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VOLUMF; 36 AUGUST 1965 NUMBER 2
COMMENTARY
THE
HANDICAPPED
CHILD
A
Si\IJN.tit 011 \Iotor Handicapped Chil-cireti \\‘1S coiivenecl at the InternatiOfl1l Children’s Centre in Paris on Decviii-l)cr 7. 8, 9, 1964. and was notal)le for the (1CCI) concern (lisplaveci by the many
rep-resentative tiations for the disabled child.
There appeare(1 to be a universal expansion
of the concept of the handicapped child to include many con(litions beyond those of an
orthopedic nature.
The
Children’s
Bweanof the United States now concerns itself
with many pro1)le11s including disorders of
any one of the senses, epilepsy, congenital heart disease, and other congenital defects. One of the l)roadest definitions was that
provided 1w Andersen of the Danish Na-tional Institi ite of Social Research wherein was included all individuals with a disease or defect of such degree that the afflicted
person. if unskilled and without support
from his surroundings “would have
diffi-cultv coping with daily life on an equal footing with others.” It was generally
con-ceded by all participating nations that
ac-ctirate statistics on the incidence of
handi-cap were not available because of
varia-tions in diagnosis and imprecise knowledge of the exact number of cases within a given
population. For the most part, estimates were based on services provided to thos(’ recognized cases within a community. The
need for more intensive case finding was
accepted 1w all.
It voiild he difficult to compare figures between nations because of differences in
the definition of the handicapped child and
because of the variations in the age groups
selected. Professor Contcharova of
Lenin-grad included individuals tip to 35 years
whose COfldlitiOtl ‘as first exhibited in
child-ho#{252}d.In Denmark the age group was 15
to 61 years and in other instances the oh-servations were restricted to a considerably
younger group. In the United States the
Crippledi Children’s Service in 1962
ren-dered services to approximately 5 per
1,000
individuals under 21 years of age. Congeni-tal malformations mclu(ling men ingocele, heart disease, orthopedic defects, cleft pal-ate, cataract, etc., constituted the largest group. A survey from five districts of France
reveals an incidence of motor handicaps
varying from 2.5 to 4.9 pt” 1,000 population with a large segment attril)utal)le to cere-bral palsy. The figure presented for Sweden was 2.04 peer 1,000 and for Czechoslovakia 11.3 per 1,000. In all instances disturbances
of the central nervous system were
promi-nent. In most cases surveys were based
upon selected communities within the
na-tion. It is likely
that
a large number ofhandicapped children within each
commu-nit’ does not come within the purview of
the reporting agencies.
l)r. Janda of Prague presented the
interesting observation that mothers of
160 THE HANDICAPPED CHILD handicapped children exhibit a stillbirth
rate some tenfold higher than a control
group.
Dr. Fabia of Paris commented on the rise
in the proportion of children with cerebral palsy between 1920 and 1954, an occurrence
noted in many of the other nations, and
believed to be due in part to the advent of
antibiotics and greater survival of children,
many of whom previously succumbed to
in-fections in earlier life. The incidence of
or-thopedic problems was extremely variable
and the early diagnosis of such malforma-tions as congenital dislocation of the hips
erratic. In some places most children with
this disorder were not discovered until after
the age of 1 year. This realization led to
emphasis on better teaching of physicians charged with the care of the infant.
An aggressive approach to the rehabilita-tion and treatment of the handicapped child
was endorsed. Dr. Sharrard, presenting the
experiences of a group from Sheffield, Great Britain, indicated that surgical treatment of
spina bifida on the first day of life as
con-trasted to conservative management, led to
significantly better results. Dr. P. Masse of
Paris discussed the effects of motor
handi-caps on growth and development and
pre-sented some interesting results on the use of bone transplants for the correction of
cer-tain major congenital malformations. A
most impressive presentation by Professor
M. Weiss of Poland exemplified a vigorous
program, primarily of physiotherapy and
education, for children with acquired
para-plegia. Modern equipment and devices to
keep these children out of bed as much as
possible and in an erect posture were
ex-hibited in an excellent film. Dr. Grossiord
of Garches, France, also presented a
vell-co-ordinated program and discussed the
need to recognize certain related problems
bureaucrat.” He emphasized the need for
co-ordination of care, overlapping of
ser-vices, a flexible program, attention to the
environment in which the handicapped child develops and home care versus
insti-tutional care. He did not take a firm posi-tion in the last matter but felt that the
de-cision depended upon the particular case
and that there were instances where the
home care could not be adequate,
espe-cially in the early stages of rehabilitation.
Professor P. Plum of Denmark found home
care programs applicable to a significant
number of handicapped children over the
age of 3 years. He recommends that the
treatment for cerebral palsy should begin
at once, that children in their homes must
have regular responsible physician care and
must attend periodically special treatment centers. He believes that they should he en-rolled in nursery schools as soon as possible perhaps as early as 2 years of age.
“Every-thing possible must be done to help the
child to hear, to see, to understand, to touch
and to move.” ‘Iadame Dehre of Paris
rendered a most interesting presentation of
an experimental study in France by
place-ment of certain handicapped children in
foster homes.
Much discussion was centered on the
‘-chological development and problems of
children with motor handicaps. These with
severe intellectual retardation are offered
very little at this time. Miss Gibbs of the
Child Guidance Training Center in London
finds no change in the “I.Q. category” in
children with cerebral palsy between an
early and a later age although a few cases
appear to drop probably l)ecause of
proi)-lems of speech. Certain problems arise in
these children as a result of excessive
ambi-tion on the part of the parents. She finds
donment, particularly in those children with flaccid paresis, are common. These children should never be left alone.
Another expression of the positive
thera-petitic approach at the Seminar was
indi-cated in the lengthy discussion of an imag-inative approach to the use of prosthesis for
children with congenital amputations. The
problem of congenital amputations is
cur-rently a major one in those European
na-tions suffering from the aftermath of the
thalidomide tragedy. Professor NI.
d’Avig-non of Stockholm presented a broad
discus-sion of the problem with a classification and a consideration of the indications for
pros-thesis. Professor Hepp of Munster truly
excited the Seminar with his ingenious work on the development of prosthetic appliances
for children. He taxes his imagination to
the utmost in order to allow these children
to “get about” whether with prosthetic
ap-pliances or electrical wheelchairs.
Most participants indicated the
impor-tance of research in order to better
under-stand the etiology of all handicapping
con-ditions with the hope of preventing them.
This interest was implemented by tile pres-ence of the eminent Professor Jost of Paris
who discussed some experimental work
re-lating to limb deformity or amputation dur-ing embryologic life.
Tile common concern of many nations on
1)0th sides of the Iron Curtain for the
dis-abled members of tile human race was
re-sponsible for a union at this Seminar based
on compassion, anti a firm medical and
sci-entific commitment. One may conclude that
better information on tile incidence of
hand-icapped individuals in all communities is
essential if appropriate care is to be brought
to them. It is also apparent that treatment
programs should be cohesive and well
inte-grated by a team which works closely
to-gether, whether the child is in the hospital
or at home. Details of one such program are
presented on pages 277-281 of this journal.
In any case, special efforts to educate these
individuals must include vocational
coun-seling, so that they may realize optimal
pro-ductive accommodations in human society.
Appropriate research into areas which may
elucidate the causes and prevention of
crip-pling conditions is to be encouraged and
supported. Just as practicing physicians
must learn to recognize defects as early as
possible, they must also discover and intro-duce all facilities for appropriate cohesive treatment within their communities, and
they should provide earnest personal sup-port to the child and family, particularly
when home care is employed.
ALFRED M. B0NGI0vANNI, M.D.
Children’s Hospital of Philadelphia
Department of Pediatrics, University of Pennsylvania
