OBJECTIVES

At the end of seminar the student will be able to understands:-

 Explain introduction of challenged child.

 Identify the causes of challenged child.

 Explain the features of challenged child.

 Explain the management of challenged child.

 Define the cerebral palsy.

 Identify the type cerebral palsy.

 Find out the causes of cerebral palsy.

 Explain the features of cerebral palsy.

 Explain the management of cerrbral palsy.

 Define the mental retardation.

 Identify score of mental redardation.

 Explain the causes of mental retardation.

 Identify the features of mental retardation.

 Explain the mgt of mental retardation.

1
INTRODUCTION

A resource for parents who want to learn skills for strengthening relationships
with children and to develop resources for coping with the stress that
accompanies this task

Parenting is the most difficult and challenging job on the planet. The demands
are many but so too are the rewards
The challenged children are major problem in pediatric health today.

Challenged child is one who deviates from normal health status either
physically, mentally, socially & requires special care, treatment & education.

The child care different from adult care in many ways. Every nurse involved
with child care must practice preventive health care.

Before starting with child care she should be clear with the difference
between adult care and child care.

INCIDENCE

According to statistics 10% of India’s population is handicapped.

According to health statistics there are about 43-47 million handicapped

children in our country at presents.

According to WHO there are about 395milion handicapped children in world.

2
TERMINOLOGY

Handicap:-

The child who is unable to achieve the full potential or fulfil a role and occur
as a result of disease, impairment or disability. Due to this handicapped child
is not able to participate in competitive sport. ex hocky, cricket, tenis etc

Disability:-

It is defined as an inability to complete certain activites e.g. loss of limbs

results in inability to walk.

Impairment:-

The Impairment related to any loss or abnormality of psychological,

anatomical structure & physiological, deviated functions like impaired vision
or loss of limb in accidents.

TYPES OF HANDICAPPED

1. Socially handicapped.
2. Physically handicapped.
3. Mentally handicapped.

3
SOCIALLY HANDICAPPED CHILD

Children are having disturbed opportunities for healthy personality

development due to social factors. Such as broken family, loss of parents,
poverty, lack of educational opportunities, mental deprivation, emotional
deprivation & neglected child.

Children who are described as "socially handicapped" feel uncomfortable in

social situations and often find it challenging to interact with other people in
appropriate ways. Because of the limitations such children with disabilities
live with, engaging with other children can cause them distress.

They can be limited in extracurricular activities depending on their specific

issues. This, in turn, makes other children look upon the child with a disability
differently. Due to these differences, barriers are formed between children.
Socially handicapped children often feel isolated because of these boundaries.
It is only one of the problems they face because of their condition.

Autism is regarded as a severe developmental disability that generally begins

within the first three years of life. Some experts believe it is the result of a
neurological disorder that changes the way the brain functions, causing delays
or problems in many different skills from infancy to adulthood. For example,
both children and adults with autism sometimes face difficulties in social
interaction. Traits of autism include being interested in repetitive activities and
failing to make eye contact with others. Children with autism tend to differ
from other children by displaying behavior which others might find difficult to
understand or may interpret as a child being "naughty," which is not the case.

4
According to Audrey Curtis, author of A Curriculum of the Pre-School Child:
Learning to Learn (2002), and Meeting the Needs of Socially Handicapped
Children: Background to My World (1981), Italian educator Maria Montessori
(1870-1952) was a key figure in meeting the needs of socially handicapped
children in Italy in the early years of the 20th century. Her methods have since
been widely adopted in the United States and in the United Kingdom.
Montessori believed that "every child is unique and is profoundly affected by
society and the environment." She argued that when the physical and
emotional needs of children, whether they have special needs or not, are met
they are more likely to take advantage of the learning opportunities on offer to
them.

PHYSICALLY HANDICAPPED CHILD

IN RECENT years, the definition of a physically handicapped child has

broadened considerably. A child is now considered physically handicapped if
he cannot, for physical reasons, participate in social, recreational, educational,
or vocational activities on fairly equal terms with other children of his age.
More effort must be put into research regarding the underlying causes of
various handicapping conditions so that prevention may eventually replace
programs of care. Meanwhile, it is realistic to plan for the early discovery and
care of physical handicaps.

Any impairment which limits the physical function of limbs, fine bones, or
gross motor ability is a physical impairment, not yet a physical disability. The
Social Model of Disability defines physical disability as manifest when an
impairment meets a non-universal design or program, e.g. a person who

5
cannot climb stairs may have a physical impairment of the knees when putting
stress on them from an elevated position such as with climbing or descending
stairs. If an elevator was provided, or a building had services on the first floor,
this impairment would not become a disability. Other physical disabilities
include impairments which limit other facets of daily living, such as severe
sleep apnea.

Areas of Need

 Early Case Findings

The first effective step in efforts to keep permanent handicap to a minimum is

to find cases as early as possible. If care is inadequate or delayed, a greater
degree of handicap may be carried into adult life. This may lessen the
individual's ability to take care of himself and make him a greater burden to
the community.

Correct medical diagnosis is usually made with reasonable promptness in the

more dramatic types of orthopedic handicaps seen in cases of poliomyelitis
and osteomyelitis, for example. Delay in correct diagnosis is more general in
other less obvious types of handicaps. For example, many registers of
handicapped children kept by state agencies list very few children under
school age with cerebral palsy, in relation to the number which might be
expected from incidence figures.

6
These group include the children with blindness, deaf & dumb, congenital
malformation-cleft lip, cleft palate, club foot.

Congenital heart disease, paralysis, leprosy, accidents, burn injury

The most important cause of physical handicaps are birth defect, malnutrition,
infection & accidents.

The physically handicapped includes

I) Orthopedically handicapped-congenital bony defect club

(foot),amputation due to accidental injury, bony defect, fracture,
arthritis.
II) Sensory handicapped-visual problems-partial or complete blindness,
auditory problems-partial hearing loss, speech problems-
stammering, dysphonia.
III) Neurologically handicapped- child include cerebral palsy, mental
retardation, convulsive disorder, hydrocephalus, spina bifida,
meningitis, paralysis.
IV) Chronic systemic disease-heart disease, bronchial asthma & diabetes
mellitus.
V) Multiple physically handicapped children-The children having
combination of orthopedically, sensory & neurological handicapped.

7
MENTALLY HANDICAPPED CHILD

Mentally handicap is now used mental retardation.

Intellectual disability (ID) or general learning disability is a generalized

disorder appearing before adulthood, characterized by significantly impaired
cognitive functioning and deficits in two or more adaptive behaviors.
Intellectual disability is also known as mental retardation (MR), although
this older term is being used less frequently. It was historically defined as an
intelligence quotient score under 70. Once focused almost entirely on
cognition, the definition now includes both a component relating to mental
functioning and one relating to individuals' functional skills in their
environments. As a result, a person with an unusually low IQ may not be
considered intellectually disabled. Intellectual disability is subdivided into
syndromic intellectual disability, in which intellectual deficits associated
with other medical and behavioral signs and symptoms are present, and non-
syndromic intellectual disability, in which intellectual deficits appear
without other abnormalities.

The terms used for this condition are subject to a process called the
euphemism treadmill. This means that whatever term is chosen for this
condition, it eventually becomes perceived as an insult. The terms mental
retardation and mentally retarded were invented in the middle of the 20th
century to replace the previous set of terms, which were deemed to have
become offensive. By the end of the 20th century, these terms themselves
have come to be widely seen as disparaging, politically incorrect, and in need
of replacement. The term intellectual disability is now preferred by most

8
advocates and researchers in most English-speaking countries. As of 2013, the
term "mental retardation" is still used by the World Health Organization in the
ICD-10 codes, which have a section titled "Mental Retardation" (codes F70–
F79). In the next revision, the ICD-11 is expected to replace the term "mental
retardation" with "intellectual disability," and the DSM-5 has replaced it with
"intellectual disability (intellectual developmental disorder)." Because of its
specificity and lack of confusion with other conditions, the term "mental
retardation" is still sometimes used in professional medical settings around the
world, such as formal scientific research and health insurance paperwork

It includes low learning abilities, poor maturation & social maladjustment in

combination.

The malfunctioning of the brain is poorly understood in most case, but the
physiological alteration may be identified in some children.

The cognitive & functional ability are affected with limitation in adaptive
ability & communication.

Self -care, home-living, social interaction skill, community relationship, self

-direction, health behavior, sefty measure, academic achievement, leisure time
utilization & working capacity are altered in mentally handicapped children.

9
CAUSES OF HANDICAPPED CHILD

There can be many reasons for the handicaps amongst the children. There are
many factors or situations before or after birth which can lead to the
abnormalities and disabilities in the children.

(i) Before birth

During prenatal period an impact on mother's womb can harm the child. If the
mother gets infection or disease, the baby is also badly affected. During
pregnancy if the mother suffers from any kind of nutritional deficiency, it can
also lead to deficiency in the baby. As a result, the baby can be physically or
mentally deficient.

(ii) At the time of birth

During the process of delivery sometimes many factors can lead to bad effect
on the child. Difficulty in delivery can cause temporary stoppage of oxygen
supply to the brain of the baby. It damages nervous tissues of the brain or
spinal cord and this effect is permanent. This can cause mental deficiency in
the baby. Sometimes the baby becomes physically handicapped.

When the doctors take help of various equipments during the delivery, for
example, in forceps delivery, the 'brain' or 'nerve' is pressed by the forceps. If
the doctor or nurse is not very well trained, they can cause damage to the
baby.

As a result, the part of body with which the pressed or damaged 'nerve' can be
related to is permanently damages. It is always advisable that delivery should

10
be done at a nursing home or hospital under the guidance of the doctor or
trained nurses. So any emergency during delivery can be tackled properly.

(iii) After birth

If proper care of the child is not done after birth then the baby may also
develop disability, e.g., if the eyes of the baby are not washed with 1% nitrate
solution there are chances of his getting blind.

(iv) Malnutrition

If the child doesn't get proper nutrition, he gets physically weak. Deficiency of
calcium leads to malformation of bones; deficiency of iodine leads to
deficiency of thyroxine hormone which upsets the process of growth of the
body.

Deficiency of vitamin 'A' can cause blindness in the children. Protein and
energy malnutrition causes 'Sukha Rog' which causes physical and mental
deficiency.

(v) Accident

Due to any accident the child can become disabled, e.g., road accident can
cripple a child and he can get blind, deaf and dumb. Sometimes wrong
medication can also cause such effects that may make the child permanently
disabled.

11
(vi) Hereditary factors

Sometimes children receive genes of disabilities or deficiencies from their

parents. The child can be blind or deaf or dumb or mentally retarded by birth.

(vii) Infectious diseases

If the child gets infectious diseases the immunity power of the child gets
diminished. He becomes susceptible to various diseases. If the child is not
properly immunised he becomes susceptible to infectious diseases like
'mumps' which can cause hearing impaired or 'polio' which can cripple the
child.

(viii) Effect of endocrine glands

Due to the disturbance in endocrine glands a child may suffer from various
physical and mental deficiency. If thyroid gland is not working properly, then
it can create many problems.

CHARACTERISTICS OF CHALLENGED CHILD

Physical characteristics

 An underdevelopment in physical growth

 Average weight and height usually less than normal peers of the same
chronological age
 Physical deformation
 Retarded movement and balance

12
Mental characteristics

 Less-than-average I.Q.
 Underdeveloped speech and language skills
 Poor: memory, attention, perception, imagination, thinking, computing
and concentration

Social characteristics

 Underdeveloped ability of social adjustment

 Lack of interests and orientations
 Irresponsibility
 Aloofness
 Aggression
 Low self-esteem

Emotional characteristics

 Emotional imbalance
 Excessive movement
 Evidence of premature or late reactions
 Primitive reactions.

Psychological and behavioral characteristics

It's important to know that statements about psychological and behavioral

characteristics of the intellectually disabled are based on the research studies,

13
comparing group of persons with and without intellectual disability.
Each individual must be considered as a unique and separate person.

Learning and memory

The most obvious characteristic of the disabled is their reduced ability to

learn, compared to their normal peers of the same chronological age. The ID
individuals have difficulty in a tending to a variety of stimuli, they are
characterized as being easily distracted and possessing very short attention
spans. The important of attention for learning in general is obvious. A child
must be able to attend to the task at hand before can be expected to learn.
Disabled children usually take longer to learn the task. The ID individual is
considered to have defects in short-term memory but not in long-term
memory.

INVESTIGATIONS

Routine blood examination-Hb%,blood group, sgot, sgpt, Esr, blood urea,

blood sugar, VDRL etc.

Physical examination.

History collection

Urine examination for microscopic.

Chest x-ray,usg if necessory.

CSF –Examination For protine & microscopic.

14
MRI,CT Scan.

Surface electromyography.

EEG

Testing intelligence.

Testing speech.

Chromosomal analysis.

Auditory testing.

Geneting screening.

Thyroid studies for metabolic screening.

MANAGEMENT OF CHALLENGED CHILD

 Management of challenged children requires multidisciplinary

approach.

 Early diagnosis & treatment must be done.

 Careful history,physical examination & necessary investigation for

early detection of handicapped conditions are important.

 Regular medical supervision & developmental assessment help to

identify the abnormal condition early in school health services.

 Treatment of particular handicapped condition by medical or surgical

mgt e.g.cataract,otitis media, leprosy, accidental injury,congenital
anamolies.

15
 Correction of deformity-visual or hearing problems by spectacles or
hearing aids.

 Physiotherapy & exercise to improve physical conditions.

 Occupational therapy according to the child’s ability & that should be

provided with music, painting, weaving, wood-work, etc.

 Speech therapy to improve communication ability.

 To provides prosthetics-provision of artificial limb in a child with

amputed leg.

 Special care for mentally handicapped children with love, warmth,

patience, tolerance, discipline & avoidance of criticism.

 Counseling & guidance to the parents & family members for

continuation of care of the children with emotional, educational &
social support.

 Referal for welfare service for assistance of aids & appliances, for
special training and education, rehabilitation & support services like
pension, scholarship, special allowances etc.

16
PREVENTION OF HANDICAPPED CONDITIONS IN CHILDREN

 Handicapping conditions of children can be prevented by improvement

of mental health & adequate care during priconceptional, prenatal &
intranatal period along with preventive measures during infancy,
childhood & adolescents.

 Genetic counseling-optimum maternal age for producing normal babies

is between 20-30 years, this information should be explained to the
couples along with prevention & different aspects of genetic &
chromosomal problems.

 Genetic screening-At risk people to prevent inherited diseases like

chromosomal or sex linked congenital anomalies-Down’s syndrome

 Reduction of blood relation marriages by creating health awareness.

 Universal immunization coverage especially for polio & MMR.

 Improvements of nuritional status of mother & children especially for

girl child, the future mother.

 Prevention of iodine deficiency & folic acid deficiency condition in

periconceptional period.

 Essential care in antenatal, intranatal & neonatal periods.

17
  Prevention of maternal & neonatal infections,birth injuries
asphyxia,hyperbilirubinemia etc.

 Avoidance of tetratogenic agents in antenatal periods & special care of

high-risk mothers & children.

 Medical termination of pregnancy of malformed fetus.

 Improvement of health awarness about the preventive measures of

handicapped condition in children by elimination of causes like
malnutrition,accidendal injuries.

REHABILITATION OF CHALLENGED CHILD

THE MEANING OF REHABILITATION

Rehabilitation is not only concerned with physical or functional
restoration/compensation of individuals disabled by injury or disease.
Attention is also given to the total quality of life in terms of wellness,
happiness and satisfaction in fulfilling the demands needs capacities of human
existence in orientation, freedom of movement, independence, expression of
self (with respect to age, sex and culture), relationship and ability to ensure
independent economic existence.
After a serious injury, illness or surgery, one needs to recover slowly. There is
the need to regain strength, to relearn skills or find new ways of doing things
one did before. This is the process of rehabilitation.
Children who are born with disabilities need stimulation for development and
adaptation – habilitation, and those who acquire disabilities also need
rehabilitation. Technically, therefore, rehabilitation is a creative procedure that
includes the cooperative efforts of various medical specialists, and associates

18
in other health, technical and environmental fields, to improve the physical,
mental, social and vocational aptitudes of the disabled, with the objectives of
preserving and improving their ability to live happily and productively on the
same level, and with the same opportunities as their neighbours.
In other words, it is a process of decreasing the dependence of the disabled
person, by developing to the greatest extent possible, the abilities needed for
adequate functioning in his individual situation in the community.

ASPECTS OF REHABILITATION
 Medical rehabilitation includes restoration of functions by prosthesis,
artificial limbs, etc
 Social rehabilitation includes restorations of family and social
relationship by replacement in the family
 Educational rehabilitation include specialized training and educational
facilities eg Braille for blind, Sign language for dumb and deaf
 Psychological rehabilitation includes restoration of personal dignity and
confidence during the period of growth and development and in adult
life
 Vocational rehabilitation includes restoration of the capacity to earn a
livelihood. This can achieved by community participation and social
legislation for handicapped individual. The community needs to offer
employment opportunity in shops, factories and other business
establishment

19
 Rehabilitation of handicapped children should be approached by
combined & co-ordinated use of medical,social,educational
psychological & vocational measures for training & retraining the
children to the highest possible level of functional ability.

 It includes all measures to reduce the impact of disabled & handicapped

conditions.

 To achieve social integration by active participation of individual in the

community.

 Medical rehabilitation includes restoration of functions by prosthesis,

artificial limbs etc.

 Social rehabilitation includes restoration of family & social relationship

by replacement in the family.

 Educational rehabilitation includes specialized training & education

facilities-braille for blind,sign language for deaf & dumb.

 Psycological rehabilitation includes restoration of personal dignity &

confidence during the period of growth & development & in adult life.

 Vocational rehabilitation includes restoration of the capacity .

 This can be achieved by community participation & social legislation

for the handicapped individual.

 The community needs to offer employments opprtunities in

shops,factories &other business establishments to the handicapps.

20
  The handicapped child need to be trained for an independent living with
special training & education.

SCHOOL & INSTITUTION FOR C.C.

 In India,there are more than 150 schools & institution for the
handicapped.

 These include day care centres,special school-blind,deaf & dumb.

 The Govt. of India provide support services to the handicapped

individuals & enabling the families to assume a large share of
rehabilitation within the family cycle.

 Non govt. organizations are also working along with Govt. institutions
for training, vocational guidance, counseling, manpower development,
research, assistance for supply of aids & applicances to the handicapped
& dissemination of informations

 The children Act,1960,provides for the care, protection, maintenance,

welfare, education & rehabilitation of socially handicapped children.

 National institute for orthopedically handicapped, Kolkata.

 National institute for Mentally handicapped, Secunderabad.

 National institute for the visually handicapped, New Delhi.

 Ali Yavar Jung National institute for Hearing handicapped, Mumbai.

 National institute for Rehabilitation, Training & Research, Chanai.

WELFARE OF CHILDREN

21
  Child welfare services.

 Child welfare Agencies.

 Child Guidance Clinic.

 Juvenile justice Act,1986.

 Welfare of Destitute children.

 Welfare of Working children.

 Prohibition of Child Marriage.

Child welfare services.

Child welfare services involve preventive, promotive, curative, developmental

& rehabilitative aspects of child care.

Attention is generally focused on three type of children-poor socio-economic

groups,i.e. children of working mothers, destitute children & handicapped
children.

Services for the basic needs of normal children

Where family & community participate.

Services for the needs of physically, mentally or socially handicapped

children.

Govt. of India, adopted National policy for children in 1974.

ICDS scheme, supplementary feeding nutrition education, production of

nutritious food. CSSM/RCH program.

22
United Nations Declaration of the Rights of child.

Child welfare Agencies.

Indian council for child Welfare.

Central social welfare board.

Kasturba Gandhi memorial trust.

The Indian Red cross society.

Day care services for children of working mother through nursery

school,balwadies,day care-centers for infants & toddlers.

INTERNATIONAL AGENCIES

 UNICEF

 WHO

 CARE

 USAID

 FAO

 USAID

 UNESCO

 International Red Cross.

23
Child Guidance Clinic

Child guidance in the United States began with an idealistic mission

characteristic of Progressive reform: prevention, first of juvenile
DELINQUENCY and then of MENTAL ILLNESS by identifying the first
signs of problems in children. Over the years, the goal of prevention faded,
and child guidance came to treat mild behavior and emotional problems in
children. The child guidance movement began in 1922 as part of a program
sponsored by a private foundation, the Commonwealth Fund's Program for the
Prevention of Juvenile Delinquency. The movement established community
facilities, called child guidance clinics, for treating so-called maladjusted
children, school-aged children of normal intelligence exhibiting slight
behavior or psychological problems.

Child Guidance Clinic was started in 1909 in Chicago.

To give psychotherapy to restore positive feelings of security in child.

Early diagnosis & T/T. Mental health improvements. Play therapy.

Modification of parents attitude.

The Child Guidance Clinic provides comprehensive mental

health,educational, developmental, behavioral, and consultative services to
Springfield and surrounding communities.  Our multidisciplinary staff offers a
variety of culturally competent programs in our clinic, at numerous
community sites, and in homes.

24
Specialized Programs Provided at Child Guidance Clinic

 Early Intervention

 Intensive Family Support

 Assessment and Treatment of ADHD

 Early Childhood

 Juvenile Firesetter Intervention Program

 Assessment and Treatment of  Sexual Behavior Problems

 Sexual Abuse Treatment

 Behavior  Management and Parent Training

 Social Skills Training and School Related Problems

25
Juvenile justice Act,1986.

It was stated that as long as children are allowed to suffer there is no true love
in the world.

The minors were exempted from the punishments and the fines because there
had to be a difference in the level of understanding of a 8 year old and an 18
year old.

The immunity to children is based on the principles of Juvenile Justice Act.

The constitutional basis for juvenile justice can be derived from Articles
15(3), 39(e) and (f) of the Constitution. Article 15(3) provides that “Nothing
in this article shall prevent the state from making any laws regarding women
and children’. Article 39 forms a part if the directive principles of the state
policy.

Clause (e) of Article 39 provides inter alia, that the tender age of children is
not abused. Clause (f) stipulates that children are given opportunities and
facilities to develop in a healthy manner and in conditions of freedom and
dignity and that youth are protected against exploitation and against moral and
material abandonment. 

 It provides a uniform legal framework for juvenile justice in the

country.

 It provides developmental approach to the child.

 It establish norms & standards for administration of juvenile justice in

terms of investigation,care,treatments & rehabilitation.

26
  It forms ruls & responsibilities.

Welfare of Destitute children.

 Destitute children are in great need-food & shelter.

 They may be deprived of parents.

 The children who have no home or who for some reason could not be
cared for by their parents are placed in institution for orphans.

 To promote growth & developments of children.

Welfare of Working children.

In 1973,the International Labor Organization passed.

15 years as minimum work age. Child labor is rooted in poverty,

unemployment& lack of education.

The Factories Act prohibits employments of children below the age of 14

years & declarespersons between the age 15 & 18 years to be adolescents.

Adolescent employee is allowed to work only between 6AM to 7PM.

27
Prohibition of Child Marriage

The Child Marriage Act,1978 fixed the legal minimum age of marriage 21
years for boys &18 years for girls.

Early Marriage has a great impact on the various aspect of child health &
regulation of fertility.

Females who marry before the age of 18 years,give birth to a large number of
children than those who married later.

Early marriage results in school drop out ,sexual hazards,obstetrical

problems,poor physical & mental health.

Child welfare should be vital responsibility of the country in all levels to have
healthy children &healthy nation.

28
NURSE ROLE IN CHALLENGED CHILD

 Nursing personnel play a vital role to assist the family members to cope
with the crisis situation for the handicapped condition.

 Planning & providing care to the handicapped children in health care

institutions & cmmunity are important nursing responsibilities including
parental involvement & community participation.

 Assisting the family to strengthen effective relationship & bondage to

prevents children from becoming socially handicapped.

 Nurses are responsible for creation of awareness in the society about the
prevention of handicaps, the abilities of the child with a handicap
condition.

 Nurses are responsible for primary, secondary terchary privention.

 The nurses should under the handicapped children.

 She should encorage the parents for taking care of handicapped child.

 She should give information about the genetic screening to the

community, it help to prevents inherited disease-Down’s syndrome,
hemophilia.

 She should give immunization to each & every under five children, it
help to prevents poliomyelitis & MMR.

 To encorage the community for avoid blood relation marriages,it help to

prevents congenital anomalies.

29
 To encourage the couples for medical termination of pregnancy of
malformed fetus.

 To give psychotherapy, physiotherapy, occupational therapy, music,

play, recrational therapy to challenged child.

 She must be understand the handicapped children problems.

 She must be done rehabilitation handicapped children properly.

 She must maintain hygine handicapped children.

30
NURSING DIAGNOSIS

 Ineffective family coping & altered parenting related to handicapped

condition.

 Anxiety of the parents & family members.

 Altered nutrition,less than body requirements.

 Potential for infection

 Injury/risk for handicapped children.

 Self care deficit r/t disease condition.

 Impaired communication.

 Impaired physical mobility.

 Altered elimination pattern.

 Intolerance activity.

 Altered sleep pattern.

 Altered growth & developments

 Altered sensory pattern.

 Knowledge deficit r/t disease condition.

31
CEREBRAL PALSY
DEFINITION

Cerebral Palsy is a non-progressive motor disorder of cerebral origin due to

damage caused to the growing brain and may be associated with abnormal
speech, mental retardation and seizures.

[Dr. Mayoor.K.Chheda]

 Cerebral Palsy is defined as a non-progressive neuromotor disorder of

cerebral origin. It includes a group of heterogenous clinical states of
variable etiology and severity ranging from minor incapacitation to total
handicap.

[O.P. Ghai]

INCIDENCE

The incidence of CP is 2 to 2.5 cases per 1000 live births.

There are an estimated 25 lakhs children and people in India with CP, making
it the commonest cause of disability.

More in males than females.

Incidence remains static because improved care during delivery is balanced by

increase in the number of premature & LBW babies.

32
ANATOMY & PHYSIOLOGY OF BRAIN

The anatomy of the brain is complex due its intricate structure and function.
This amazing organ acts as a control center by receiving, interpreting, and
directing sensory information throughout the body. The brain and spinal cord
are the two main structures of the central nervous system. There are three

33
major divisions of the brain. They are the forebrain, the midbrain, and the
hindbrain.

Anatomy of the Brain: Brain Divisions

The forebrain is responsible for a variety of functions including receiving and
processing sensory information, thinking, perceiving, producing and
understanding language, and controlling motor function. There are two major
divisions of forebrain: the diencephalon and the telencephalon. The
diencephalon contains structures such as the thalamus and hypothalamus
which are responsible for such functions as motor control, relaying sensory
information, and controlling autonomic functions. The telencephalon contains
the largest part of the brain, the cerebrum. Most of the actual information
processing in the brain takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The
midbrain is the portion of the brainstem that connects the hindbrain and the
forebrain. This region of the brain is involved in auditory and visual responses
as well as motor function.

The hindbrain extends from the spinal cord and is composed of the
metencephalon and myelencephalon. The metencephalon contains structures
such as the pons and cerebellum. These regions assists in maintaining balance
and equilibrium, movement coordination, and the conduction of sensory
information. The myelencephalon is composed of the medulla oblongata
which is responsible for controlling such autonomic functions as breathing,
heart rate, and digestion.

34
ETIOLOGY

Prenatal causes:

Maternal- Intrauterine infections, maternal chorio-amnionitis, hypertension,

MR, seizures hypothyroidism, teratogenic exposure during pregnancy,
placental complication, trauma-physical or mental.

Fetal- IUGR, LBW babies, multiple pregnancies, neural tube defects,

microcephaly, other anatomical cerebral abnormalities.

Intranatal causes:

Perinatal asphyxia, prolonged labour, abnormal presentation, instrumental

delivery, caeserean section, infections.

Postnatal causes:

Neonatal hyperbilirubinaemia, neonatal sepsis, neonatal meningitis,

intracranial haemorrhage, metabolic causes, convulsions.

RISK FACTORS

 Germinal matrix haemorrhage.

 Subependymal haemorrage(Periventricular leukomalacia)

 Intra-ventricular haemorrhage on both sides.

 I U infections, I U cerebral strokes.

 Low-birth weight.

35
Birth asphyxia &Birth trauma Congenital malformations-Dandy walker
syndrome, Arnold- chiari syndrome, etc. Kernicterus. Genetic disorders.

FUNCTIONAL CLASSIFICATION

Near normal(Does not require support for activity)

Mild restriction of activity(requires support for complex activity)

Moderate restriction of activity(requires support for day to day activity)

Severely restricted activity(Bed ridden totally dependent for all kind of routine
activity)

SPASTIC QUADRIPLEGIA

 Complete immobility due to motor weakness of all four limbs

 Hypertonia (spasticity)of all four limbs with brisk reflexes and bilateral
extensor plantars.

 Contractures of elbows and knees and presence of deformities.

 Bulbar palsy leading to difficulty in swallowing leading to aspiration of

food.

 Incontinence of urine and stools due to lack of control over bladder and
bowel

 Convulsions

 Mental Retardation

 Speech disturbances

36
PATHOPHYSIOLOGY

In mild cerebral palsy ,the brain appears normal, but may be under weight &
has sparse subcortical white matter & sparse nerve fibres.

In severe cerebral palsy ,there may be various pathological lesions like

cerebral atrophy, cavity formation in subcortical white matter, atrophy of basal
ganglia, leukomalacia, porencephaly, microcephaly, cerbral lesions vascular
occlusions & gliosis.

CLINICAL MANIFESTATIONS

 Delayed gross motor development: Discrepancy between motor

ability and expected achievement tends to increase with successive
developmental milestones as growth advances.

 Abnormal motor performance:

 Early sign is unilateral hand use at about 6 months.

 Abnormal crawl with progression by hand movements only and with

lower extremities and hips hiked along, much like a ‘bunny-hop’ is
seen in diplegia.

 Hand dominance does not develop until the preschool age.

 Hemiplegic children crawl asymmetric using unaffected hand and leg to

propel themselves on either the buttocks or the abdomen.

 Spasticity- child will stand or walk on toes.

 Dyskinetic- uncoordinated or involuntary movements.

37
 Athetosis- facial grimacing, writhing movements of the toungue, fingers
and toes .

 Others- poor sucking, feeding difficulties with tougue thrust, head

stammering, tremor on reaching, truncal ataxia.

 Alterations of muscle tone:

 Increased or decreased resistance to passive movements.

 Opishotonic posture( exaggerated arching of back)

 Stiff on handling or dressing.

 Difficulty in diapering due to spasticity of hip adductor muscles and

lower extermities.

 Extension of entire body on sitting position, rigid and unbending at the

hip and knee joints.

 Abnormal posture:

 Prone :hips higher than trunk with the legs and arms flexed or drawn
under the body.

 Supine: scissoring and extension of legs and with the feet plantar flexed.
Spasticity: mild or severe

 Persistent infantile resting and sleeping posture(arms abducted at

shoulders,elbows flexed, and hands fisted)

38
  Reflex abnormalities: obligatory tonic neck reflex at any age or
nonobligatory persistence beyond 6 months of age , hyperactivity of the
moro, plantar and palmar grasp.

 Associated disabilities: MR, ADHD, seizures and impairement of

special senses

DIAGNOSTIC EVALUATION

 Routine investigations

 Tests to determine the etiology / associated malformations: USG skull,

MRI brain, CT scan brain

 Evaluation

 Testing for inborn errors of metabolism

 Karyotype (genetic testing)

 Lumbar puncture and CSF examination

 Test done to detect associated disabilities or complication of CP.

i. EEG, IQ test, visual screening, fundus examination auditory

assessment, x ray chest, orthopedic evaluation

39
 DIFFERENTIAL DIAGNOSIS

 Neurodegenerative disorders .

 Hydrocephalus and subdural effusion.

 Brain tumors or space occupying lesions.

 Muscle disorders.

 Ataxia telangiectasia.

PREVENTION

Often the cause of cerebral palsy is not known, and nothing can be done to
prevent it. However, some important causes of cerebral palsy can be prevented
in many cases, including premature birth, low birth weight, infections, and
head injuries. 

Avoid using cigarettes, alcohol, and antibiotic drugs during pregnancy: these
increase your risk of premature delivery. 

Seek appropriate prenatal care as early as possible in the pregnancy. Many

women schedule a prepregnancy visit so they can be properly prepared for a
healthy pregnancy. Appropriate care is available from physicians, physician
assistants, nurse practitioners, and certified nurse-midwives. 

Rubella (measles) during pregnancy or early in life is a cause of cerebral

palsy. Testing for rubella immunity before you become pregnant allows you to

40
be immunized, which protects both you and your baby from contracting this
potentially illness. 

Appropriate prenatal care includes testing for Rh factor. Rh incompatibility is

easily treated but can cause brain damage and other problems if untreated. 

Routine vaccinations of babies can prevent serious infections such as

meningitis that can lead to cerebral palsy. 

Make sure your child is restrained in a properly installed car seat and wears a
helmet when riding on a bicycle.

MANAGEMENT

 Participation of parents

 Multidisciplinary team approach

 Methods to decrease spasticity:

 Non- pharmacological therapy- physiotherapy, occupational

therapy, electrical stimulation, Educational, use of outhouses,
manipulative methods.

Intrathecal Baclofen

 Pharmacological therapy:

Oral drugs-

diazepam or nitrazepam

Baclofen: older children started in a dose of 2.5 mg.

41
 Dantrolene sodium: starting dose is 0.5 mg/kg/day

Ti zanidine: started at a dose of 1 mg at night and then maintained upto

0.2- 0.4mg/kg/day

Parentral drugs-

Botulinum toxin injection

Intrathecal Baclofen

 surgical treatment:

tenatomy, orthopedic surgeries like osteotomy, tendon lengthening,

arthrodosis, stereotactic surgery, muscle slide procedure, selective posterior
rhizotomy etc

 Treatment of associated features:

Convulsions, treatment of visual disturbances, speech therapy, hearing

impairement, behavioural problem, drooling of saliva, special education.

NURSING MANAGEMENT

Increasing mobility and minimizing deformity. Maximizing growth and

development.Protecting the child from physical injury.

Teaching the parents and family members. Convey acceptance, affection,

friendliness and promote a feeling of trust and dependability .

42
Caring behavioural problems. Encouraging health maintenance. Encouraging
rest and relaxation. Preventing infection.

Providing for nutritional needs Assisting with feeding management and toilet
training. Preventing child abuse. Providing care during hospitalization.

Follow-up

The overall goal for ongoing care of individuals with CP is to help them
reach their full physical, mental, and emotional potential. Generally, this
includes living as much as possible in the mainstream of their society and
culture. People with CP tend to be happiest and most productive when they
can go to school with, live with, and work with their peers. 

Children with CP require regular sessions with their physical, occupational,

and speech/language therapists, as well as frequent check-ups with their
medical and surgical teams. The exact schedule of visits is determined by the
severity of the child’s condition and his or her response to treatment. A
multidisciplinary CP clinic allows for frequent and complete care with the
minimum of inconvenience

43
MENTAL RETARDATION

Mental retardation refers to the most severe general lack of cognitive &
problem solving skills.

Mental retardation is defined as a condition of incomplete development of

mind, which is especially characterized by sub normality of intelligence and
associated with impairment in adaptive behavior.

It is also known as cognitive developmental delay.

AAMR DEFINITION

 The AAMR definition requires a delineation of intellectual functioning,

functional strengths and weakness in a number of real- world adaptive
skills and onset before 18 years of age.

 The child must manifest sub average intellectual functioning, which

means an IQ of 70 to 75 or below.

 In addition, the child must demonstrate functional impairment in at least

2 of 10 adaptive domains, including communication, self-care, home
living, social skills, community use, self-direction, health and safety,
functional academics, leisure, and work.

44
CLASSIFICATION OF MENTAL RETARDATION:

LEVEL (IQ) PRE SCHOOL – MATURATION DEVELOPMENT

Mild-50-69 Often not noticed as retarded by casual observer but is slower

to walk, feed self, and talk than most children;

Follows same sequence in development as normal children.

Moderate-35-49 Noticeable delays in motor development, especially in speech; responds

to training in various self-help activities

Severe -20-34 Marked delay in motor development; little or no communication skills;

may respond to training in elementary self –care (e.g., self -feeding)

Profound– Gross retardation; minimum capacity for functioning in sensorimotor are

below 20 needs total care.

LEVEL (IQ) SCHOOL AGE(6-12 YRS)– TRAINING & EDUCATION

Mild-50-69 Can acquire practical skills and useful reading and

arithmetic to a third to sixth grade level with special education; achieves

mental age of 8 to 12 years .

Moderate-35-49 Can learn simple communication, elementary health and safety habits,

45
 and simple manual skills; does not progress in functional reading or arith

achieves mental age of 3-7 years .

Severe -20-34 Usually walks, barring specific disability; has some understanding of spe

some response; can profit from systematic habit training;

achieves mental age of toddler .

Profound – Obvious delays in all areas of development; shows basic emotional respo

below 20 may respond to skillful training in use of legs, hands, and jaws;

needs close supervision; achieves mental age of young infant .

Types of mental retardation

 Mild mental retardation-IQ level-51to70.

 Moderate mental retardation IQ level-36to50.

 Severe mental retardation IQ level-21to35.

 Profound mental retardation IQ level-below 20.

Causes of M R

Genetic syndromes-dow’s syndrome.

Congenital anomalies-hydrocephalus microcephaly.

Intrauterine infections-ante partum hemorrhages.

46
Perinatal conditions-birth trauma

Environmental & sociocultural factors-poverty,broken family

Sign & symtoms

Poor feeding.

Weak sucking poor weight delayed or decreased visual response.

Delayed head trunk controls.

Poor mother-child interaction.

Delayed speech language disabilities.

Delayed motar (standing & walking).

Failure to achieve independence.

Hyperactivity.

Poor memory.

Poor concentration.

Emotional problems.

Cerebral palsy.

DIAGNOSTIC EVALUATION

47
 Federal Law and Individuals with Disabilities Education Act ensures
that each child with a delay or suspected of having a delay has a
multidisciplinary evaluation by a team.

 No single test can diagnose MR.

 The multidisciplinary evaluation should be individually tailored to the

child.

 Rule out sensory deficits by assessment of vision and hearing.

 Medical evaluation should include developmental history, sequential

developmental assessments, family history and physical examination.
The positive findings determine the direction of the individual
evaluation.

1. Unusual appearance (dysmorphic features) warrants genetic

workup.

2. History consistent with loss of developmental milestones and

positive family history warrants workup for presence of an inborn
error of metabolism(diagnosed by blood and urine analysis) or
lead poisoning.

3. Children with microcephaly, macrocephaly or neurologic

abnormalities may require a CT scan or MRI.

4. Electroencephalogram is necessary for children with seizures.

 Psychological testing (appropriate tests selected by a child

psychologist):

48
 a) The Bayley Scales are used to assess fine motor, gross motor and
language skills and visual problem solving in infants of
developmental age of 2 months to 3 years.

b) The McCarthy Scale offers a “general cognitive index” that is

roughly equivalent to an IQ score.

c) The Stanford- Binet intelligence Scale is used to test children

with mental abilities of 2 years and older.

d) The Wechsler Preschool and Primary Scale of Intelligence

measures mental age of 3 to 7 years.

e) The Wechsler Intelligence Scale for children III tests children

whose functional age is above a 6- year level.

f) The Vineland Scale tests social-adaptive abilities- self-help skills,

self-control, interaction with others, cooperation; the Adaptive
Behavior scale is similar to Vineland but also measures
adjustment.

MANAGMENTS

Mental retarded child needs mgt in multidisciplinary team approach.

Adequate diagnostic facilities to detect associated problems &appropriate

management of the specific condition should be arranged.

49
Family members & parents need to counselling regarding various aspects of
the condition & necessary mgt.

Parents should be explained, informed & discussed about the long term care at
home situation according to the child’s IQ level & associated problems.

Importance to be given on promotion of self -care ability &independence of

child.

Routine basic care, immunization, growth monitoring, nutritional

requirements & tender loving care to be provided to the child.

Psychological & emotional support needed for parents & family members.

The child needs love-affection, appreciation, discipline for tender loving care
from parents & family members.

Special education arrangement & available facilities should be discussed with

the parents.

The child may be send to day care centre or special school or vocational
centers or workshop.

The child needs supports to develop potentials to the maximum & to become
independent as possible for self care.

PREVENTION

1. PRIMARY PREVENTION STATEGIES-

Those designed to

50
  Preclude the occurrence of the condition that causes retardation-
include rubella immunization

 Genetic counseling, especially in terms of Down or Fragile X

syndrome

 Use of folic acid supplements during pregnancy to prevent neural

tube defects

 Education regarding the dangers of ingesting alcohol during

pregnancy

 Adequate prenatal care and childhood nutrition

 Reduction of head injuries

2. SECONDARY PREVENTION ACTIVITIES-

Those designed to identify the condition early and institute treatment to
avert cerebral damage- include prenatal diagnosis or carrier detection of
disorders, such as down syndrome, and newborn screening for treatable
inborn errors of metabolism, such as congenital hypothyroidism,
phenylketonuria, and galactosemia.

3. TERTIARY PREVENTION STRATEGIES:

51
Those concerned with treatment to minimize long-term consequences- include
early identification of conditions and appropriate therapies and rehabilitation
services.

These include medical treatment of coexisting problems, such as hearing and

visual impairment in Down’s syndrome and programs for infant stimulation,
parent training, preschool education, and counseling services to preserve the
integration of the family unit.

NURSING INTERVENTIONS WITH MR CHILDREN

 The goal of caring for a retarded child is to promote his optimum

development as an individual within the family and community.

 The nurse is in a vital position to teach parents how to foster learning in

their child.

1. Educating MR children

2. Promoting independent self-help skills

3. Promoting optimum development in children

4. Helping families adjust to future care

5. Caring for hospitalized retarded children

52
1. EDUCATING MR CHILDREN

 In order to learn how to teach MR children it is necessary to investigate

their learning abilities and deficits.

 MR children have a marked deficit in their ability to discriminate

between two or more stimuli because of difficulty in paying attention to
relevant cues.

 Demonstration is preferable to verbal explanation and learning should

be directed toward mastering a skill rather than understanding scientific
principles underlying the procedure.

 Another deficit of retarded children is in short –term memory.

 Learning through a step-by-step process requires the teacher to break

down each task into its necessary components. For example, if the child
is learning to tie a shoe, the teacher must practice the skill, divide into
steps, and teach each step completely before proceeding to the next
activity.

 Programs based on motivation principles of positive reinforcement for

specific tasks or behaviors have demonstrated marked improvement in
retarded children’s ability to learn.

2. PROMOTING INDEPENDENT SELF-HELP SKILLS

 Parents need assistance in promoting normal developmental skills that

are almost automatically learned by other children.

53
  For the nurse to be successful in meeting this goal, the parents must be
supported, included as the primary rehabilitators with the child, and
provided with written detailed descriptions of the stimulation program.

 Feeding

 Toileting

 Dressing

 Grooming

Feeding:

 Self-feeding is recognized as the first major self-help skill that children

learn.

 It actually involves the integration of fine motor skills, visual

perception, and gross motor skills.

 Before beginning a self-feeding program the nurse should do a task

analysis, breaking the process of feeding into its smallest component
parts. For example, the tasks in self-feeding with a spoon include: the
child

1. Orients to the food by looking at,

2. Looks at the spoon,

3. Reaches for it,

4. Touches it,

54
 5. Grasps it

6. Lifts it,

7. Delivers the spoon to the bowl

8. Lowers it into the food

9. Scoops food onto the spoon

10.Lifts it

11.Delivers the spoon to his mouth

12.Opens his mouth

13.Inserts the spoon into his mouth

14.Moves his tongue and mouth to receive the food

15.Closes his lips

16.Swallows the food and

17.Returns the spoon to the bowl

Toileting:

 Independent toileting is another major self help skill that can be taught
using behavioral modification principles. It should be started after self-
feeding, since this is the normal sequence of development.

 The nurse begins by assessing the child’s physical readiness for a toilet-
training program:

55
  Can he sit by himself

 Can he stand alone

 Does he balance well, walk backward and forward, and climb

onto a chair

 Can he retain urine for at least 2 hours

 All of these skill require coordinated movement, posture, and balance

and suggest that the child is physically and neurologically ready for
toilet training

 A task analysis of toileting reveals the following steps, which parents

must systematically reinforce in positive, natural spontaneous ways:

1. Sitting on the toilet or potty-chair and playing there without

fussing, crying or attempting to get off,

2. Eliminating into the toilet on a regular basis when sitting on it,

3. Waiting to eliminate before being placed on the toilet,

4. Indicating the need to eliminate before going into the bathroom,

5. Asking to go to the toilet or just going to it,

6. Remaining dry for longer periods of time,

7. Climbing onto the toilet independently,

8. Helping undressing himself before getting onto the toilet,

9. Independently undressing himself before getting onto the toilet,

56
 10.Wiping independently,

11.Flushing the toilet,

12.Dressing ,

13.Washing his hands with soap in a correct manner, and

14.Drying his hands with a towel.

Dressing:

 Dressing skills develop without special training in normal

children, usually as a consequence of autonomy and imitation.

 For children who are retarded, special training is necessary to

promote this skill.

 Factors that interfere with spontaneous learning include

 immature motor skills,

 lack of motivation,

 physical handicaps, or

 lack of opportunity.

 The level of independence in dressing varies according to the

degree of retardation.

 Mildly and moderately retarded children without physical

handicaps can become independent in all dressing skills, except
for more complex tasks such as color coordination.

57
 Severely retarded children can achieve most dressing skills,
except the ability to fasten complicated closures, such as buttons
or ties.

 Profoundly retarded children are usually able to assist in

undressing and dressing and dressing but achieve no independent
skills.

 Prior to instituting a self- dressing program, the nurse assesses the

child’s physical readiness by doing a task analysis of the
following gross and fine motor skills:

1. Can stand alone,

2. Can balance in a chair or on the floor without support,

3. Can lean free from the chair when seated,

4. Can raise one knee up toward the chest when seated,

5. Can place either hand on the opposite shoulder,

6. Can place one or both hands on top of head,

7. Has apposition with one or both hands

8. Can grasp and hold slim objects with one or both hands,

9. Can pick up a 1- inch button using thumb and forefinger,

10.Can push with one or both hands with all fingers grasped
around an object.

58
3. Promoting optimum development in children

1. Optimum development involves more than achieving independence. It

requires appropriate guidance for establishing acceptable social
behavior and personal feeling of self-esteem, worth, and security.

2. These attributes are not simply learned through a stimulation program.

Rather they must arise from the genuine love and caring that exists
among family members.

a. play:

Play is based on the child’s developmental age. For the retarded child, the
need for sensorimotor play may be prolonged for several years. The nurse
guides parents toward selection of suitable toys and interactive activities.

Parents should use every opportunity to expose the child to as many different
sounds, sights, and sensations as possible. Appropriate play includes musical
mobiles, stuffed toys, water play, floating toys, rocking chair or horse, baby
swing, bells, and rattles. The child should be taken on outings, such as trips to
the grocery store or shopping centre, other people should be encouraged to
visit in the home, and the child should be related to directly, such as cuddling,
holding, rocking, talking to him in the en face position, giving him rides on
the parent’s shoulders and so on.

b. communication:

Verbal skills are often delayed more than other physical skills. Speech
requires hearing and interpretation (receptive skills) and facial muscle
coordination (expressive skills). Both may be impaired in MR children.

59
Singing attracts the child’s attention so that he attends to the cue longer.
Parents also must remember that since learning is slower, their teaching must
continue longer.

Shaping techniques are useful in fostering meaningful vocalization. Every

time the child vocalizes a sound that either represents a letter of an alphabet or
an intelligible syllable, the parent reinforces him with praise and social
approval.

c. discipline:

Discipline must begin early. For the retarded child, limit-setting measures
must be simple, consistent, and appropriate for his age. Control measures are
based on teaching a specific behavior- not on understanding the reasons
behind it.

Behavior modification is an excellent technique for limit setting. For example,

to teach the child to stay in the yard and not run in the street, the parent makes
a simple rule, such as “you must stay behind the gate”. If the child breaks the
rule, the parent immediately shows disapproval.

d. Socialization:

Socialization describes a process which may lead to desirable, or 'moral',

outcomes in the opinion of said society. Individual views on certain issues,
such as race or economics, are influenced by the view of the society at large
and become a "normal," and acceptable outlook or value to have within a
society. Many socio-political theories postulate that socialization provides
only a partial explanation for human beliefs and behaviors, maintaining that

60
agents are not 'blank slates' predetermined by their environment.[3] Scientific
research provides some evidence that people might be shaped by both social
influences and genes. Genetic studies have shown that a person's environment
interacts with his or her genotype to influence behavioral outcomes

Parents should be encouraged early to teach their child socially acceptable

behavior: waving good-bye, saying “hello” and “thank you,” responding to his
or her name and greeting visitors.

Opportunities for social interaction and training should begin at an early age
such as infant stimulation program and appropriate preschool programs.

These programs provide education and training, as well as opportunities for

social interaction with other children and adults.

Challenges For Paediatric Nurse

Communication with child.

Parents understanding.

Pain management.

Medications /dose calculation to the child.

Taking Care of I.V.

Art Of Pediatrics.

Distraction.

Pediatrics Drug Calculations.

61
What are the special demands?

 There are special communications challenges associated with children’s

nursing, the most obvious of which is that a small child cannot say what
hurts or articulate its fears and needs.

 You will need to be very intuitive and immensely reassuring. Non-

verbal communication skills, and the ability to play sensitively with a
child will be vital.

Recommendations For Pediatric Nurses

 Children looks Nurses as Caregivers, Teachers And

 Comforters

 Enjoy caring for children

 Take child development course

 Intersectoral coordination

 Multidiciplinary co-ordination

62
REHABILITATION AND TRAINING OF CHALLENGED CHILDREN

INTRODUCTION

The one having physical or mental disability, more often than not, becomes a
parasite on the family and the community making life a miserable, experience.
In the life pattern of developed countries, disabled today have become
aproductive member of the society and can look back on their life with
satisfaction.
In contrast, in traditional societies like India, due to low aconomy conflict
with ignorance, the disabled have yet to find a place in the mainstream of
social life, away from the usual occupation of begging.

THE MEANING OF REHABILITATION

Rehabilitation is not only concerned with physical or functional
restoration/compensation of individuals disabled by injury or disease.
Attention is also given to the total quality of life in terms of wellness,
happiness and satisfaction in fulfilling the demands needs capacities of human
existence in orientation, freedom of movement, independence, expression of
self (with respect to age, sex and culture), relationship and ability to ensure
independent economic existence.
After a serious injury, illness or surgery, one needs to recover slowly. There is
the need to regain strength, to relearn skills or find new ways of doing things
one did before. This is the process of rehabilitation.

63
Children who are born with disabilities need stimulation for development and
adaptation – habilitation, and those who acquire disabilities also need
rehabilitation. Technically, therefore, rehabilitation is a creative procedure that
includes the cooperative efforts of various medical specialists, and associates
in other health, technical and environmental fields, to improve the physical,
mental, social and vocational aptitudes of the disabled, with the objectives of
preserving and improving their ability to live happily and productively on the
same level, and with the same opportunities as their neighbours.
In other words, it is a process of decreasing the dependence of the disabled
person, by developing to the greatest extent possible, the abilities needed for
adequate functioning in his individual situation in the community.

ASPECTS OF REHABILITATION
 Medical rehabilitation includes restoration of functions by prosthesis,
artificial limbs, etc
 Social rehabilitation includes restorations of family and social
relationship by replacement in the family
 Educational rehabilitation include specialized training and educational
facilities eg Braille for blind, Sign language for dumb and deaf
 Psychological rehabilitation includes restoration of personal dignity and
confidence during the period of growth and development and in adult
life
 Vocational rehabilitation includes restoration of the capacity to earn a
livelihood. This can achieved by community participation and social
legislation for handicapped individual. The community needs to offer

64
 employment opportunity in shops, factories and other business
establishment

PATTERNS OF REHABILITATION

The occupational skills to be learned must be within the

individual capacity to perform them. Physical limitation or handicaps should
direct training toward tasks that can be performed. The observation evaluation
and testing of attitude and skills in a trial work situation offers the most sound
basis for selection of those suitable for training.
The readiness to work can best be determined in a workshop or
trial job placement. Attention will be directed to the above criteria when the
patient has shown clinical improvement when he has improved in individual
and group therapy, when ward behavior has improved and there has been an
increase in his ability to form social relationship.
The SINGER vocational evaluation system has twenty modules
of training including carpentry, sheet metal work, cooking and baking, sales
and processing , medical services, simple urinalysis, office services, needle
trades, bench assembly, electrical wiring and engine services.
 Daily employment:
This is an incentives which motivates most handicapped patients. It has
the facility for testing the patient in a loosely supervised work situation
and shows up his abilitiesin a real workshop environment, his
relationships with other work people and his reaction to the community.
Placing of a infant in a normal environment outside the hospital will

65
 encourage improvement in most aspect of living. The patient leaves the
hospital each day to attend his work and returns in evening. He receives
pay for work he does, one part of which he allowed to keep for pocket
money, another part used for his upkeep and another part is deposited in
his bank account which he can withdraw when need arises.
 Industrial Rehabilitation Centres:
This centres do not officially take the mentally handicapped patient for
training. The mentally handicapped patient is taught some semi skilled
or unskilled work in surroundings which stimulate confidence.the work
and the environment hours of work and conditions of service are exactly
the same as in industry, without the severe competition. Adequate
guidance and supervision are given during this training period which
lasts from 3-4 month
 Long leave:
All detained patients are eligible for this privilege after a suitable
period of controlled behavior in hospital. The period of this leave is
upto 6 month after which the patient should be discharged or returned to
hospital. Whilst the patient is on leave he is visited regularly by the
parent hospital social worker or by the social services department
personnel
 Sheltered workshop:
The Sheltered Workshop Helps The Patient To Become Employable To
Help Prevent Behavior Disorder From Occurring To Give The
Handicapped Person, To Help The Families A Period Of Freedom From
Stress Of Supervision, To Give The Person Give Dignity Of Work As

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 Going To Normal People And Earning A Little Money. The sheltered
workshop permits orientation to work, development of work attitudes
and occupational skills in a setting acceptable to the handicapped
children.
 The day hospital
It provides a complete medically supervised treatment program me for
the mentally handicapped patient who is able to travel and whose
continued presence in the home is not too stressfull.
 Day hospitals allow
 Earliar release from hospital
 Easier transition from hospital to home become possible when the
treatment takes the patient out of the home to reduce stress on family
yet permits him to go home and sleep in house
 Many patients can be managed at home who would either have been
hospitalized
 Occupational centres:
These centres now schools under the direction of local authority
provide continued training for patient granted long leave by the hospital
who are not suitable for industrial occupation who can continue their
training under supervision which will help in main training their
standard of improvement, attendance is voluntary. Transport to and
from the centr and tea and food is provided free.
Graded form of education and all varieties of occupation and
entertainment are still aiming at the maximum development of the
patients potentialities and capabilities.

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  Lodgings :
Lodgings are necessary for all patients suitable for life in the
community who either have no home to go or for homes which cannot
provide the necessary stable environment and it is deemed wiser to
board the patient out
 Wage regulation and trade union restriction
Employees quite naturally select persons who will give a good day
work for a days pay and do not require strict supervision. Trade union may not
look kindly on the small payment scheme for the work done by mentally
handicapped person and this may require local decision

 Speeding up of industrial processes

Industry and agriculture are becoming more mechanized specialized. Bonuses
are are often given in industry on a team basis, and because the handicapped
cannot keep pace, resentment is caused amongst the other team member
 Recreational therapy
This form of treatment consist of both physical training and
entertainment. Physical training includes gymnastics, calisthenics and
aethletics. Recreation includes amusements, games, walks, music, dancing,
concepts, reading and personal hobbies.
This is difficult to make contact with severely handicapped patient
through the normal channels of persuasion and appeal, but he will respond to
play. This instinctive response is the first step in the socialization of patients.
Most stimuli act through sensation of sight, hearing or touch, or a
combination of these. The majority of patients will respond to visual sensory

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stimuli and will repeat movements performed in their presence. Those who
will not responds may be aroused by auditory and touch stimuli.
Functions of recreational therapy
It promotes and provides new interest which can be used to develop
dormant interests. By this way the patients can be occupied and their
instinctive energies will be sublimated into socially accepted channels.

ANALYSIS OF INDIVIDUAL ACTIVITIES ARE AS FOLLOWS

 Gymnastics and calisthenics: these activities comprise formal
exercises which require to be specially adapted to meet the
therapeutic needs of the individual groups of patients
Calisthenics permits a series of graded movement from the very
simple repetitive types to the more complicated and difficult
types and is suitable for use with all grades of patients, either
individually or group of patients. The movement should be
performed rhythmically rather than fast and jerky. The use of
music facilitate rhythgmic movement, providing it is soft so that
it doesnot distract the attention of the operator. It should only
indicate the time and rhythm of the movement.
 Outdoor games: games as a form of treatment should reach the
greatest number of patient possible, as the maximum mental and
physical benefit are derived from them. Many patients who will
not or cannot take an active part inn the various games will enjoy
looking on.
 Athletics; special days should be set aside as gala days when the
entire hospital population takes an active or passive part in the

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 program me. The program me should include running, jumping,
tug-of war, relay races and novelity events, such as egg and
spoon race, wheelbarrow and obstacles races. Music can be
provided on these occasion by the hospitals orchestra, which may
includes patients and staffs. The realism of the program me will
be enhanced if prizes are given to the winners of the different
events and will contribute to the socializing effect of the day.
 Indoor games: indoor games form a good substitute for outdoor
games when these are not possible and there is no limit to the
number and types of games available
 Music entertainment: musical form of entertainment can
provide active and passive recreational treatment which can be
arranged either indoor or out and can include concerts, wireless
programmers, band concerts,choirs and musical cinemas shows.
It is through music that the greatest number of patients can be
reached. It reacts on their emotion and promotes healthy and
desirable moods. It helps to convert an unfavorable moment to
favorable one giving cheerfull and brighter and has unlimited
powers of entertainment giving a much to the performers and
listeners.
 Percussion bands: most patients are capable of atking an active
part and of deriving great enjoyment. Specially provide
enjoyment to all those who are only able to listen. Drums,
triangles, cymbals, bells, castanets and tambourines are the
instruments used, and the whole orchestra is under the direction
of a conductor who is usually a patients.

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 Choirs: small numbers can participate and the large group only
get benefitted in a passive way.since these are mobile can provide
entertainment to all those confined to bed
 Impromptu concerts: at these functions patients are allowed to
volunteer to provide musical, vocal or recitation items.
 Cinema shows and television suitable films: it has recreational
value and educational value. Television has been found to be of
greatest value as a calming and educational medium.
 Dancing: the value of dancing as a form of entertainment with
socializing effect is difficult to overestimate. All grades of
patients receive both mental and physical benefit from it. The
rhythm of the music stimulates the desire to move with a flowing,
swinging action which is aimed at in all muscular activity. This
type of movement is least fatiguing and provides the greatest
enjoyment
 Ballroom dancing: this can be graded to suit the mental and
physical capacities of the patients. It is a form of entertainment
which is complete in itself and can be completed as a part of the
program me of socials and parties.
 Eurhythmics: music and actions are combined to provide
expression through movement, coordination and attention are all
developed as well as an increase in knowledge of other part of
body. Simple forms can be used with severely handicapped and
whilst a complex one can be use with minimal handicapped
patients

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  Walks and coach: sight seeing excursions each of these activities
should be a regular feature of the recreational program me. Walks
should be a regular feature when whether is favorable and route
chosen should be varied to avoid monotony.
Coach trips should be organized as often as possible to seaside,
scenic beauty spots, and to suitable theatre shows
 Hobbies : all patients able benefit from these should be guided
and encouraged in the choice of occupational interest. Hobbies
commonly met with mentally handicapped are cultivation of
individual garden plots, the patient having freedom of choice of
cultivation for animals and bird and stamp collecting.
 Libraries : a patient library can take 2 forms
 A patient can visit a room set apart where books of all kinds are
available for him to make his own choice
 The libraries can visit each ward on an appointed day each week with a
book trolley filled with books in which the more intelligent patient
might be interested Books suitable for mentally handicapped are as
pictorial books, books with simple pictures, Illustration are more
suitable for severely handicapped. Severely handicapped; highly
pictured colour books
 A qualified librarian and staff nurse who has a knowledge of the patient
are very very important to choose the right book for handicapped
children.
 Scouts and guides: special branches of the scout and guide movement
has been formed to meet the needs of the mentally handicapped. Most
hospitals appreciate the stabilizing and socializing affect of the two

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 groups and have formed their own scout and guide troops.
Opportunities are available for the scouts and guides from the hospital
to enter national competitions. One of the greatest advantages to any
patient is that when he leaves the hospital to live outside he may have
the opportunity to join a similar organization and the bond of common
folloship will provide him with the friendship guidance he need
 Patient clubs: patient club can play an important part in rehabilitation
of challenged children and through their influence and discipline most
problems can be solved. The aims of such organization should be made
known to all who are in membership and should include
1. TO inculcate pride in self and a sense of loyality towards the
hospital
2. To stimulate a belongingness to an organization
3. To stimulate children to think and and organize in future.
4. To be a medium through which outside organization may be
invited to take an active part in hospital recreational activity in a
more intimate manner than is possible in organized field of
games.
It will be necessary for one of the nurses to act as secretary, and he or she
should be prepared to carry out the committees instruction. A sense of
responsibility is inculcated into the greatest majority of patients, even the most
antisocial patients through the club discipline.

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VOCATIONAL TRAINING & WORK
 Placement :
The rehabilitation management aims for social and occupational adjustment in
adulthood. Proper and need based guidance is essential for appropriate
vocational training and work placement.
It is necessary to see his willingness for the work, before he is given a job. A
simple checklist to assess the individual's readiness includes degree of
independence in ADL, social skills, reaction to superiors, work ability,
behavior and health status.
The various types of work are available according to the resources in the
community and the ability of the mentally retarded person. In rural areas, he
can be involved in farming, bees keeping, poultry, dairy and other simple
service jobs. In the urban areas, he can be involved as attendant, helpers for
semiskilled or unskilled jobs.
The vocational guidance counsellor should make a proper analysis of the job
as well as suitability of the retarded person to fit in before placing the person.
Satisfactory job placement will be possible only if the job requirement and the
concerned retarded person's ability are matched.
The proper and periodical follow-up is necessary after job placement of the
mentally retarded person. They are more successful in jobs which requires
simple repetitive operations than those where they have to make decisions or
change the activities.
The mentally retarded can be gainfully placed in the work in three situations
i.e. self employment, sheltered employment and open employment depending
upon his level of retardation, aptitude, resources in the family and community.

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  Focus on Abilities
Here is the good news: Once we know what our goals for a child should be,
we can draw on his many capabilities to help him achieve those goals. The
motor system is not the only capability children have, and we can often take
advantage of even limited motor ability.
Let's take a child like the one in your class, who has weaknesses on one side
of his body but has control over some muscles. He has one arm that's working
well, so he can reach for things and show you what he wants. Even without a
good, functioning arm, the child can convey ideas verbally or with signals. So
he can learn to be purposeful.
It's vital to use all of the child's operating senses and abilities, including
language skills and the ability to see, smell, hear, and move certain body parts.
Like many others in his situation, this little boy apparently does not feel that
he can make things happen.
That could lead him to regress or to escape into his own private world when
the going gets rough.

A different child in his situation might have temper tantrums. But if you can
work around the limitations of his muscles and create situations that allow him
to explore his own assertiveness, you will be helping him enormously.

You might pair him up with another carefully chosen child, and find activities
in which the boy with motor problems can be an assertive play partner.
Although his speech is not always clear, he does have verbal skills.

Now, suppose you suspect that he is gifted musically. Draw on that. You
know he can't dance, but he can use one arm very well. So he can hold a baton

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and lead other children who are playing different instruments. He is assertive
and making things happen. You, the teacher, have engineered it, evened the
playing field. The key is to create social games where this child does not have
to be just a passive follower.

 Encourage Involvement

Another thing you might do to encourage involvement is use a tape recorder

for children to "write" stories. The physically challenged child can get
pleasure from creating along with his peers.

Outdoors, if this child can't participate in a kickball game, you might

encourage him to play with others in the sandbox. Encourage the children
there to create a drama with toys, using their voices rather than their bodies.

Here again you are helping the physically challenged child practice the skills
he does have. Remember to always praise his efforts. The harder the task, the
smaller the steps, and the greater the external rewards should be.

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  BENEFITS OF SPORTS PARTICIPATION

The term "participation" is defined by the World Health Organization as the

nature and extent of a person's involvement in life situations and includes
activities of self-care, mobility, socialization, education, recreation, and
community life.

Participation in activities is the context in which people form friendships,

develop skills and competencies, express creativity, achieve mental and
physical health, and determine meaning and purpose in life.

Children with disabilities tend to be more restricted in their participation than

their peers: a gap that widens as children become adults. One way in which
health care professionals can assist children with disabilities to participate
fully in the lives of their families and communities is by promoting
participation in sports, recreation, and physical activities in the least restrictive
environment.

The primary goals for increasing physical activity in children with

disabilities are to reverse deconditioning secondary to impaired mobility,
optimize physical functioning, and enhance overall well-being. Regular
physical activity is essential for the maintenance of normal muscle strength,
flexibility, and joint structure and function and may slow the functional
decline often associated with disabling conditions.

 Overall, the participation of children with disabilities in sports and

physical activities can decrease complications of immobility.

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  Sports participation enhances the psychological well-being of children
with disabilities through the provision of opportunities to form
friendships, express creativity, develop a self-identity, and foster
meaning and purpose in life.Special Olympics participants show
heightened self-esteem, perceived physical competence, and peer
acceptance when compared with nonparticipants. Parents of Special
Olympians reported that their child's participation promoted social
adjustment, life satisfaction, family support, and community
involvement.

FACTORS WHICH DETERMINES PARTICIPATION

The most frequently identified barriers to the active participation of children

with disabilities in sports and physical recreation are the child's functional
limitations (18%), high costs (15%), and lack of nearby facilities or programs
(10%). In fact, adolescents with disabilities cited the cost of specialized
equipment as the most frequent reason for nonparticipation. Participation is
further influenced directly by time, the home environment, and the child's
perceived self-competence and indirectly by social support from schools and
communities, family demographics, and family and child preferences.

Families who engage in physical activities themselves tend to promote similar

participation for their children with disabilities. Moreover, inactive role
models, competing demands and time pressures, unsafe environments, lack of
adequate facilities, insufficient funds, and inadequate access to quality daily
physical education seem to be more prevalent among populations with special
needs. Overall, environmental and family factors seem to be more significant

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determinants of participation than characteristics of the children themselves.
The establishment of short-term goals, emphasizing variety and enjoyment,
and positive reinforcement through documented progress toward goals can
help spark and sustain the motivation for participation

FACTORS TO BE CONSIDERED WHILE CARING FOR

PHYSICALLY CHALLENGED CHILD

development like physical, emotional, mental and social is slower, to a greater

or lesser extent, than that of a normal child, even though the handicapped
child is of normal intelligence. So his/her concept of himself/herself, as a
separate entity, is more difficult to achieve from the beginning. Mostly the
physically disabled children are blocked by the frustration and due to the
frustration these children attack on others or himself/herself.

1 .Building the Self-concept and Self-esteem:

It was found from the reviews that these children have very poor self-concept
as well as poor self-esteem so it is the duty of every person to encourage and
develop confidence in the children. There are many activities these children
can be involved in games and creative activities. This will help in
development of positive self-concept, self-worth and self-esteem.

2. Acceptance of ones disability:

Rather than being ashamed of their disability these children need to accept it.
It is the responsibility of the community that they provide healthy
environment for these children and develop positive attitude regarding their
disability.

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3 .Physical activities:

There is an absence of physical activity that the children enjoyed. There are
many activities these children can be involved in like games, sports and
creative activities. This will help in channelizing their energies and reduce the
frustration level.

4. Social involvement: Physically

challenged institutionalized children's social involvement was very low.

Institutions should provide outdoor activities like picnics, educational trips,
camps, so that these children interactwith other peoples and try to understand
the world. In this way they try to modify their behavior and also try tocontrol
their emotions especially frustration reactions.

5 .Community based rehabilitation:

Community can help by giving free seats to these students in various

professional as well as vocational courses. This will motivate these students to
go in for higher education, as theybelong to low-income families.

6 .Vocational training: Although the institution provides vocational training

like knitting, tailoring and music but itis not sufficient in today's world to earn
his or her living so institute should go in for computer education, technical
education and provide more avenues to children

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VISUAL REHABILITATION AND EARLY TRAINING

Long Cane Use: A Case Study" appears in the Winter 2010 issue of AER
Journal: Research and Practice in Visual Impairment and Blindness. The
article discusses the philosophy behind the early introduction of the long cane
and follows an Australian child's orientation and mobility training from the
age of 14 months to the age of 4 years, Like any toddler, T's first explorations
with her long cane included feeling it, chewing it, and banging it around. To
make it an essential part of her daily life, it was named "Tinkerbell" and
accompanied T and her family wherever they went. Gradually, rules about
using the long cane were introduced, including keeping it on the ground,
grasping it with the index finger pointed down, and using an appropriate arc
width.

T's orientation and mobility training during this time emphasized fun and
exploration. She was encouraged, but not required, to use the long cane. Over
time it became automatic for her to reach for it inorder to travel independently

The training included exposure to other visually impaired children who use a
long cane, allowing older children to serve as role models for the younger
ones. T attended Braille Nest, a weekly group program for visually impaired
children who are enrolled in their local schools, where they are generally the
only child with such an impairment.

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An essential part of T's success and all such early childhood orientation and
mobility programs is collaboration among those teaching the child. The
orientation and mobility specialists, early childhood teachers, parents, and
classroom teachers were made aware of techniques and terminology and
helped to reinforce them. T and other children like her are able to start school
independently with a set of positive skills already in place.

Inclusive Toys for Visually Impaired Children

Playing is an important and necessary part of childhood. When children play,

they discover and learn about themselves, their surroundings, and how to get
along with others. Toys encourage play and discovery and teach children
about people, places and things. Toys also promote social skills, emotional
development, and communication. While playing with toys, children develop
fine and gross motor skills necessary for participating in sports and other
recreational activities.

All children need to play and learn the skills that toys teach. Choosing toys for
children with special needs, though, is not as easy as child’s play. Selecting
toys for children with visual impairments can be more difficult, since much of
play and learning with toys is done through sight. Inclusive toys for visually
impaired children must offer additional encouragement in learning about their
environment and the different ways to explore it.

Following the below guidelines will help in choosing inclusive toys for
visually impaired children. Remember, though, each child has different

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abilities and unique interests. Toys should prompt children to use their
imaginations and spark their creativity.

 Choose toys that talk or produce sounds. To teach children with visual
impairments to rely on their auditory skills, toys should talk or make
real life noises. Products such as Hide ‘n Squeak Eggs by Tomy
introduces children to cause and effect as each egg makes noise. The
egg carton’s layout can also begin to teach about the Braille cell.

 Toys with bright colors, or ones with high contrast or lights encourage
children to best use the degree of vision they have. The Vtech Move &
Crawl Ball lights up and gets a child to move. This self-moving ball
plays music and animal sounds, and teaches numbers and shapes.

 Climbing and riding toy promote physical activity, movement, and

exploration. The Chicco Musical Roller is great for straddling or laying
over the roller while playing with a toy on the floor. It plays music, too.

 Use dolls, stuffed animals, and puppets to promote awareness of people,

places and things. The Jester book and doll a by The Jester & Pharley
Phund, encourages interaction and stimulates a child’s imagination. The
brightly colored doll has movable limbs and promotes interaction with
the character while improving a child’s auditory tracking skills.

 Find toys with different surfaces and textures. Toys with flexible or
rubbery surfaces, such as balls, rattles, and dolls appeal to children and
encourage them to feel common objects. Jumbo lacing beads, for

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 example, have many different shapes and textures that make a unique
textile experience. The Latches Puzzle encourages children to use their
fingers to manipulate different kinds of latches.

 Craft and art activities help enhance creativity. Crayola’s Color Me a

Song plays music as your child draws. For a child with limited vision,
the music can be extra incentive to draw. For the child without vision,
the music serves as primary feedback. Either way, this toy encourages
scribbling if children can see their drawing or not, and scribbling is both
fun and great for fine motor skills.

 Games are important to promote cooperation, sharing, and social

development. The Bop It game by Hasbro encourages social skills as
children compete to the beat as spoken and musical commands test their
reflexes, strengthening motor skills.

In selecting inclusive toys for visually impaired children, remember that

playing needs to be educational, but most of all, it needs to be fun. Children
receive the most benefits from playing when parents join the fun and talk
about activities with children. Proper adult supervision is always necessary to
ensure safety, too.

Source: Helping your Customers Choose Toys for Children who are Blind or
Visually Impaired by American Toy Institute and American Foundation for
the Blind.

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ORIENTATIONTRAINING

Orientation training is essential for getting children acquainted with their

bodies and their surroundings. Mobility training is needed for helping them to
get moved from one position or place to another in their environment.

Visually impaired children mostly make use of sound to detect any obstacle
in their path. A simple training about the different sounds, their direction and
distance made in the streets, in the kitchen, or going home from school may
help visually impaired children to travel independently. They should be
trained for making use of other senses to make safe movement. The way of
these children should be clear for their safe and efficient mobility.

Human guide system is the most common form of assistance to help these
children with orientation and mobility. They are trained in the human guide
system so that they can travel safely with another person.

Dog guide system is also useful in training these children for movement. A
trained dog is used by such a child as his/her guide. It is not very useful as a
dog cannot take a visually impaired person to the desired place itself.

They can also be trained to make use of cane for their mobility. They move
independently with the help of a cane. It is very essential that these children
should be trained from their early childhood the art of using canes for
developing independent movement in the society.

Electronic travel devices have been created to help these children with
independent movement. Some examples are, sonic guide, laser beam cane etc.

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These devices can provide an amazing assistance to these children to acquire
independent movement.

These are just some of the specific instructional techniques and tools that will
help visually impaired children develop independent movement at home,
school and in the community.

SPECIAL EDUCATION TRAINING: The specialized skills visually

impaired children must learn include:

Technology and computer proficiency--using computer and

telecommunication equipment and software adapted for blind or visually
impaired people.

Literacy--reading and writing with braille, large print, optical devices, or

training in effective use of available vision.

Safe and independent mobility--using specific orientation and mobility

techniques, long canes, or other mobility tools.

Social interaction skills--understanding body language and other visual

concepts. Personal management and independent living skills--learning
specialized techniques for personal grooming, food preparation, money
management, and other tasks.

Places for visually impaired children to receive their education

Children with visual impairments receive educational services from an array

of options that includes residential and special schools specifically designed
for blind and multiply disabled children, and special classes, resource rooms,

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and itinerant teaching services in regular education classrooms in the child's
community--where most visually impaired children are educated. Based upon
the individual needs of children and input from their parents and educators,
specialized schools, or classes are appropriate educational options for certain
students. In addition, special schools frequently provide outreach support and
technical assistance to public schools in their states.

Challenges faced by visually impaired children

Although many school programs provide the specialized instruction needed by

students who are visually impaired, there is much room for improvement. Too
many visually impaired students leave school without having mastered the
skills or knowledge essential for further education, gainful employment, and
independent living at home and in their communities.

There is a severe shortage of orientation and mobility specialists and qualified

teachers of visually impaired students, which restricts access to the specialized
skills these children need.

This means that students with visual impairments frequently receive

instruction from personnel who are not qualified to teach critical skills such as
braille, cane and other travel skills, and effective use of available vision.

This problem is even more alarming in rural communities, where shortages of

qualified personnel are most acute.

Equally detrimental is the continued perception by many that residential and

special schools for blind and visually impaired children are too costly, or,

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because most visually impaired children are educated in regular education
classrooms, unnecessary.

This fallacy persists despite the fact that education experts agree that for some
children, special schools are the best placement option, and that the
Individuals with Disabilities Education Act passed by the U.S. Congress
makes access to all educational placement options, including special schools,
every child's right.

Aural/Audiologic Rehabilitation for Children

Often with children, aural rehabilitation services would more appropriately be

called "habilitative" rather than "rehabilitative." "Rehabilitation" focuses on
restoring a skill that is lost. In children, a skill may not be there in the first
place, so it has to be taught -- hence, the services would be "habilitative," not
"rehabilitative."

Specific services for children depend on individual needs as dictated by the

current age of the child; the age of onset of the hearing loss; the age at which
the hearing loss was discovered; the severity of the hearing loss; the type of
hearing loss; the extent of hearing loss; and the age at which amplification was
introduced. The aural rehabilitation plan is also influenced by the
communication mode the child is using. Examples of communication modes
are auditory-oral, American Sign Language, total communication, Cued
speech, and manually coded English.

The most debilitating consequence of onset of hearing loss in childhood is its

disruption to learning speech and language. The combination of early

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detection and early use of amplification has been shown to have a dramatically
positive effect on the language acquisition abilities of a child with hearing
loss. In fact, infants identified with a hearing loss by 6 months can be expected
to attain language development on a par with hearing peers.

Aural rehabilitation is the process of identifying and diagnosing a

hearing loss, providing different types of therapies to clients who are hearing
impaired, and implementing different amplification devices to aid the clients
hearing abilities.

components of aural rehabilitation:

1. Detection: also called awareness, this category has to do with

recognizing the presence or absence of sound.
2. Discrimination: in this category, a person would be able to say if two
sounds are same or different.
3. Recognition: in the recognition a person is able to identify what the
sound or word is.
4. Comprehension: when comprehending, a person is not only able to
identify the sound, but understand what that sound means. For example,
upon hearing the doorbell the person would know to get up and answer
the door.

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 General steps for aural rehabilitation of a child

Aural habilitation/rehabilitation services for children typically involve:

 Identification of hearing loss

 Audiologic evaluation
 Hearing aid and or assistive listening device evaluation and use
 Parental guidance to to select appropriate therapy program
 Early intervention program
 Training in auditory perception:
This includes activities to increase awareness of sound, identify sounds,
tell the difference between sounds (sound discrimination), and attach
meaning to sounds. Ultimately, this training increases the child's ability
to distinguish one word from another using any remaining hearing.
Auditory perception also includes developing skills in hearing with
hearing aids and assistive listening devices and how to handle easy and
difficult listening situations.
 Using visual cues.
This goes beyond distinguishing sounds and words on the lips. It
involves using all kinds of visual cues that give meaning to a message
such as the speaker's facial expression, body language, and the context
and environment in which the communication is taking place.
 Improving speech.
This involves skill development in production of speech sounds (by
themselves, in words, and in conversation), voice quality, speaking rate,
breath control, loudness, and speech rhythms.

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 Developing language.
This involves developing language understanding (reception) and
language usage (expression) according to developmental expectations.
It is a complex process involving concepts, vocabulary, word
knowledge, use in different social situations, narrative skills,
expression through writing, understanding rules of grammar, and so on.
 Managing communication.
This involves the child's understanding the hearing loss, developing
assertiveness skills to use in different listening situations, handling
communication breakdowns, and modifying situations to make
communication easier.
 Managing hearing aids and assistive listening devices.
Because children are fitted with hearing aids at young ages, early care
and adjustment is done by family members and/or caregivers. It is
important for children to participate in hearing aid care and
management as much as possible. As they grow and develop, the goal is
for their own adjustment, cleaning, and troubleshooting of the hearing
aid and, ultimately, taking over responsibility for making appointments
with service providers.

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ROLE OF A NURSE IN AURAL REHABILITATION:

A nurses uses various various rehabilitative therapies which includes

 Hearing aid orientation: the process of providing education and

therapies to persons and their families about their use and expectation of
wearing hearing aids to improve communication.
 Cochlear implantation: is a device that is surgically implanted in the
brain to help the user hear. The device runs through the cochlea in the
ear and sends electronic messages to the brain when sound is detected.
 Listening strategies: the process of teaching hearing impaired persons
common and alternative strategies when listening with or without
amplification to improve their communication. The assistive listening
device includes,
 TTY: it is a text device that hooks up to a telephone. Two people
with TTYs can type back and forth over a phone line to
communicate.
 Captioning: it is a service available on all newer Television made.
The words that are said on a TV show or a movie will appear at
the bottom of the screen for a person with a hearing loss.
 Amplifiers: an amplifier can be attached to a telephone to make
the voice heard on the other end of the line louder.
 Telephone light vibration: devices can be attached to telephone or
doorbell with light or vibration to make alert them that someone
is at the door

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 Alarming alerting devices: these can be attached to fire alarms or
other alerting things so a person can see a light or feel a vibration
if one of these alarms goes off.
 Hearing dogs: it can alert a deaf person of danger as well as daily
events such as as a phone ringing.
 Speech reading: the process of using or teaching the
understanding communication using visual cues observed from
the speakers mouth, facial expressions, and hand movements
 Auditory training: the process of teaching an individual with a
hearing loss the ability tom recognize speech sounds, patterns,
words, phrases, or sentence via audition.
 The Unisensory: therapy philosophy that centers on extreme
development of a single sense for improving communication
 Cued speech: the process of using and teaching manual hand or
facial movements used to supplement an auditory- verbal
approach to the development of communication competence
 Total communication: the process of using and teaching speech,
language, and communication skills simultaneously using manual
communication, speech, and hearing.
 Manual communication: the process of using and teaching
communication via finger spelling and with a signed language.

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SPECIAL EDUCATION:

When the child turns 3, an Individualized Education Program (IEP) is

developed. The services provided are designed to maximize the child's success
in the general education environment and transition to postsecondary
education programs (vocational, higher education, technical). Again, the IEP
may specify audiology services, speech-language pathology services, and the
services of teachers of the deaf and hard of hearing. Each professional has a
role to play in the child's educational achievement and success.

Organization of deaf child

VAANI is an organisation that works to empower the deaf child. Its role is to
act as a catalyst. Rather than delivering services, VAANI supports the

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development of accessible sustainable services for deaf children and their
families whilst working closely with the overall development strategies of the
country. VAANI works with local organisations to build on existing good
practices to develop a resource base and understand what works for deaf
children and their families in India.

 . Deaf Aid society, Bangalore Sheela Kotvala Institute for the Deaf,
Rustum Bhag, HAL Road,
Bangalore- 560017
 Nassio Karnataka Branch, Bangalore Hamsadwani Deaf Children
school, No.32,
Hale Bannimangala, Indiranagar 1st stage, Bangalore
. National Association for the Blind, Karnataka,Branch, Bangalore
Mobility training Centre, CA site, No.4, Jeevanbhimnagar, Bangalore-
560075

CONCLUSION

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Many individuals with disabilities are still, to a large extent, socially
segregated and experience negative societal stereotypes and low performance
expectations, rendering them with limited opportunities for participation in
group physical activities.

These attitudinal barriers in the community contribute to a lack of awareness

regarding current programs and opportunities for participation.

Although specialized programs are beneficial, the participation of children

with disabilities with other children in community activities can reduce
societal barriers.

It is a common misconception that children with disabilities are susceptible to

trauma and, therefore, should avoid rigorous sporting activities that are
typically associated with injury.

Although athletes with disabilities have rates of injury similar to those of other
athletes, fear of injury frequently remains a barrier to participation. Overall,
misconceptions and attitudinal barriers at the level of the individual, the
family, and the community need to be addressed to integrate children of all
abilities into recreational and sports activities.

Role Of Pediatric Nurse

96
 Attend to morbidity, mortality, and contributing factors at the micro and
macro levels of society.

 Support programs of study that are longitudinal, sequential, and

comparative and that continue to examine phenomena from small to
larger contexts.

 Move from reviews of the literature, concept analyses, and proposals for
investigation

 Focus on the interventions and outcomes of a study .

 Synthesize the above mentioned recommendations to generate research

beyond the theoretical and small-scale application.

 Draw evidence-based conclusions based on scientific findings.

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Research Study

Children's nursing and interprofessional collaboration: challenges and

opportunities

Abstract

Interprofessional working has been the subject of recent debate in the nursing
press.•

Despite this heightened scrutiny little attention has been given to putting this
development in the context of practitioners working within children's nursing.

This paper seeks to• redress this imbalance by focusing on the challenges and
opportunities for professional development that interprofessional collaboration
working offers.

This is illustrated by• acknowledging existing themes of good practice, and

identifying the potential for new ways of working that maintain professional
status, skills and knowledge but also facilitate wider collaboration

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Challenges in maintenance of Interdisciplinary collaboration

Improving team structure and heightening communication

Interdisciplinary learning opportunities have been effective in developing

collaborative skills among those new to their professions

A recent systematic review of evidence for the effectiveness of

interdisciplinary education as a strategy to build collaborative relationships
found no definitive outcomes

Culture change is at the heart of improving communication, teamwork, and

collaboration

Improving communication is evidence-based care that benefits patient safety

and care quality.

BIBLIOGRAPHY

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 1. Behrman’s R. E. Nelson’s “Text-book of Pediatrics”, Published by
Elsevier Publications, 17 th edition, 2006, pp 10-12.

 2. Datta P.S., “Pediatric nursing” Jaypee Brothers publications, 1 st

edition, 2007, pp 2-6

 3. Dorothy R. Marlow’s, “Textbook of Pediatric Nursing”, Saunders

Elsevier publications, 6 th edition reprint, 2009, pp 1-8

 4. Wong’s, “Nursing care of infants and children”, Elsevier’s

Publications 6 th edition, 2007 pp 1-8

 5. Robin, A. R. (1998).  ADHD in adolescents: Diagnosis and

treatment.  New York: Guilford. (info@guilford.com; 800-365-7006)

 6. Barkley, R. A. (1998).  Your Defiant Child: 8 steps to better

behavior.  New York: Guilford.

 7. Nadeau, K., & Biggs, S. (1995).  School strategies for ADD teens. 
VA: Chesapeake Psychological Services. Call the ADD Warehouse at
800-233-9273 to order.

 8. Reiff, M. I. (2004).  ADHD: A complete authoritative guide.  Elk

Grove, IL: American Academy of Pediatrics.  141 Northwest Blvd., Elk
Grove, IL 60007

 9. Wilens, T. (1999).  Straight talk about psychiatric medications for

kids.  New York: Guilford (phone: 800-365-7006).

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 Internet access:-

 http://patientinfo.nimh.nih.gov/SchizophreniaPediatric.aspx

 www.schizophrenia.com/index.php

 www.mentalhealthamerica.net/index.cfm?objectId=C7DF8F81-
1372-4D20-C84C5539FAB14576

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