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 featurs of cerrbral palsy.

 Explin the management of cerrbral palsy.

 Define the mental retardation.

 Identyfy score of menntal redardation.

 Explain the causes of mental retardation.

 Identfy the featurs of mental retardation.

 Explain the mgt of mental retardation.

1
INTRODUCTION

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.

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 hockey, cricket, tennis etc.

Disability:-
It is defined as an inability to complete certain activites e.g.loss of limbs results in
inability to walk.

2
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.

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.

PHYSICALLY HANDICAPPED CHILD

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.

3
 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.

MENTALLY HANDICAPPED CHILD

Mentally handicap is now used mental retardation.

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.

CAUSES OF HANDICAPPED CHILD

Congenital anomalies.

4
Genatic disorder.

Poliomyelitis.

Communicable disease.

Perinatal condition.

Malnutrition.

Accidental injuriy & social-cultural factors.

Central nervous system dysfunction.

Heart Disease.

Bronchial asthma.

Muscular dystrophy.

Social abuse.

Organic problems-cerebral palsy,paralysis.

FEATURS OF CHALLENGED CHILD

Fracture

Rickets

Paralysis

Meningitis

Encephalitis

Cerebral palsy

5
Birth defects

Visual blindness

Refractory error.

Auditory disfunction

Hearing loos

Speech disorders

Child abuse

Drug Addiction

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.

MRI,CT Scan.

Surface electromyography.

EEG

6
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.

 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.

7
 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.

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

PREVENTION OF HANDICAPPED CONDITIONS IN CHILDREN

 Handicapping conditions of children can be prevented by improvement of

mental health & adequate care during preconception, prenatal & intranasal
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.

8
  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.

 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

 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.

9
 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.

 The handicapped child need to be trained for an independent living with

special training & education.

10
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.

11
WELFARE OF CHILDREN

 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.

12
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.

13
Child Guidance Clinic

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.

Juvenile justice Act,1986.

 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.

 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.

14
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 &
declares

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

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

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.

15
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.

 To encourage the couples for medical termination of pregnancy of

malformed fetus.

16
  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.

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.

17
  Knowledge deficit r/t disease condition.

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.

18
ANATOMY & PHYSIOLOGY OF BRAIN

19
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.

Birth asphyxia &Birth trauma

20
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

21
  Speech disturbances

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.

22
 Dyskinetic- uncoordinated or involuntary movements.

 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)

 Reflex abnormalities:

23
 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

DIFFERENTIAL DIAGNOSIS

 Neurodegenerative disorders .

 Hydrocephalus and subdural effusion.

 Brain tumors or space occupying lesions.

 Muscle disorders.

24
  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 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.

25
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.

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:

26
 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 . 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

27
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

PHYSIOTHERAPY

“Great works are performed not by strength, but by perseverance.”

Samuel Johnson

MENTAL RETARDATION

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

It is also known as cognitive developmental delay.

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.

Perinatal conditions-birth trauma

28
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.

INVESTIGATIONS

Detailed history.

Family history.

Birth history

Chromosomal studies

29
Csf study

X ray skull

Ct scan &MRI

IQ Test

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.

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.

30
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

Early marriage & teenage pregnency should be avoided.

Care of the girl child need special attention from the young age with good
nutrition,immunization-rubella,iodine deficency should prevented.

Each & every person understand to healthy mother can give birth of the healthy
child.

Genetic counseling given to the community,it help to prevents genetic &

chromosomal abnormalities.

Good obstetrical care is importants to prevents etiological factors related to mental

retardation.

Essential neonatal care to be provided to prevent neonatal complications like CNS

infections,kernicterus etc which is cause of MR.

31
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.

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

32
  Take child development course

 Intersectoral coordination

 Multidiciplinary co-ordination

Role Of Pediatric Nurse

 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.

REHABILITATION AND TRAINING OF CHALLENGED CHILDREN

33
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. 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

34
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

PATTERNS OF REHABILITATION

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 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
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
36
 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 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
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  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.
 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

38
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 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.

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 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
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.

40
 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.
 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
41
 can be used with severely handicapped and whilst a complex one can
be use with minimal handicapped patients
 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.

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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 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
 TO inculcate pride in self and a sense of loyality towards
the hospital
 To stimulate a belongingness to an organization
 To stimulate children to think and and organize in future.
 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.
 Focus on Abilities
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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 and lead
other children who are playing different instruments.

45
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.

  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.

46
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.
 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.

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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 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

48
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.

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,
49
 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

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

50
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.

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

51
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 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.

52
 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 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.

53
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.

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.

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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.
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

55
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, 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.

56
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, 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

57
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 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.

General steps for aural rehabilitation of a child

Aural habilitation/rehabilitation services for children typically involve:

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 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.
 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

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 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.

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.

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 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
 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

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  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.

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 development of

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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

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CONCLUSION

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.

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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

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

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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.

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

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

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contd........

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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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