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CEREBRAL PALSY AND INTELLECTUAL DISABILITIES
Consequences of Hypoxic-Ischemic
Encephalopathy
by Jennifer
Ostroff
 Hypoxic-ischemic
encephalopathy (HIE) is a condition
that causes brain damage due to insufficient
oxygen flow during childbirth. HIE can
result from any condition, injury, or
complication that causes the brain to
have a reduction in blood flow and oxygen
deprivation (Robertson
& Perlman, 2006). These risk
factors include: maternal
diabetes, pregnancy-induced
hypertension, intrauterine
growth retardation (IUGR), maternal
hypotension-shock, severe bleeding,
placental
insufficiency or abruption,
umbilical
cord prolapse, prolonged expulsive
period, and dystocia.
Hypoxic-ischemic encephalopathy can
result in infant mortality and morbidity;
it often causes long-term brain damage
such as intellectual disabilities, delayed
development, seizures, and cerebral
palsy (Sotero
de Menezes & Shaw, 2006).
One of the
most common techniques used to measure
the severity, and monitor the progress
of an infant with HIE, is a three-stage
categorization method known as the Sarnat
and Sarnat system. This system helps
to determine the most useful long-term
prognosis and future decisions specific
to the individual infant. The timing
and type of individual childhood follow-up
after HIE are dependent upon the presence
and intensity of impairments (Robertson
& Perlman, 2006). Key concerns
are adequate feeding and nutrition,
head growth, visual awareness, and motor
development. Oral-motor function, including
facial and mouth muscle tone, salivary
control, coordination of feeding and
swallowing, and early vocalization,
are evaluated (Sotero
de Menezes & Shaw, 2006).
Patients
with motor, speech, or cognitive disabilities
need early intervention programs, at
zero to three years of age, to provide
serial testing and therapy by occupational,
physical, and speech therapists in order
to maximize their developmental outcome.
Testing by a neuropsychologist is crucial
in placing these children in the appropriate
school environment (Sotero
de Menezes & Shaw, 2006).
Further adapted physical education programs
or therapies depend upon the permanent
impairments of the HIE insult. Examples
of two possible permanent disorders,
cerebral palsy and intellectual disabilities,
are as follows (Robertson
& Perlman, 2006).
The rate
of cerebral palsy (CP) and intellectual
disabilities in the surviving infants
with HIE is frequently used as an end
point for comparison among the various
factors and symptoms thought to be associated
with perinatal
hypoxemia and ischemia
(Sotero de Menezes
& Shaw, 2006). Severe cerebral
palsy, caused by neonatal HIE, is usually
detected by 12 months of age, and more
moderate forms of cerebral palsy by
two years of age (Robertson
& Perlman, 2006).
CP is a chronic,
non-progressive neurological disorder,
which appears in infancy or early childhood,
and permanently affects body movement
and muscle coordination
(Himmelmann, G. Hagberg, Beckung, B.
Hagberg, and Uvebrant, 2005).
It is caused by abnormalities inside
the cerebral cortex that disrupt the
brain's ability to control movement
and posture (Himmelmann
et al., 2005).
The majority
of children with CP have congenital
cerebral palsy, meaning they are born
with it. This type of CP is caused by
four types of brain damage including:
damage to the white matter of the brain
(periventricular
leukomalacia), abnormal development
of the brain (cerebral
dysgenesis), bleeding in the brain
(intracranial
hemorrhage), and brain damage caused
by lack of oxygen to the brain (hypoxic-
ischemic encephalopathy). A small percentage
of children have acquired cerebral palsy,
which means the disorder begins after
birth. In these cases, the causes of
CP are more easily detected and usually
result from brain damage in the first
few months of life, brain infections,
or head injuries from a motor vehicle
accident or fall (NINDS,
2009).
The most
common forms of cerebral palsy are classified
by the type, extent, and location of
the child's disabilities. The terms
spastic (stiff muscles), athetoid (writing
movements), or ataxic (poor balance
and coordination) are used to describe
the type of movement disorder involved
with CP. The Latin suffixes paresis
(weakened) and plegia (paralyzed) are
used to describe the severity of a child's
affected limbs.
Lastly, the
location or number of affected limbs
is described using the Latin prefixes
hemi (half), quad (four), and di (two).
A child can also have a combination
of the different types of CP, known
as mixed cerebral palsy, where some
of their muscles may be stiff while
others are floppy (NINDS,
2009). Unfortunately, it is very
common for children with CP to have
additional medical conditions because
CP involves the brain, and the brain
controls various body functions. Therefore,
CP can affect intellectual development,
cause seizures, and impair vision, hearing,
speech, and behavior
(Himmelmann et al., 2005).
Although
CP cannot be cured, treatment and adapted
physical activity programs can be implemented
to help children learn new ways to accomplish
the tasks that challenge them. The earlier
the treatment begins, the better chance
the child has of overcoming developmental
disabilities and enjoying a near-normal
adult life.
People with
CP should utilize a physical therapy
program that incorporates specific sets
of activities to prevent deterioration
of muscles that aren't being used, along
with exercises to keep muscles from
becoming fixed in an abnormal position.
Strength training and other types of
exercise should also be used to increase
muscle performance. In order to optimize
upper body function and improve posture
and mobility, children should participate
in occupational therapy. This type of
therapy will also help children master
daily life activities such as eating
and dressing, which helps promote independence
and self-reliance. Braces and other
orthotic devices are often utilized
to compensate for muscle imbalance and
increase independent mobility
(NINDS, 2009).
Recreational
therapies, like horseback riding, and
behavioral therapies improve a child's
gross motor skills, speech, self-esteem,
and emotional well-being
(NINDS, 2009). Applying these
types of physical therapy programs to
children with cerebral palsy will greatly
improve their quality of life.
As noted
earlier, both hypoxic-ischemic encephalopathy
and cerebral palsy are related, or can
lead to intellectual disabilities (formerly
known as mental retardation) and developmental
delays (Sotero
de Menezes & Shaw, 2006).
The American Association on Intellectual
and Developmental Disabilities ([AAIDD],
2009) defines the term "intellectual
disability" as a "disability
characterized by significant limitations
both in intellectual functioning and
in adaptive behavior, which covers many
everyday social and practical skills"
(Definition section,
para. 1). It refers to a particular
state of functioning that begins before
the age of 18, has many components,
and is affected positively by individualized
supports. Intellectual functioning refers
to one's general mental capacity such
as reasoning, learning, and problem
solving. Adaptive behavior is comprised
of three skill types including conceptual
skills, meaning literacy and language;
social skills, such as interpersonal
skills and self-esteem; and practical
skills, referring to one’s everyday
activities (AAIDD,
2009).
Children
with intellectual disabilities can and
do learn many of the same skills as
the average child; they just develop
them at a slower rate (Centers
for Disease Control and Prevention [CDC],
2005). There are different degrees
of intellectual disability, ranging
from mild to profound. The severity
of one's intellectual disability can
be measured by their intelligence quotient
(IQ), or by the types and amount of
support they need. Different testing
methods are necessary to construct an
individualized support plan specific
to each child with an intellectual disability
(Reid, 1982).
A combination
of informal and formal testing techniques
can be used to assess the child's physical
and motor fitness, fundamental motor
skills and patterns, and skills in aquatics,
dance, sports, and games. The testing
results are used to determine the child's
strengths and weaknesses, to develop
annual and short term objectives, and
to record the child's growth and development
(Stopka &
Todorovich, 2008). The tailored
support plans constructed from these
testing results are made to enhance
one's functioning within their own environment
and culture, enabling them to have a
better quality of life
(AAIDD, 2009).
Physical
education programs greatly benefit children
with intellectual disabilities because
they not only promote physical health,
but also positively affect one's intellectual
and emotional stability, the acquisition
of motor skills, and the development
of leisure time and social skills (Reid,
1982). Keogh suggests three types
of movement outcomes as an outline for
understanding the positive correlation
between movement and physical education
objectives for children with intellectual
disabilities.
The first
movement outcome Keogh describes is
movement control, or the ability to
move one's body in relation to environmental
demands; thus, promoting higher levels
of fitness and the acquisition of motor
skills. The second movement outcome
is movement behavior, which identifies
personal-social behaviors related to
the participation in physical activities.
Once one's personal-social behaviors
are indentified, the physical educator
can use movement to promote positive
behaviors such as confidence (Reid,
1982). The final motor outcome
Keogh describes is movement experience,
which indirectly provides the child
with aspects of perception, cognition,
language, and socialization. Active
learning strategies that incorporate
social tactics, reading, and arithmetic
directly into motor tasks should be
integrated into physical education programs
for children with intellectual disabilities
(Reid, 1982).
Physical
educators and special educators must
adopt strategies aimed at teaching important
physical skills and increasing levels
of fitness in children with learning
disabilities. There are a variety of
models and instructional procedures
that provide methods for teaching adaptive
physical education to children with
learning disabilities (Reid,
1982). Most of these models include
teaching a particular skill or task
through exploration, repetition, and
reinforcement. Educators and students
need to explore different methods of
tackling a challenging task to find
what works best for the student with
the intellectual disability.
For example,
if a student lacks a necessary skill
required to complete a particular task
the instructor may first need to teach
and reinforce the skill to the child
before proceeding to the more complex
task. The educator also needs to consider
the use of appropriate equipment needed
to allow a child with an intellectual
disability to successfully participate
or complete the task at hand (Stopka
& Todorovich, 2008)). For
example, the child may need adapted
equipment, such as a T-ball set, in
order to practice the skill of swinging
the bat without concern for predicting
the trajectory of an oncoming ball(Reid,
1982)).
In conclusion,
hypoxic-ischemic encephalopathy can
cause infant mortality or permanent
neurological morbidity (Sotero
de Menezes & Shaw, 2006).
Adapted physical therapy for an infant
who has HIE is very individualized and
dependent upon the permanent impairments
caused by the insult. Congenital cerebral
palsy and intellectual disabilities
are two common disorders that can result
from HIE (Robertson
& Perlman, 2006). Although
neither disorder can be cured, applied
physical education programs that stress
physical activity can help treat them
both. Physical activity promotes health,
emotional and social stability, and
the acquisition of motor skills, all
of which benefit a person with cerebral
palsy or intellectual disabilities
(NINDS, 2009; Reid, 1982).
references
Jennifer
graduated Magna Cum Laude from the University
of Florida in August 2010 with a Bachelors
of Science in Health Education and Behavior.
She is currently working as a Dermatological
Medical Assistant in New York City.
She plans on attending Physician Assistant
School in Summer 2011.
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