CHAPTER 10: Intellectual Disabilities: Focus On Down syndrome

INTRODUCTION

Summary: Physical Therapist role in children with intellectual disabilities are

also challenging and important including evaluation and intervention. The

management for the child with Down syndrome is outlined as a model strategy

for Physical therapist, it delineating the interactive effects of common

impairments with such disabilities and the role in managing the impairments

to promote maximum best function of child environment.

Reflection: Being a physical therapist student, the role of PT in pediatric is

challenging as we should have knowledge to what children characteristics, we

also should evaluate and provide treatment to genetic, neurological, and

orthopedic disorders.

HISTORICAL REVIEW

Summary: In history, treatment to people with intellectual disabilities had an

intriguing, interesting, and still unfolding interactional relationship. Before,

people with intellectual disabilities were ignored, left to perish, abused, and

even left to die, but as time goes by they received some care by having shelters,

treatment, discrimination against and segregation of people with intellectual

disabilities were finally recognized as negative and undesirable.

Reflection: People with intellectual disabilities needed some care and maximum

level of support as they exhibit simultaneous and interactive impairments.

Before they being discriminate and abused but now there are institution that

support children with intellectual disabilities. Society can also support

nowadays as a whole, and therefore the countless legislatures and service

providers of today’s society, view intellectual disabilities along a changing

paradigm, with a more functional definition and a focus on the interaction

between the person, the environment, and the intensities and patterns of

needed supports.

DEFINITION

Summary: According to American Psychiatric Association (2013), intellectual

disabilities is a (1) deficits in general abilities, this deficit in mental ability is

reflected in functional challenges in “reasoning, problem solving, planning,

abstract thinking, judgment, learning from instruction and experience and

practical understanding” ; (2) an individual with intellectual disabilities will

concurrently have deficits in adaptive functioning, which are “how well a

person meets community standards of personal independence and social

responsibility, in comparison to others of similar age and sociocultural

background”, in further of this intellectual disabilities describe a performance

state in which functioning is impaired. Intellectual disabilities are generally

regarded as a condition existing in an individual that is described by the

specific performance of the individual not due to a specific trait, although it is

influenced by certain characteristics or capabilities of the individual.

Reflection: To understand the patient with intellectual disabilities, it requires

knowledge of the individual’s capabilities as well as an understanding of the

behavior within the structure and expectation of the individual’s personal and

social environment because it is central to understand how the the concept of

intellectual disabilities and how it shifts the emphasis from measurement of

traits to understanding the individual’s actual functioning in everyday living.

INCIDENCE

Summary: Males are frequently been diagnosed than females in the mild range

(ratio of 1.6:1), this ratio varies some sex-linked genetic syndromes.

Reflection: Across the world there are some people and children with

intellectual disabilities and based on the information that I researched “The

prevalence of autism spectrum disorder, intellectual disability, other

developmental delay, and any developmental disability was higher among boys

compared with girls and the prevalence of any developmental disability was

lower among Hispanic children compared with children in all other race and

ethnicity groups” (Benjamin Z, et.al (2017).

DIAGNOSIS

Summary: A diagnosis of intellectual disabilities is based on the criteria

embodied within the definition reflecting intellectual functioning level, adaptive

skill level.
Reflection: As a future health worker and Physical Therapist, I should have

knowledge to how diagnosing patient with intellectual disabilities by giving

assessment in Intellectual Functioning and Adaptive Skill Level. To determine

the child’s intellectual functioning is significantly below average is arrived at

through the administration of a standardized intelligence test, below an IQ of

100 considered “normal, or an IQ of 70 or 75 or below. While in Adaptive skill

level, deficits in two or more areas of adaptive functioning must be present,

thus showing a generalized limitation in adaptive skill level.

CLASSIFICATION

Summary: In classifying children with intellectual disabilities the key elements

are capabilities, environment, functional limitations, and participation

restriction. Current classification carries with it an application of the new

diagnostic criteria directly correlated with need for support. Other

classifications are Educational Classification that practices special education

which shaped both definition of intellectual disabilities and the need for

supports. It also includes Medical Classification using levels of support needed

by an individual, using a range of mild, moderate, severe, and profound.

Reflection: Supporting children with intellectual disabilities can be improved

their individual and life cycle. It can be through other people, technology, or

habilitation services.
ETIOLOGY AND PATHOPHYSIOLOGY

Summary: Etiology of Intellectual disabilities can be categorized as prenatal,

perinatal, and postural causes. There are 350 etiologies that had been

identified some of this are movement disorders and associated disorders.

Reflection: The causes of having Intellectual disabilities can be through

hereditary, accident, or illness. It based on what causes can be having

intellectual disabilities can be severe or not.

PRIMARY IMPAIREMENTS

Summary: The primary impairments of Intellectual disabilities are Neuromotor

Impairments which result of primary pathology in the central nervous system

(CNS). It can also be deficits in motor control, coordination, postural control,

force production, flexibility, and balance. The other primary impairment are

Learning Impairment where have poor memory, limited generalization, and

poor motivation.

Reflection: Physical therapists assess and treat these impairments to maximize

the function of cognitive, performance and potential of children with

intellectual disabilities to improve their life cycle.

PHYSICAL THERAPY EVALUATION AND INTERVENTION PRINCIPLES

Summary: The key elements of assessing should focus on child functioning.

The four important elements of assessment are: (1) therapist must analyze both

what the child can do and the processes underlying the observed skills and

behaviors; (2) evaluative procedures used for children, particularly children

with intellectual disabilities, often differ from the more rigid clinical procedures

used for adults; (3) therapist must be able to identify not only the disability but

also the child’s abilities; (4) therapist must always concurrently assess sensory

processes and attention. There are also Sensory assessments where in the

therapist assessing Visual, Auditory, Tactile, Vestibular, and Self-stimulation.

Reflection: As a future PT it’s important to assessing the child with intellectual

disabilities with flexible evaluation and organized strategy. PT intervention is to

enhance developmental skill attainment and to improve function.

KEY ELEMENTS OF PHYSICAL THERAPY INTERVENTION

Summary: The child’s ability to respond appropriately and effectively in terms

of movement, intellectual function, and attitudes and feelings serves as the

major long-range goal of intervention. Activities in the intervention program

should be interesting, fun, and meaningful. The developmental of child’s

potential must be in all areas of learning, motor, cognitive, and affective. In the

Learning characteristics overview of cognitive development is necessary to

understand the cognitive limitation of the child with intellectual disabilities and

to design effective treatment programs to overcome those cognitive limitations.

Piaget has also theory about intellectual development where in can be useful in
understanding the various degrees of cognitive impairment seen in intellectual

disabilities. Children with intellectual disabilities are less able to grasp abstract

concepts than concrete concepts. The ability of the person with intellectual

disabilities to remember is related to the type of retention task involved. The

learning challenge has been understood and the child has invented new

strategies that are found to be useful in performing within the environment.

Reflection: As a PT student I must have knowledge and understand the

Intervention General Principle of PT intervention in children with intellectual

disabilities and the learning characteristics of it. Also, the intervention to limit

cognitive impairment and to limit physical impairments and functional

limitation of it.

A MANAGEMENT MODEL FOR PHYSICAL THERAPISTS FOR THE CHILD

WITH DOWN SYNDROME

Summary: Down syndrome is a chromosomal disorder resulting in 47

chromosomes instead of 46. Down syndrome is the most common cause of

intellectual disabilities and is encountered frequently by pediatric PTs. Down

syndrome results in neuromotor, musculoskeletal, and cardiopulmonary

pathologies, which all require management by pediatric PTs. Brain weight in

individuals with Down syndrome is 76% of normal, with the combined weight

of the cerebellum and brain stem being even smaller—66% of normal. There is

also microcephaly, and the brain is abnormally rounded and short with a

decreased A-P diameter, specifically called microbrachycephaly. Visual and

hearing deficits, and speech impairments are common in children with Down

syndrome and must be identified on physical therapy assessment and

intervention. Visual deficits include congenital as well as adult-onset cataracts,

myopia (50%), farsightedness (20%), strabismus, and nystagmus. Forty percent

of children with Down syndrome are born with congenital heart defects; most

commonly, atrioventricular canal defects and ventriculoseptal defects. Children

with Down syndrome demonstrate many musculoskeletal differences of

concern to the PT. Linear growth deficits are observed, including a decrease in

normal velocity of growth in stature, with the greatest deficiency between 6 and

24 months of age,75–77 leg-length reduction,78 and a 10% to 30% reduction in

metacarpal and phalangeal length.

Reflection: Children with Down syndrome are gifted and special person. Down

syndrome patient must be treat with care and aware to their health status. As

down syndrome is a lifelong syndrome, Intervention must include an

understanding from a functional, dynamic systems perspective.

THE PERSON WITH INTELLECTUAL DISABILITIES MOVING INTO AND THROUGH

ADULTHOOD: KEY MANAGEMENT ISSUES

Summary: Intellectual disabilities and Down syndrome both represent types of

developmental disabilities. Down syndrome, typically begin intervention in

childhood, the PT is likely to be the clinician to follow that client into and

through adulthood. Physical therapy evaluation and intervention should

include preventative management for the early onset of any number of these
disorders. Evaluation methods may require that standardized tests be modified

for use with the cognitively impaired individual.

Reflection: Persons with intellectual disabilities/down syndrome can now

expect an increased life expectancy and will experience the same age-related

changes that occur in the general population by the help of Physical Therapist.

PT evaluate and assess by an individualized and multidimensional approach to

meet these wide-ranging needs of adults with developmental disabilities.

CHAPTER 18 (20): Pulmonary and Respiratory Condition in Infants and

Children

INTRODUCTION

Summary: Pulmonary diseases and respiratory disorders continue to be major

causes of both mortality and morbidity for children throughout the world.

Respiratory illness is the most common reason for hospitalization in children

with severe neurological impairment and is the most common cause of death in

these children. Chapter 18 stated about the fragility of the neonatal and

pediatric respiratory system, the process of development of that system, and

the need for aggressive treatment of disorders of the system.

Reflection: As a future PT, understanding the condition of children with

pulmonary and respiratory disease is important, as we examine and give

intervention to help treat them. We aim at reducing the severity of pulmonary

disease in infants and children.

GROWTH AND DEVELOPMENT OF THE LUNGS

Summary: Lung development also provides insight into some unique aspects of

the growth, particularly in number, of pulmonary alveoli. Four specific periods

of lung growth have been confirmed and include the embryonic, pseudo

glandular, canalicular, and saccular periods from post-conception weeks 0 to

6,6 to 16, 16 to 24, and 24 to 40(term), respectively. The earliest sign of lung

development occurs during the embryonic period, from 0 to 6 weeks’ gestation.

The lung buds continue to grow and subdivide into smaller airways during the

5th to 16th week of gestation, termed the pseudo glandular period because the

lung tissue looks similar to glandular cells. The major events that mark the

16th to 26th week, the canalicular period, are thinning and flattening of the

epithelium that will become the type I pneumocytes or alveolarcells. Processes

within the period of alveolar multiplication may limit the potential for achieving

the adult number of pulmonary alveoli.

Reflection: Lung development is important as child growing up. It may cause

pulmonary and respiratory disease if the lung has a problem.

PREDISPOSITION TO RESPIRATORY FAILURE

Summary: It describe the fully several mechanism if acute respiratory failure in

child and infants. Acute respiratory disease can be affecting the respiratory
system. Respiratory failure can be defined as a condition in which impairment

of gas exchange within the lungs poses an immediate threat to life. The most

important general factor predisposing infants and children to acute respiratory

failure is their high incidence of respiratory tract infections. Two major

structural factors—airway size and poor mechanical advantage for the

respiratory muscles—contribute to respiratory failure in a young child. A small

amount of mucus, bronchospasm, or edema can effectively not only occlude

the peripheral airways but may also obstruct the larger, more proximal

bronchi.

Reflection: Physical therapist important issue is respiratory metabolism as

child can cause increased consumption of oxygen, increased heat loss, and

increased water loss secondary to a faster respiratory rate when the metabolic

rate is high.

PHYSICAL THERAPY EXAMINATION OF CHILDREN WITH RESPIRATORY

DISORDERS

Summary: Children with respiratory disease examination is based on Guide to

Physical therapist practice by reviewing first the complete medical chart of a

child for assess of PT. PT also assess the living environment, general health

status, medical/surgical history, the current condition, functional status,

medication and other clinical test. PT also quick check to detect other health

problems in cardiovascular system, integument, musculoskeletal, and

neuromuscular to be considered as diagnosis, prognosis, and plan of care.

Assessing ventilation and gas exchange is more important for tests and

measure to the child with pulmonary disease. PT also inspects the chest

examination document that is presenting symptoms. To determine the

symptoms PT use auscultation by listening to the lungs with stethoscope, they

also palpate the thorax of the child patient, lastly is to identify areas of

abnormal lung density. Assessment of pain, both its source and perceived level,

is an important part of the examination.

Reflection: As a PT student I must know how to assess the child with

respiratory disease. I must also know what may the cause, to intervention or

examine. Also, an assessment of the family’s knowledge and ability to

participate in the child’s care is important when planning discharge from the

hospital.

PHYSICAL THERAPY FOR CHILDREN WITH PULMONARY DISEASE AND

RESPIRATORY DISORDERS

Summary: Physical therapy for the infant or child with pulmonary disease or

respiratory disorder can be categorized into three general areas that often

overlap: (1) AC for removal of secretions, either by traditional postural drainage

with percussion and vibration (PDPV) or more contemporary techniques that

will be discussed at some length. (2) Breathing exercises and retraining. (3)

Physical reconditioning including aerobic exercise, strength training, and other

types of exercise for the thorax. Of all types of physical therapy treatment for
patients with respiratory problems, AC in its many formats and approaches

has been most extensively studied.

Reflection: PT intervention to pulmonary disease and respiratory disease by AC.

or PDPV, breathing exercise, and exercises to help them to breathe normal.

There are also different position to help them to cough and suctioning.

ATELECTASIS

Summary: Primary atelectasis occurs in the neonate as a result of pulmonary

immaturity, and at any age as a result of inadequate respiratory effort.

Secondary atelectasis occurs when gas in a lung segment is reabsorbed

without subsequent refilling of that segment. Common causes of secondary

atelectasis in children include external compression of lung tissue, obstruction

of the bronchial or bronchiolar lumen, and respiratory compromise secondary

to musculoskeletal or neuromuscular disorders.

Reflection: PT should full understand pathophysiology to help them

understand the patient chart. PT intervention can be deep breathing,

strengthening of the respiratory muscles and change in position to afford better

aeration to the poorly ventilated lung areas.

RESPIRATORY MUSCLE WEAKNESS

Summary: Respiratory muscle weakness in children, as in adults, may result

from any disorder affecting any link in the chain of neuromuscular events that

produce contraction of the respiratory muscles. Weakness or paresis of the

respiratory muscles may be either mild and transient or severe and

irreversible. The underlying pathologic process is the primary determinant of

the duration and severity of the weakness. The physical therapist should

develop a therapeutic regimen to treat the muscle weakness and to prevent or

treat the resultant pulmonary symptoms within the limitations imposed by the

disorder.

Reflection: PT examine by determine the breathing pattern; therapist has also

several methods to evaluate respiratory muscle strength. PT intervention is

exercise to strengthen inspiratory and expiratory muscles, especially the

abdominal muscles that are necessary for effective coughing.

ASTHMA

Summary: Asthma in children is characterized by several factors. Boys seem to

predominate over girls by as much as a 2:1ratio. The physiologic changes

responsible for the signs and symptoms of asthma are thought to be initiated

when IgE in the sensitized child binds with receptor sites on mast cells. A

fascinating aspect of asthma in children is the exercise-induced component.

With strenuous exercise for a period of time, usually 5 to 10 minutes, a child

can develop many manifestations of asthma (e.g., dyspnea, wheezing, and

airway obstruction) that may reverse spontaneously or with treatment. Medical

management of the child with asthma has two major phases—treatment of the

acute attack and control of chronic asthma.

Reflection: I learned that the PT examination of children with asthma is largely

based in clinical situation. It also includes lung auscultation to identify the

location of bronchial secretions and to assess whether areas of the lungs are

poorly ventilated. PT intervention was by relaxation technique for patient to

reduce their anxiety. It also their plan to improve aerobic endurance, work

capacity, and strength are major goals in the long-term management of

asthmatic children.

CYSTIC FIBROSIS

Summary: CF is the most common life-limiting genetic disorder affecting

primarily Caucasians. The disease is inherited in an autosomal recessive

pattern. The clinical presentation of CF varies, but usually includes

combinations of productive cough, abnormally frequent and large stools, failure

to thrive, recurrent pneumonias, rectal prolapse, nasal polyposis, and clubbing

of the digits. Pulmonary involvement in CF begins with the production and

retention of thick, viscous, poorly hydrated secretions within the airways.

These secretions provide a medium in which bacterial pathogens flourish.

Management of CF is directed toward decreasing pulmonary infection and

airway obstruction, replacing pancreatic enzymes to help reverse the

nutritional deficiency, and providing appropriate psychosocial and emotional

support to the child and family. Psychosocial and emotional support for
patients with CF and their families is the responsibility of all professionals who

work with this population.

Reflection: PT assess and give intervention to help patient with cystic fibrosis,

they also examine the child to determine the cause/ symptoms. I learned that

PT management begins invariably with AC techniques taught to the parents of

newly diagnosed children. PT also provides exercise to the patient to help them

strength their muscle.