware offers the following guidelines:^[85]

Impairment is the correct term to use to define a deviation from normal, such as not being able to make a muscle move or not being able to control an unwanted movement. Disability is the term used to define a restriction in the ability to perform a normal activity of daily living which someone of the same age is able to perform. For example, a three year old child who is not able to walk has a disability because a normal three year old can walk independently. Handicap is the term used to describe a child or adult who, because of the disability, is unable to achieve the normal role in society commensurate with his age and socio-cultural milieu. As an example, a sixteen-year-old who is unable to prepare his own meal or care for his own toileting or hygiene needs is handicapped. On the other hand, a sixteen-year-old who can walk only with the assistance of crutches but who attends a regular school and is fully independent in activities of daily living is disabled but not handicapped. All disabled people are impaired, and all handicapped people are disabled, but a person can be impaired and not necessarily be disabled, and a person can be disabled without being handicapped.

The term “spastic” describes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The Spastics Society was formed.^[86] The term “spastics” was used by the charity as a term for people with CP. The words “spastic” and “spaz” have since been used extensively as a general insult to disabled people, which some see as extremely offensive. They are also frequently used to insult able-bodied people when they seem overly uncoordinated, anxious, or unskilled in sports. The charity changed its name to Scope in 1994.^[86] In the United States the word spaz has the same usage as an insult, but is not generally associated with CP.^[87]

[edit]Misconceptions

Spastic Cerebral Palsy, the most common form of CP, causes the muscles to be tense, rigid and movements are slow and difficult. This can be misinterpreted as cognitive delay due to difficulty of communication. Individuals with cerebral palsy can have learning difficulties, but sometimes it is the sheer magnitude of problems caused by the underlying brain injury that prevents the individual from expressing what cognitive abilities they do possess.^[88]

[edit]Media Representations and Documentaries

Maverick documentary filmmaker Kazuo Hara criticizes the mores and customs of Japanese society in an unsentimental portrait of adults with cerebral palsy in his 1972 film “Goodbye CP” (Sayonara CP)”. Focusing on how the CP victims are generally ignored or disregarded in Japan, Hara challenges his society’s taboos about physical handicaps. Using a deliberately harsh style, with grainy black-and-white photography and out-of-sync sound, Hara brings a stark realism to his subject.^[89]

South Korean director Lee Chang-dong‘s third feature film, “Oasis“, features a main character with cerebral palsy. The film’s plot tells about the difficult romance between a mildly mentally disabled man who was just released from jail after a two and a half year sentence for involuntary manslaughter and a woman with severe cerebral palsy. The movie also shows how the two main characters are treated by their families and perceived by the people around them. The film was a critical success, earning prizes in numerous film festivals. Among the most important were the special director’s prize given to Lee Chang-dong at the Venice Film Festival and the Marcello Mastroianni award for best “first time” actress given to Moon So-ri at the same event.

[edit]Notable cases

• Emperor Claudius, the Roman Emperor who was also a stutterer and walked with a limp is believed to have had CP.^[90]
• Abbey Curran, American beauty queen who represented Iowa at Miss USA 2008 and was the first contestant with a disability to compete. She also made an appearance on The Ellen DeGeneres Show and CBS ‘The Early Show’.^[91][92][93]
• Stephen Hopkins, signer of USA Declaration of Independence, reputed to have stated, “My hand trembles, but my heart does not.”^[94]
• Karen Killilea, the subject of the book Karen (1952) and its sequel, With Love from Karen (1963), by her mother Marie Killilea.^[95]