Presentation on cerebral palsy (CP), with a focus on CP in Singapore. It examines the characteristics and impacts of CP, the possible educational pathways and assessments available for those with CP. We (my presenter, Camelia and I) believe that those with CP can lead fulfilled lives.
2. Cerebral Palsy
- Heterogenous group of
motor function disorders
- Non-curable
- Life-long condition
- Non-progressive
- May be congenital or
acquired
3. Prevalence
- 1 in 500 babies or
0.2%
- Occurs equally
among males and
females
4. Causation
- Insult / Injury to the brain
- In single or multiple areas of motor centers
- E.g. Meningitis, bleeding in the brain
- Development malformations, failures
- Cerebral dysgenesis
- Neurological damage
- Illness
- Lack of oxygen
- Trauma to the head during labour and delivery
- Infections
- Rubella, cytomegalovirus
11. *Degree of Severity
Mild
- Can live independently, move without assistance; his or her daily activities are not limited.
- 20%
Moderate
- Require self help for assisting their impaired ambulation capacity
- need braces, medications, and adaptive technology to accomplish daily activities.
- 50%
Severe
- Totally incapacitated and bedridden, significant challenges in accomplishing daily activities.
No CP
- Signs of CP, but impairment acquired after completion of brain development
- Incident that caused the cerebral palsy Eg. Traumatic brain injury or encephalopathy
12. *Symptoms
Early Signs
Baby Below 6 Months
- Head lags when picked up
- Stiff and/ or floppy
Baby Older than 6 Months
- Does not roll over
- Cannot bring hands together
- Difficulty bringing hands to mouth
General Symptoms
- Posture / balance problem
- Loss of control or coordination
- Abnormal tone
- Abnormal strength
- Abnormal reflexes
- Persistent motor delay
- Cognitive deficit
- Associated handicaps
15. Hands-On Activity (5-7min)
Goal: To experience what it is like to have
cerebral palsy or a caregiver
Client’s goal: To put on and button a shirt
Caregiver’s goal: To encourage independent
function
20. *Impact of Disability: Language
- Information input
- Auditory information processing
- Muscular control
- Over muscles of the mouth, tongue, throat
- Respiratory coordination
- Communication output
- Disjointed speech
- Slurred speech
- Cued speech / Sign language
- 1 in 4 cannot talk
21. *Impact of Disability: Language
- Augmentative & Alternative Communication
- Any device, system or method that improves the
ability of a person with a communication impairment
to communicate effective
- Types
- Aided communication: low-tech, high-tech
- Unaided communication: facial expression,
gestures
22. *Impact of Disability: Social
- Self
Adolescence
- Research found lower self concept in females →
physical appearance, social acceptance
Adults
- Less participation in social interactions, employment,
marriage and independent living compared to adults
without CP
24. *Impact on the Family
- Adequate knowledge helps family to cope
better
- Frustration
- Financial costs
- Need for behaviour management
- Financial costs
- Social Stigma
27. Cerebral Palsy Alliance Singapore
- Established in 1957
- Formerly Spastic Children’s Association of
Singapore
- Vision: Empowering all persons with CP to
realise their full potential and lead fulfilled,
dignified lives.
28.
29. Educational Pathways
Early Intervention Programme for Infants and
Children (EIPIC)
- Students: 6 months - 6 years
- Provide early intervention
- Prepare them for admission into Special Ed or mainstream school
- Provide holistics and individual development programmes
- Interdisciplinary team: interventionist, physiotherapist, occupational
therapist, speech and language pathologist, social worker,
psychologist
- Curriculum domains: cognitive, adaptive, social, fine motor, gross motor,
social-communication
30. Educational Pathways
Cerebral Palsy Alliance Singapore School
- Students
- Junior levels (7-12 years)
- Senior levels (13-18 years)
- Curriculum
- SPED
- Learning outcomes: living, learning, working
- Domains: social-emotional, academic (literacy, numeracy, science), daily living, vocational,
physical education and sports, the arts
- Programmes
- Academic: OWL
- Functional: EAGLE
- High Support: DOVE
- Community Integration Activities
- Total Defence Day, Racial Harmony Day, National Day
- Co-curricular Activities
- E.g. boccia, music and dance, scouts, special arts, swimming, deskbells and percussion
31. Educational Pathways
- Sensory impairment
- PSLE
- Mainstream education
- Intellectual disability
- Vocational education programme
- Delta Senior School or Metta School
- National vocational certification
- ITE Skills Certificate
- WDA Workforce Skills Qualifications
- Others
- Training centres / workshops
- Volunteer Welfare Organisations
- Open employment or
- Sheltered workshops / Work activity centres
32. Educational Implications (1)
Collaboration
- Necessary to ensure successful experiences
and support teachers to solve learning and
behaviour problems
- Specialist support
- Physical therapist, occupational therapist,
educational psychologist, speech language
pathologist, orthotist, counsellors, social workers
33. Educational Implications (2)
Environmental Modifications
- Accessibility and mobility
within school
- Transportation and
mobility between home
and school
- Toileting needs
- Seating arrangements,
desks, worktops
34. Educational Implications (3)
Teaching Modifications
- Special allowances for
academic requirements
- Reduced workload
- Extra time for completing
assignments,
examinations
35. Educational Implications (4)
Assistive Technology
- Any systematic device
or method for
accomplishing a
practical task
- Mobility devices
- Communication devices
- Writing implements
36. Assessments
Assessments
- Intelligence Tests
- Vineland
- WISC
- Waschler
- Academic performance
- Capacity to learn
- Others
- Adaptive delay or
impairment
- Communication level
- Emotional status
- Health
- Motor abilities
- Social ability
- Vision and Hearing
39. Suggested Videos
Singapore case study of CP: https://www.youtube.com/watch?v=PyxJmHi6atk
Singapore Unsung Heroes: https://www.youtube.com/watch?v=-OIvZTOI3Gw
Singapore National Cerebral Palsy Football Team: https://www.youtube.com/watch?v=kg07tCb8ddk
Maysoon Zayid on TED: https://www.youtube.com/watch?v=buRLc2eWGPQ
41. References
Challenging Behaviour and Cerebral Palsy, Capability Scotland, http://www.capability-
scotland.org.uk/media/57694/challenging_behaviour_and_cerebral_palsy_12.pdf
Emerson, E., Cummings, R., Barrett, S., Hughes, H, McCool, C. & Toogood, A. (1988). Challenging behaviour and
community services: 2. Who are the people who challenge services? Mental Handicap, 16, 16-19.
Olawale, O. A., Deih, A. N., & Yaadar, R. K. (2013). Psychological impact of cerebral palsy on families: The African
Perspective. Journal of Neurosciences in Rural Practice, 4(2), 159-163.
Penner, M., Xie, W. Y., Binepal, N., Switzer, L., & Fehlings, D. (2013). Characteristics of pain in children and youth with
cerebral palsy. Pubmed. doi: 10.1542/peds.2013-0224.
Shapiro, B. (2008). Health and well being of adults with cerebral palsy. Current Opinion in Neurology, 21(2), 136-142.
doi: 10.1097/WCO.0b013e3282f6a499.
Shields, N., Murdoch, A.,Loy, Y., Dodd, K. J., & Taylor, N. F. (2006). A systematic review of the self-concept of children
with cerebral palsy compared with children without disability. Developmental Medicine & Child Neurology, 48(2), 151-
157. doi: http://dy.doi.org/10.1017/S001262206000326.
Nomanbhoy D.M., & Nonis K.P. (2004).Learners with Physical Disabilities. In Levan Lim & Marilyn Mayling Quah (Eds.)
Educating Learners with Diverse Abilities. Singapore: McGraw-Hill Education
Reddihough, D. S., & Collins, K. J. (2003). The epidemiology and causes of cerebral palsy. Australian Journal of
physiotherapy, 49(1), 7-12.
Notas do Editor
Presenters Goals:
Complexity of CP in the disability and treatment
Giving people a good overview of what CP is and is like
Focus on educational pathways, interventions and strategies
Cerebral (Latin: Cerebrum)
Affect part of brain
Palsy (Para: beyond; lysis: loosening)
Lack of muscle control
A heterogenous group of movement disorders
an umbrella term
not a single diagnosis
Can be congenital (before, during birth) or acquired (28 days after birth)
Insult / Injury to the brain
Fixed, static lesions
In single or multiple areas of the motor centers of the brain
Early in central nervous system development
Development malformations
Brain fails to develop correctly
Neurological damage
Can occur before, during or after delivery → Causal Pathway
Illness, severe lack of oxygen or blood flow to the brain, stroke
Infection
Placenta or blood of mother
Every CP person is unique. CP persons might need help in one or more areas such as cognitive, functionality, mobility, fitness, emotional, psychological, speech, social, sensory and independence.
Interview
History taking
May include all that may predispose an infant to brain damage or CP
Risk factors
Psychosocial factors
Family adaptation
Child’s health history
Often admitted to hospitals for corrective surgeries and other complications
Respiratory status
Motor function
Presence of fever
Feeding and weight loss
Any changes in physical state
Medical regimen
No treatment to cure cerebral palsy
Brain damage cannot be corrected
Crucial that there is:
Early identification
Multidisciplinary care
Support
General management
Proper nutrition and personal care
Pharmacologic
Botox, Intrathecal, Baclofen
Control muscle spasms and seizures
Glycopyrrolate
Control drooling
Pamidronate
May help with osteoporosis
Surgery
Loosen joints
Relieve muscle tightness
Straightening of different twists or unusual curvatures of leg muscles
Improve the ability to sit, stand and walk
Physical adis
Orthosis, braces, splints
Positioning devices
Walkers, special scooters, wheelchairs
Special education
Rehabilitative services
Speech and occupational therapies
Family services
Professional support
Neuroimaging:
Magnetic Resonance Imaging
Computer Tomography Scan
EEG
Laboratory Tests
Blood tests, urine tests
Assessment tools
Peabody Development Motor SKills
Denver Developmental ScreenTest II
Spastic CP: Tight or stiff muscles
Dyskinetic CP: Difficulty controlling and coordinating muscles
Twisting and repetitive movements
Chorea: Dance-like Irregular movements
Athetosis: Slow and involuntary movements → present as rest and in attempts to move
Ataxic: Depth perception and balance affected
Intention tremor occurs when reaching for an object, and worsens as they go nearer to the object
Quadriplegia (4)
Both arms and limbs are affected (so are mouth, face and trunk)
Triplegia (3)
Three limbs are involved, usually affecting both arms and one leg
Hemiplegia (2)
One side of the body affects. The arm is usually more affected than the leg
Monoplegia (1)
Only one limb is involved, usually affecting an arm
The children with cerebral palsy gained bladder and bowel control at older age in comparison with their siblings and healthy children. They also had more frequent enuresis and urinary infections.
Hearing
Visual
Refractive errors
Most prevalent visual impairments:
Hyperopia (farsightedness)
Myopia (nearsightedness)
Astigmatism
Strabismus
Crossed eyes
Amblyopia
Lazy eye
Brain purposely suppresses the weaker eye preventing the child from having blurred or double vision
Cataracts
Clouding of the lenses
Cortical blindness
Brain cannot interpret and process information correctly
Intellectual & Functional Problems
Eating, Sleeping
Communication
Digestive, Bladder and Bowel movement
Pain → Contractures, Abnormal postures, Skin breakdown
Seizures, Epilepsy → Partial seizures, Generalized seizures
Intellectual impairment, Mental Retardation, Learning Disabilities
Psychological/ Behavioural
Emotionally unstable/ Problems
Behavioural/ Conduct Problem
Others
Dental Problems
Sensory Integratory Problems
Pain: http://www.ncbi.nlm.nih.gov/pubmed/23858420
Mental retardation
Brain functioning
35% will have normal intelligence
Includes above average intelligence
Learning difficulties
Short attention span
Motor planning difficulties
Perceptual difficulties
Language difficulties
Literacy
When it comes to literacy, children with cognitive impairments may not read like other children, but it doesn’t mean they are incapable of understanding what words mean.
Different methods of learning eg. visual cues, technology and demonstration to aid learning
Cerebral palsy often affects the language centers of the brain that control speech. In mild cases of cerebral palsy, a child may have difficulty using the correct words, but in more severe cases, a child’s ability to verbally express himself or herself might be seriously impeded. Under these circumstances, the speech and language pathologist will assist in finding ways in which the child can begin to communicate through ques (winking or lifting a finger), sign language, or with the assistance of augmentative communication devices (DynaVox or computers).
Articulation
Moderate to profound vocal communication disorders (70-80%). The muscles that control speech are often affected. Poor speech can complicate cognitive assessment.
Dysarthrias
Most common
Difficulty controlling muscles to coordinate speech movement
Hypernasal
Hyponasla
Speech may sound slow and slurred
Voice Problems
Spastic Palsy
Harsh vocal quality, increased intensity, high pitch
Athetoid Palsy
Hoarse vocal quality, fluctuating intensity, variable pitch
Ataxic Palsy
Hoarse vocal quality, fluctuating intensity, and variable pitch
Dysphagia
Related to muscular speech mechanisms
Due to muscles beginning spastic, athetosis, ataxic or flaccid
People with cerebral palsy may cough, gag, or choke when eating.
Challenging behaviour
“behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to and use of ordinary community famiclities (Emerson et al 1988)
Reasons:
Biological causes, genetically linked, levels of arousal
Learned
May be a means of communication
Sign of distress, anger, frustration, discomfort, pain
May be response to environment: over/ under stimulation
Asian Women’s Welfare Association School
Spastic Children’s Association School now known as Cerebral Palsy Alliance of Singapore School of which we take an indepth look
CPAS
Early Intervention [Preschool: 0-6 years]
Special Education → SPED [7-18 years]
MOE
Access to mainstream schools
Approved Training Centres / Organisations
Vocational training
Teacher to student ratio: 1:6
Delta Senior School / Association for Persons with Special Needs
Metta Welfare Association
CPAS: Goodwill, Rehabilitation and Occupational Workshop (GROW)
Sheltered workshop
Vocational training
Assembly work
Social enterprise initiatives
Orange Garden Cafe
Art and Craft Workshop
Pushcarts
We are still in the planning phase to help our clients with job placements. Our GROW workshop is our best example. Trainees get allowances and are sheltered and trained for projects such as Pilot Pen Project, Direct Funeral, Panasonic (Refrigerator & Aircon)
Multiple assessments conducted by psychologists
Placement is ultimately based on the student’s needs that can best be met.
Regularly reassessing appropriateness of placement is necessary
Decision will require a collaborative appraoch involving student, transdisciplinary team and the parents
Beautiful artwork
Maysoon Zayid - actress, comedienne, activist
Jack Caroll -- Winner of US’s got Talent 2013
Laurentia Tan -- Silver & Bronze medalist at 2012 Summer Paralympics, London
Singapore CP Football team
