CPMS COLLEGE OF NURSING

CONTENT FOR

PRACTICE TEACHING
ON
CHALLENGED CHILD

Date of Submission:
Date of Teaching:

Submitted to: Submitted by:

Ms. Smiti Bora Amy Lalringhluani
Lecturer M.sc. Nursing 1 st year
CPMS College of Nursing CPMS College of Nursing
Guwahati
INTRODUCTION

A challenged condition makes the normal functions of the individual very difficult & leads to
dependency. These conditions are increasing day by day due to changing life style &
complicated environment. It is a social problem. Often physically and mentally challenged
children are made subjects of sympathy. We should remember that a physically or mentally
challenged child has rights too and more than sympathy, the child requires our empathy.
More often than not, physical and mental disability is considered a curse in society. The
families of such children treat them as a burden. But we forget that these children have
special needs which we need to fulfill.

TERMINOLOGIES
1. Challenged: Challenged refers to having a physical or mental condition that makes
ordinary activities more difficult than they are for other people.
2. Impairment: Impairment refers to any loss or abnormality of psychological, physiological
or anatomical structure or function like autism, impaired vision or loss of a limb in an
accident.
3. Disability: Disability refers to an inability to carry out certain activities considered normal
for the individual’s age, sex, etc. as a result of impairment.
4. Handicap: Handicap is defined as a disadvantage for a given individual resulting from
impairment or a disability, which limits and prevent the fulfillment of a role, which is
normal for that individual, depending on age, sex, social and cultural functions.
- WHO
5. Handicapped children: Handicapped children refers to those with presence of impairment
or other circumstances, those are likely to interfere with normal growth and development
or with the capacity to learn.
- Wong’s

INCIDENCE
 10% of India’s population is handicapped in one way or the other.
 In India about 45 million handicapped children at present.
 Worldwide, there are about 400 million handicapped children

ETIOLOGY
1. Physical (orthopedic):
- Congenital bony defect
- Sequelae of fractures
- Arthritis
- Residual rickets
- Chondrodystrophies
- Amputation due to accidental injury

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2. Neurologic:
- Mental retardation
- Behavioral or learning disabilities
- Post-polio residual paralysis (PPRP)
- Post meningitis
- Encephalitic sequelae
- Cerebral palsy
- Epilepsy
- Convulsive disorders
- Degenerative disorders of central nervous system may cause neurological
handicap in children
- Birth defects such as hydrocephalus, spina bifida

3. Sensory:
i. Visual: Blindness (partial or complete), refractory errors
ii. Auditory: deaf, dumb, mutism, partial hearing loss
iii. Speech: dysarthria, stuttering, dysphonia, stammering

4. Chronic systemic diseases:

- Heart disease (both congenital and acquired)
- Bronchial asthma
- Diabetes mellitus
- Malabsorption syndrome
- Muscular dystrophy

5. Social:
- Child abuse and neglect
- Drug addiction
- Orphan

RISK FACTORS
A baby may be either born with a challenge or may acquire it later in life

Preconceptual factors

RISK
Antenatal and Intranatal
FACTORS factors

Postnatal factors

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A. Preconceptual factors
a) Genetic and chromosomal factors:
- Diseases that are transmitted genetically may be autosomal dominant,
autosomal recessive or sex-linked.
- An alteration in genes and chromosomes due to any defect or mutation, can
initiate the process of malformation that may lead to physical or mental
disability.

B. Antenatal and Intranatal factors

a) Asphyxia:
- Lack of oxygen supply to the fetal brain during gestation, due to placental
factors may lead to serious mental defects in fetus.
- Prolonged and difficult labor may worsen the condition of neonate.
b) Birth trauma:
- Prolonged labor and difficult instrumental delivery may cause cerebral
damage.
- In case of breach delivery, hyperextension of head or stretching of vertebral
column may give rise to spinal cord injury that may cause physical
impairments in the baby.

C. Postnatal factors
a) Biochemical disorders:
- In the neonatal period, baby is at high-risk of hypoglycemia, hypocalcemia
or kernicterus which can cause cerebral damage.
b) Infections:
- Infections like meningitis, encephalitis, poliomyelitis, etc. may result in
neurological and physical defects and disability.
c) Trauma:
- Cerebral contusion, cerebral hemorrhage and head injuries after road
traffic accidents can lead to neurological deficits in the person.
- Road traffic accidents may also lead to crush injuries of limbs, leaving the
person crippled and handicapped.
d) Nutritional deficiencies:
- Nutritional deficiencies like Vitamin A deficiency and Vitamin D
deficiency can lead to night blindness, skeletal deformities, etc.
e) Maternal factors:
- Maternal factors leading to handicaps in babies are Rh incompatibility,
medications given to the mother during first trimester of pregnancy.
- Some other conditions such as multiple pregnancies, forceps delivery,
premature rupture of membrane, Cord prolapse, maternal Hypertension or
diabetes etc.

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TYPES OF CHALLENGES

TYPES

PHYSICAL MENTAL SOCIAL

A. PHYSICALLY CHALLENGED

1. Blindness:
 According to WHO the inability to count fingers in day light from a distance of 3
meters is defined as blindness
- Visual impairment, also known as vision impairment or vision loss, is a
decreased ability to see to a degree that causes problems not fixable by usual
means, such as glasses.
- Some also include those who have a decreased ability to see because they do
not have access to glasses or contact lenses.
- Visual impairment is often defined as a best corrected visual acuity of worse
than either 20/40 or 20/60.
- Visual impairment may cause people difficulties with normal daily activities
such as driving, reading, socializing, and walking.
 Problem faced by blind child
- Problem of attachment
- Unable to use hand as organ of perception
- Problem on locomotion
- Dependence on parents and caregiver
- Behavioral problems
- Less social interaction
- Less playing activity
 Prevention Of Blindness
- Provide good antenatal care
- Immunization – measles, rubella
- Genetic counseling and screening
- Prevent infection
- Prevent pre term birth and
- provide excellent neonatal care
- vitamin A supplement
- health education about eye safety, personal hygiene and nutrition for health
promotion

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 -Treatment of causes of childhood blindness
 Retinopathy of prematurity (ROP)
 Cataract
 Glaucoma
 Management
- Physiotherapy
- Orientation and mobility instructors
- Mobility aid and guides
- BRAIL technology

2. Deafness:
 A person who is not able to hear as well as someone with normal hearing . It can
affect one ear or both ears, and leads to difficulty in hearing conversational speech or
loud sounds
- Hearing loss, also known as hearing impairment, is a partial or total inability
to hear.
- A deaf person has little to no hearing.
- Hearing loss may occur in one or both ears.
- In children, hearing problems can affect the ability to learn spoken language
and in adults it can create difficulties with social interaction and at work. In
some people, particularly older people, hearing loss can result in loneliness.
- Hearing loss can be temporary or permanent.
- Hearing loss may be caused by a number of factors, including: genetics,
ageing, exposure to noise, some infections, birth complications, trauma to the
ear, and certain medications or toxins.
 Levels of hearing impairment:

Mild deafness 25 to 39db

Moderate deafness 40 to 69db
Severe deafness 70 to 89db
Profound deafness 90db <

 Impact of hearing loss

- Functional impact
- Poor Academic Performance
- Social and emotional impact
- Economic impact
 Management
- Sign language
- Hearing devices - hearing aids, assistive listening devices and cochlear
implants.
- Lip-reading skills
- Speech therapy
- Use of written or printed text

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3. Dumbness:

 Dumbness is an impairment of speech or sound production, fluency, voice or

language which significantly affects a child’s educational performance or their social,
emotional or vocational development.
- It may be a result of trauma or injury to Broca's area, located in the left inferior
frontal cortex of the brain.

 Types of speech disorders:

i. Dysfluent - word repetitions, part word repetitions, prolongations, broken
words, incomplete phrases

ii. Articulation Disorders - Occur because of a physical abnormality that prevents

clear speech ( eg: Cleft palate)

iii. Fluency disorders - Stuttering, Partial-word Repetitions ("b-bboy"), or

prolonging sounds and syllables (sssssnake).

iv. Resonance or Voice Disorders - problems with the Pitch, Volume, quality of
the voice that distract listeners from what's being said.

v. Apraxia – difficult production of words ( eg: "potato" may become "topato"

and next "totapo")

vi. Muteness - complete inability to speak

 Management
- Early identification of speech impairment
- Elimination of hearing impairment
- Medical and surgical intervention for underlying causes
- Psychological counseling
- Avoid making fun of their voice or speech
- Voice or Speech therapy
- Physical therapy
- Cognitive rehabilitation

4. Crippled/ Orthopedic disability:

 A cripple is a person with a physical disability, particularly one who is unable to walk
because of an injury or illness.
 Orthopedic disability occur when movements in over body are affected due to disease,
injury, any absence or deformities in the joints, bones, muscles or an injury in nervous
system
 Loco motor disability means disability of the bones, joints or muscles leading to
substantial restriction of the movement of the limbs

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  Management
- Correction of Deformities
- Physical Therapy
- Occupational Therapy
- Massage Therapy
- Prosthetics
- Devices for positioning and mobility (Canes, Walkers, Crutches, Wheelchairs,
Specialized exercise equipment, specialized chairs, desks, and tables for
proper posture development).

B. MENTALLY CHALLENGED

1. Mental retardation:
 Mental retardation is defined as significantly sub average general intellectual
functioning, resulting in associated with concurrent impairment in adaptive behavior,
which manifests during the developmental period.
(American Association on Mental Deficiency)
 Intellectual disability (ID), also known as general learning disability and mental
retardation (MR), is a generalized neurodevelopmental disorder characterized by
significantly impaired intellectual and adaptive functioning.
- Once focused almost entirely on cognition, the definition now includes both a
component relating to mental functioning and one relating to an individual's
functional skills in their daily environment.
- As a result of this focus on the person's abilities in practice, a person with an
unusually low IQ may still not be considered to have intellectual disability.
 Mental retardation classification:

Classification I.Q level

Mild 50- 70
Moderate 35-50
Severe 20-35
Profound <20

 Effect on children
- Failure to achieve developmental milestones.
- Deficiencies in cognitive functioning such as inability to learn or to meet
academic demands.
- Expressive or receptive language problems.
- Psychomotor skill deficits.
- Difficulty performing self-care activities.
- Neurologic impairments.
- Medical problems, such as seizures.
- Low self-esteem depression and labile moods.
- Irritability when frustrated or upset.
- Lack of curiosity
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  Treatment modalities
- Behavior management.
- Environment supervision
- Monitoring the child’s developmental needs and problems.
- Programs that maximize speech, language, cognitive, psychomotor, social,
self-care, and occupational skills.
- Family therapy
- Early intervention or children younger than age 3 with mental retardation.
- Provide day schools to train the child in basic skills, such as bathing and
feeding

2. Cerebral Palsy:
 Cerebral palsy (CP) is a disability that affects ability to control muscles caused by
damage to the brain while the brain is developing.
- It is a form of chronic motor disability which is non-progressive, non-fatal
and yet incurable and results from damage to the growing brain before or
during birth or in postnatal period.
- It is the most common cause crippling in children.
- Though mental retardation is associated in about 25 to 50% cases of CP, it is,
by no means, an essential feature of the clinical picture.

 Effects of cerebral palsy

 Abnormal Muscle Tone
 Abnormal movements
 Skeletal deformities
 Seizures
 Speech problems
 Swallowing problems
 Hearing loss
 Vision problems
 Dental problems
 Bowel and/or bladder control problems

 Management
 Physical therapy
 Orthotics
- Immobilization
- Night splints
 Control of spasticity
- Baclofen GABA agonist which inhibits release of excitatory
neurotransmitter at level of spinal cord
- Botulinum-A toxin which inhibits exocytosis of Acetylcholine
 Orthopedic surgery

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C. SOCIALLY CHALLENGED

A Socially challenged child may be defined as a child whose opportunity for a healthy
personality development and full unfolding of potentialities are hampered certain
elements in his social environment such as parental inadequacy, environmental
deprivation, (lack of learning opportunity) and emotional disturbance

Category of socially Challenged Children:

1. Orphans:
 An orphan is someone whose parents have died, are unknown, or have permanently
abandoned them.
- In common usage, only a child who has lost both parents due to death is
called an orphan.
- Death or disappearance of, abandonment or desertion by, or separation or loss
from, both parents can also an orphan.
- An orphan does not have any surviving parent to care for them.

 Problem associated with orphans

- Developmental retardation
- Conduct and sleep problem
- Personality problem
- Bed wetting
- Disturbance in eating
- Depression During adulthood
- Antisocial problem
- Drug addiction
- Alcoholism
- Marital problem

2. Neglected or abused children:

 Child abuse may include any act or failure to act by a parent or a caregiver that
results in actual or potential harm to a child, and can occur in a child's home, or in the
organizations, schools or communities the child interacts with.
 Neglect is a form of abuse where the perpetrator, who is responsible for caring for the
child, fails to provide the right care and attention to a child's needs, including food
and a safe environment, or to a child's emotional needs including warmth, security
and love. A lack of these things are likely to result in serious damage to the child's
health or development
 Consequences of neglect or abuse
 Developmental delays- Poor social skills
 Delayed physical and mental growth
 Neurological impairments
 Experience extended poverty or unemployment
 Face chronic illnesses or early death
 Cognitive deficits
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  Emotional development problems
- Unusual fussiness
- Fear
- Lack of interest in activities
- Being anxious or avoiding people
- Difficulty in making friends
- Being withdrawn.
 The effects on behavioral development
- Anti-social behavior
- Early sexual activity
 Poor mental health, such as exhibiting low self-esteem, anxiety, depression,
or suicidal tendencies
 Insecure-anxious attachment.
- Attachment difficulties and difficulty in formation of relationships in
the future
 Affects intellectual ability and cognitive ability
- Sudden decline in academic performance
- Anxiety or impulse-control
 Failure to thrive

 Management
 For Parents
 Treatment for
- Substance abuse
- Depression or other mental health problems
- Low self-esteem
- Violent behavior
 To realize responsibility regarding child
 Educating and helping parents to correct their erroneous thinking and
behavior
 For Child
 Child-centered interventions include
- pediatric care
- mentoring
- Behavioral and mental health treatment
 Provide stimulation programme to emotionally neglected child
 Develop timely and comprehensive assessments or placed in foster
home

3. Children of divorced or step parents:

 A separation or divorce is a highly stressful and emotional experience for everyone
involved, but children often feel that insecurity in their life. At any age, it can be
traumatic to witness the dissolution of marriage and the breakup of the family.
Inevitably, such a transitional time doesn’t happen without some measure of grief and
hardship.
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 Effects of divorce or separation on children
a) Infants
- Loss of appetite
- Upset stomach – may spit up more
- More fretful or anxious.
b) Toddlers
- More crying
- Sleeping Problem
- May feel anger
- May worry when parent is out of sight
- May withdraw, bite or be irritable
- Temper tantrums
c) Preschoolers
- Feels uncertain about the future
- May feel responsible
- May hold anger inside
- May become aggressive and angry toward parent he/she lives with
- May have more nightmares
- Experiences feelings of grief because of sudden absence of parent.
d) School age
- Feels unfaithful and feels a sense of loss.
- Feels rejected by the parent who left
- Ignores school and friendships
- Worries about the future
- Complains of headaches or stomachaches
- Experiences loss of appetite, sleep problems, diarrhea, urinary frequency.
- Learning problem in school
e) Preteens and adolescents
- Feels angry and disillusioned
- Feels abandoned, that parent is leaving him/her not the other spouse
- Shows extreme behavior (good and bad)
- Involved in high-risk behaviors (drugs, shoplifting, skipping school)
- Anti-social behavior
- Drug or alcohol abuse
- Problem in maintaining relationship
- Worries about financial matters.
 Management
 Not expose child to conflict between parents
 Listen to child and provide emotional support
 Child should be reared to respect to both parents
 Child should taught that both parents are nice people but are separating
because of they have different views about life

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4. Delinquents:
 Juvenile delinquency, also known "juvenile offending", is the act of participating in
unlawful behavior as minors (juveniles, i.e. individuals younger than the statutory age
of majority).
 Most legal systems prescribe specific procedures for dealing with juveniles, such as
juvenile detention centers and courts, with it being common that juvenile systems are
treated as civil cases instead of criminal, or a hybrid thereof to avoid certain
requirements required for criminal cases.
 Depending on the type and severity of the offense committed, it is possible for people
under 18 to be charged and treated as adults.

DIAGNOSIS/ ASSESSMENT OF THE CHALLENGED CHILD

Common features which may be helpful in identifying disabilities are:

 Deviation from normal behavior is the first indicator of physical, mental or

neurological impairment
 Absence of normal reflexes
 Feeding problems
 Lack of movements or uncoordinated movements
 Abnormal posture of newborn.

MANAGEMENT OF CHALLENGED CHILD

I. Disability intervention/limitation
The aim is to safeguard against or, at least, halt the progression of the disease process
from impairment to disability and handicap.
This can be achieved by two major strategies
a) Medical intervention during impairment, the earliest stage
b) Social and environmental intervention in terms of dependence and social cost
for the disability and handicap, the later stages.
II. Disability Prevention

1. Primary Prevention
 Genetic counseling
 Genetic screening
 Reduction of consanguineous marriage
 Pregnancy planning
 Rh incompatibility treatment
 Immunization of mother and baby
 Vitamin A prophylaxis
 Improve nutritional status of mother and child
 Prevention of iodine and folic acid deficiency
 Provide essential care in prenatal, Intranatal, postnatal period
 Prevent maternal and neonatal infection
 Prevent birth injury, asphyxia, hyperbilirubinemia
 Special care to high risk mother –abortion, premature birth
 Encourage to kick bad habits such as smoking or alcohol abuse.

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 2. Secondary Prevention
 Careful history
 Regular medical supervision and developmental assessment
 Treatment of particular handicap condition
 Correction of deformity
 Physiotherapy and exercise to improve physical condition
 Occupational therapy
 Speech therapy to improve communication ability
 Prosthetics
 Special care for mentally handicapped children with warmth , love ,
tolerance, discipline, avoid criticism
 Counseling and guidance
 Referral for welfare services

REHABILITATION OF THE HANDICAPPED CHILDREN

 Rehabilitation of handicapped children should be approached by combined and co-
ordinated use of medical, social, educational, psychological and vocational measures
for training and retraining the children to the highest possible level of functional
ability.
 It includes all measures to reduce the impact of disabled and handicapped conditions
to achieve social integration by active participation of the individual in the
community.
 Process of rehabilitation should involve the following aspects:

1. Medical rehabilitation
- Includes restoration of functions by prosthesis, artificial limbs, etc.

2. Social rehabilitation
- Includes restoration of family and social relationship by replacement in the
family

3. Educational rehabilitation
- Includes specialized training and educational facilities, e.g. Braille for
blind, sign language for deaf and dumb

4. Psychological rehabilitation
- Includes restoration of personal dignity and confidence during the period
of growth and development and in adult life

5. Vocational rehabilitation
- Includes restoration of the capacity to earn a livelihood. This can be
achieved by community participation and social legislation for the
handicapped individual. The community needs to offer employment
opportunities in shops, factories and other business establishment to the
handicaps

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NATIONAL WELFARE SERVICES FOR HANDICAPS
The following institutes are set up by the Government of India as premier institutes in their
respective fields to cater to the needs of the handicapped in the area of education,
development of manpower, training, vocational guidance, counseling, research,
development of suitable service models and low-cost aids and appliances:
a. National institute for Orthopedically Handicapped, Kolkata.
b. National institute for Mentally Handicapped, Hyderabad.
c. Ali Yavar Jung National lnstitute for the Hearing Handicapped, Mumbai.
d. National Institute for the Visually Handicapped, New Delhi.
e. Institute for the Physically Handicapped, New Delhi.
f. National Institute for Rehabilitation Training and Research, Cuttack.

The approaches of management should include the following aspects:

» Careful history, thorough physical examination and necessary investigations for early
detection of handicapped conditions are important
» Regular medical supervision and developmental assessment help to identify the
abnormal condition early in initial stage by maternal and child health (MCH) or school
health services
» Treatment of particular handicapped condition by medical or surgical management eg.
Cataract, otitis media, leprosy, accidental injury, rickets, congenital anomalies, etc.
» Correction of deformity, e.g. visual or hearing problems by spectacles or hearing aids
» Physiotherapy and exercise to improve physical conditions
» Occupational therapy according to the child’s ability and that should be provided with
music, painting, weaving, woodwork, pottery, etc.
» Speech therapy to improve communication ability
» Prosthetics, e.g. provision of artificial limb in a child with amputated leg
» Special care for mentally handicapped children with love, warmth, patience, tolerance,
discipline and avoidance of criticism
» Counseling and guidance to the parents and family members for continuation of care
of the children with emotional, educational and social support
» Referral for welfare services (Government NGOs) for assistance of aids and
appliances, for special training and education, rehabilitation and support services like
pension, scholarship, special allowances, etc.

NURSING MANAGEMENT OF CHALLENGED CHILD

 Nursing personnel play a vital role to assist the family members to cope with the crisis
situation for the handicapped condition. Planning and providing care to the
handicapped children (especially physically and mentally handicapped) in health care
institutions and community are important nursing responsibilities, including parental
involvement and community participation.

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  Assisting the family to strengthen effective relationship and bondage to prevent
children from becoming socially handicapped. Nurses are responsible for creation of
awareness in the society about the prevention of handicaps, the abilities of child with
a handicap condition and the potentialities present in him/her.
 Nursing care for the physically and mentally handicapped children in hospital and
home should emphasize on the following aspects.
 Adolescent Health Transition Project recommends
- By age 14, ensure that a transition plan is initiated and that the
individualized education plan (IEP) reflects post high school plans
- By age 17, explore health care financing for young if needed and notify the
local division of vocational rehabilitation by the autumn before the teen is
to graduate from high school of the impending transition. Initiate
guardianship procedures, if appropriate
- Notify the teen that all rights transfer to him or her at the age of majority.
Check the teens eligibility for Supplemental Security Income (SSI) the
month, the child turns 18. Determine if the child is eligible for SSI work
incentives
- The youth is attending college, contact the college campus student
disability service program
- By age 21, ensure that the young adult has registered with the Division of
Developmental Disabilities for adult services, if applicable.

Nursing Diagnosis:

 Ineffective family coping and altered parenting related to handicapped condition

 Anxiety of parents and family members
 Altered nutrition less than body requirement
 Potential for infection
 Self-care deficient
 Ineffective communication
 Impaired physical mobility
 Altered elimination pattern
 Activity intolerance
 Sleep pattern disturbance
 Altered sensory perception (visual/ auditory)
 Altered growth and development
 Diversional activity deficit
 Knowledge deficit regarding continued care of handicapped children

CONCLUSION
Challenges develop as the consequence of the disability. It is defined as a disadvantage for a
given individual resulting from impairment or a disability that limits and prevents the
fulfillment of a role which is normal for that individual, depending on age, sex, social and
cultural factors.

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REFERENCE
1. A Sudhakar, “Essentials of Pediatric Nursing”, 1st edition, 2017, Jaypee publications
2. A Padmaja, “Textbook of Child Health Nursing”, 1st edition, 2016, Jaypee Publications
3. Hockenberry, “Wong’s nursing care of infants and children”, 2003, 7th edition, Elsevier
4. Marlow R Dorothy, “Textbook Of Pediatric Nursing”, 6th edition, 2010, Elsevier
5. Sharma Rimple, “Essentials of paediatric Nursing”, 2021, 3rd edition, Jaypee, New Delhi
6. https://www.slideshare.net/mahaveerswarnkar/physically-mentally-socially-challanged-
children

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