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Lecture # 101:
Introduction to Rehabilitation of Children

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.


 
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A Child's Brain
If you hold a newborn baby so that his eyes are just inches from brightly patterned wallpaper - Zzzt: a neuron from his retina makes an electrical connection with a neuron in his brain's visual center. If you gently touch his palm with a toy: he grasps at it, it drops, and you return it to him with soft words and a smile: Zzzt - neurons from his hand strengthen their connection with neurons in the motor cortex of his brain. He cries in the night; you feed him and he looks up and sees you, because God knows that the distance from the eyes of a baby in a parent's crooked elbow to the parent's eyes exactly matches the distance that the baby's eyes can focus. Zzzt - neurons in the brain's amygdala send pulses of electricity through the circuits of the brain that control emotion. He feels safe and content. AND you thought you were just doing normal activities with him.

Meditate Word By Word On This Verse:
1 Corithians 2:9.

When a baby is born, his brain is filled with neurons that are waiting to be connected to one another. Some of the neurons are already linked together - those that command breathing, control heartbeat, regulate body temperature and produce other unconditional reflexes. But trillions more are available to be programmed to compose music, do calculus, or erupt in anger. If all these neurons are used, they become integrated circuitry in the brain, connecting with each other, but if they are not used, they may be lost. (Recent research shows that it may be possible now to activate these "lost" neurons.) It is the experiences of childhood that determine which neurons are used and what connections are made in the brain. They also determine if a child is bright or dull, fearful or self-assured, articulate or tongue-tied.

By adulthood, the brain is crisscrossed with more than 100 billion neurons. Each neuron reaches out to thousands of others so that the brain has about a trillion connections. These connections give the human brain its unrivaled power over all other living things on earth. As a baby develops, at the age of 2-4 months, there is a growth spurt in neural connections in his brain. This time period relates to when a baby really notices the world around him. The peak of this fast growth ends at the age of 8 months when each neuron is connected to approximately 15,000 other neurons.

There are limits to the brain's ability to create connections. These are related to time. Critical periods are times of opportunity when the greatest numbers of connections between the neurons are made. With the passing of each birthday, new neuron connections in the brain decrease in number. These findings are both promising and disturbing. They suggest that with the proper input into the brain at the right time, a child can accomplish much. If a child misses making connections in his brain, he may be handicapped. For this reason, activity and stimulation of a newborn child up to the age of 2 years old is critically important. This does not mean that the brain stops developing after the age of 2 years, but that there is a time period when we can optimally help a baby develop neural connections that will help him later on in life. Sensory neurons (feel, touch, taste, etc.) develop most rapidly in early childhood; the emotional system is fully developed in puberty (ages 11-13), and the center of understanding in the frontal lobes of the brain develop through the age of 16.

Question:
1. When a baby is born, his neuronal circuits are:
(Select the best answer.)
a) fully developed.
b) integrated ciruitry.
c) waiting to be connected to one another.

 


 

There are some special skills that are important in helping the newborn child develop his brain. We will discuss some of them.

Language: In the world of the newborn, before there are words, there are sounds. These are phonemes or the smallest parts of a language. When a baby hears a phoneme over and over, neurons from his ear stimulate the formation of connections in his brain's audio-cortex. Neurons for sounds that are similar are close to one another in the brain, but those for dissimilar sounds are far apart.

By 6 months of age, it has been found that infants in various countries have different auditory patterns than in others. Children become functionally deaf to sounds absent from their native tongue. By 12 months, most infants have lost the ability to discriminate sounds that are not significant in their language. This is why learning a second language can be difficult after the auditory pattern has been developed. Related languages such as Russian and Bulgarian are easier to learn since many of their words have the same phonemes that the child has in his brain. With this pattern of circuits, the child can eventually turn sounds into words. The more words a child hears, the faster he learns a language. Infants whose mothers speak to them often know more words than the children with mothers who are not as verbal with their babies. To function well in society we need a large vocabulary, and it can grow through repeated exposure to words.

Music: The age at which a child is introduced to music affects the formation of connections between neurons in the brain. The younger the child is when beginning to play an instrument the larger the amount of the brain that is used for playing. Like other circuits or patterns in early life, the ones for music endure. Adults who have not played an instrument for years can, with a little practice play the songs from he learned in childhood. This is much like the muscle memory we have for riding a bicycle.

Question:
2. Auditory patterns are formed after 6 months because:
(Only one of the following answers is correct.)
a) a baby hears many sounds.
b) he hears language-specific phonemes.
c) his mother speaks to him.

 


 

Emotions: The main circuits for emotion are laid down before birth. Then parents begin to influence their development. Attunement (paying attention) to a baby is the strongest influence. A caregiver helps a child when he tries to give back to the child his inner feelings. For example, if a baby's squeal of delight is meet with a hug and a smile, circuits for this emotion are reinforced. It is thought that the brain uses the same pathways to generate an emotion as to respond to an emotion. So if an emotion is reciprocated or answered by the parent, the electrical and chemical signals in the brain are reinforced. But if the emotions are repeatedly met with indifference or a clashing response, those circuits become confused and fail to strengthen. In one study of child-mother interaction, a baby whose mother never responded to her daughter's excitement over new experiences became passive and did not feel excitement or joy. The key word here is "repeatedly" - one dismissive response will not scar a child for life.

Experience can also affect formation of the brain's calming circuitry. One father gently soothes his crying infant and another drops him in his bed. One mother hugs a child who has scraped a knee and another may scream, "It is your own stupid fault". The first responses above are attuned to the child's distress - he cannot express himself in any other way than to cry. The second responses are abnormal patterns of emotional response based on a baby's needs. Between the ages of 10 and 18 months, a cluster of cells in the prefrontal cortex of the brain is hooking up to the emotional control sections of the brain. The circuit that is made between them seems to be able to calm an agitated emotion by combining reason with the emotion. Researchers believe that parental soothing trains this circuit so the child eventually learns to calm himself.

Stress and constant threats also rewire emotional circuits. These emotional circuits are in the amygdala, a little almond-shaped structure deep in the brain that scans incoming sights and sounds for emotional response. Impulses from receptors in the eye and ear reach the amygdala before they get to the rational, thoughtful cortex. If a sight, sound, or experience has been painful before - for example, a drunken father who comes home and yells and sometimes hits the child - the amygdala floods the brain with neurochemicals and the child is extremely fearful. That is why even the remembrance of a father for some people is as frightening experience.

Furthermore, these circuits can stay excited for days and the brain remains on high alert after a frightening experience. When this happens, the brain focuses attention on facial expressions and angry noises that signal danger. As a result, the brain cortex is not able to develop properly and has trouble understanding complex information such as a native language and math.

Question:
3. The amygdala is:
(Only one of the following answers is correct.)
a) the part of the brain that is first affected by sensory receptors.
b) a neurochemical.
c) a frightening experience.

 


 

Implications for Children
In early childhood and during school days, children need music and physical education classes. Scientists now believe that music trains the brain for higher forms of thinking. One experiment showed that children who studied piano were better at spatial intelligence, that is, the ability to visualize the world accurately. Also, researchers now know that exercise is not only good for the heart, but also for the brain. During exercise, the blood flow to the brain increases and brings it nutrients needed for its growth and formation of nerve connections. Experiments have shown that children who exercise regularly get better grades in school.

Children can also be more active in the classroom. Rather than sitting in their seats and memorizing facts or numbers, it is better for them to use their hands and minds for understanding math and even history. If children build a model of some historical place or event the memory of building a model comes through the sensory system. For example there is the touch and the smell of the wood and the smell of the glue as the children glue the pieces of wood together. From the built model, the brain can create a multidimensional memory that is easier to retrieve as well as the factual account of history.

Children can also begin to learn higher forms of mathematics at a younger age. That does not mean that they study calculus, but they are able to learn some of the concepts of calculus. As already mentioned, it is easier to learn a second language as a child. Russian schools have demonstrated that children are very capable of learning more complicated concepts and foreign languages at an early age.

Question:
4. To understand math and history better, younger students need to use all of their ______:

 


 

Implications for Disabled Children
When a disabled child is born, it may be easy to put him aside and let him die. There are others who live in children's homes or "internats." Life in these homes is difficult and adequate staffing is hard to find. The children may be in bed most of the time without outside stimulation. Perhaps if they were given the right kind of sensory and emotional stimulation, their lives could be different. Despite the fact that their bodies or minds may not be normal, that does not mean that the neurons in their brains do not work and cannot make connections with the outside world.

Just as with disabled adults, children need to learn to be up and about. Some disabled children will not be able to walk, but they can sit. If someone takes time to give them the right kind of training, caring for them would not be such a hard task. Perhaps a child could sit to eat instead of lying in his bed. Maybe he can even partially feed himself. Perhaps he could even learn to walk!

However, all of this stimulation takes time, effort, and trained personnel. If trained personnel can work together to solve the child's problems, life can be easier for everyone. If each child has a plan to help him, the staff can use the plan daily to help them care for the child. How can we know the plan for a child? A plan is made individually for him after an assessment process. At the present time there are standard treatment plans for all types of disabilities. There are always some basic treatments that need to be done daily such as sensory stimulation and passive range of motion exercises. To make a plan individual, the child's specific training needs are added to the plan. For example, he may need teaching on how to grasp a spoon to eat. As noted above, this training needs to begin when the child is very young so that he can learn and understand the world around him as much as possible.

Why do we want to help these children? Would it not be easier to let them die? In earlier times and in certain societies, this has been the norm. However, there are many parents who love these children and want them despite their handicaps. Also, there are governments who care for such children so they are not left to die. Most of all, God loves them and knows that they exist. A disabled baby is in need of the same loving care that normal children receive so that he can attain his maximum potential. It is not important to argue about the cause of the disability or if it was caused by sin. The fact is that the child exists and we need to do what we can for him.

What does the Christian community do for such children? The early church, if you remember, was against abortion and infanticide. Early Christian hospitals had permanent places for the disabled. If Christians are to be salt and light in the world and our local communities, our attitudes toward the handicapped child can be a witness. In fact, many Christians are witnesses in Russia through working in orphanages and becoming adoptive parents to children with disabilities.

We sometimes think of what a large job it is to care for ALL the disabled children. And we are thankful that disabled children are a minority in society. But if we focus on one child or the family, we can help one person, instead of the whole population of disabled. If each of us helps just one person, it will have an effect on those around us.

Question:
5. Can disabled babies be stimulated to learn in a similar way as non-disabled babies?
yes / no.

 


 

Here are some values that we can have toward disabled children and their families:

  1. Children have many capabilities that have not been used. We can develop new visions of what is possible.
  2. Persons with disabilities can contribute positively to their families and communities by teaching values such as patience, persistence, acceptance, honor, and love.
  3. Children and their families have many natural capacities and can increase their strengths.
  4. Parents can direct their own lives. Giving them information and encouragement allows them to make decisions.
  5. Connections with others improve the quality of life. Therefore families need to communicate with others in the community who can help them: family, teachers, church, and friends.
  6. Being less able mentally or physically does not mean a person is less worthy. Disabled children can participate in normal life.

During the next few weeks, we will be using terminology that may be unfamiliar to you. Here are some of the words and their definitions:

Appropriate Education - A rule requiring schools to provide individually tailored education that benefits the student and is based on an evaluation.

Assessment - Refers to the specific features of a student's evaluation and can include formal and informal tests, student records, observation of a student in a classroom, with his friends, and at home.

Behavioral contracting - A contract between a child and another person (teacher, parent) to behave in certain ways. If the child follows the contract, he gets awards that the contract has outlined.

Cognitive Training - Helping a person use the residual thinking and perception skills he has after a severe injury. There is no guarantee that this training will be successful, but often it improves a person's ability to function in school and with other people. There are three types:

Compensatory Strategy Training - Helps a person to remember, organize, and understand information. For example, a mother will check with her disabled child every day to be sure that he has all the materials needed for school and understands his daily schedule.

Functional Retraining - Makes use of everyday activities to teach thinking skills. These skills are sequencing an activity - what one does first, second, and following so that a task is finished. It involves planning an activity and what is necessary to complete the activity. Retraining also includes judgments about things and people and problem solving to get what one wants.

Cooperative Learning - The practice of having students with disabilities and students without disabilities learn together with one another in the classroom and other activities. In this way, the disabled students learn more appropriate behavior and try to imitate the non-disabled students.

Component Training - Intensive training in memory, organization, perceptual motor skills, and attention. For example, a child's physical education teacher may have him walk on a balance beam to improve his spatial orientation skills.

Differential reinforcement - Encourages appropriate behavior by reinforcing positive behavior. The focus is on praising the good behavior rather than punishing the inappropriate behavior.

Externalizing Behavior Problems - These are social behavior problems that include persistent aggression, inability to follow rules, inability to complete assignments of homework, and a high number of negative behaviors. For example, a student may throw books or papers if he becomes frustrated with his schoolwork. Most of these children have behavior or emotional disorders.

Inclusion - The maximum integration of students with disabilities into general classes in school. The students with disabilities may spend part of the day in the general classroom and part of the day in a special education classroom where they work intensively on skills they need to learn.

Functional Skills or Adaptive Skills - These are everyday skills used in the home, school, work, and community. These skills enhance a person's ability to function independently at home and in the community. Skills such as bathing, dressing, using public transport and going to a job are all examples of functional skills.

Internalizing Behavior Problems - These are a general category of social behavior problems that include social withdrawal, depression, and anxiety.

Language Disorder - A communication disorder in which the student cannot use the rules of the language system to produce a message. The student also cannot understand a written message.

Language Learning Disability - An inability to read and write.

Mental Retardation - Impaired functioning characterized by limitations of intelligence and related adaptive skills.

Metacognition - This is the awareness of how one thinks and the monitoring of one's thinking. Research suggests that many persons with learning disabilities have deficits in the following areas of metacognition: knowing strategies for acquiring, storing, and processing information; understanding when, where, and why these strategies are important, and selecting and monitoring the use of these strategies wisely.

Motor Skills - The ability to handle objects physically and control movements.

Nonverbal Reasoning - The ability to form and remember associations, understand relationships, and make generalizations.

Palsy - The lack of muscle control.

"Hyperactive-impulsive" attention deficit - A disorder that includes the following characteristics: inability to sit still, excessive talking, and inability to play quietly.

"Inattentive" Attention Deficit - A type of attention deficit disorder where students do not listen to a teacher, are forgetful, and easily distracted.

Reading Disabilities - A group of disabilities that includes word recognition errors (omissions, insertions, substitutions, reversals), comprehension errors (difficulty recalling or discerning basic facts, sequencing or themes), and other behaviors such as losing the place where they were reading and reading in a halting manner.

Stereotypical Behaviors - Inappropriate, repetitive acts that a child displays. Examples include rocking back and forth, waving fingers in front of one's face, and twirling objects. For many years, professionals believed that these behaviors did not have any constructive purpose. However, there is research to suggest that some children with autism may be trying to communicate boredom and agitation.

Evaluation
In order to understand A child, we must do an assessment. The assessment period is not simply done in an hour. A child needs to to be carefully watched for problems he is exhibiting. Often we may have a comment from a parent or kindergarten teacher that a child has temper tantrums and doesn't seem to understand what he reads. You may also notice a child whose behavior is consistently different from societal norms or age group.

We must help the child develop self-control techniques: place the emphasis on transferring responsibility to the student to change his behavior, on how the change will be made, observing if the changes actually happen, and giving himself reinforcement for making changes.

As you do an assessment, be very specific about what you see and the way in which you write your observations. From these observations, you can construct a plan for helping the child. With each objective you hope to accomplish with the child, you must have a plan for achieving that objective. Here is an example of a behavior plan for a young girl in first grade who has a reading problem and how the objectives are written to change her behavior. Since she is having trouble reading, the plan is to help her read fluently in one year's time. This will involve intensive reading instruction in a separate, quiet classroom for one hour a day with the special education teacher. Here are examples of what the teacher hopes to accomplish in a semester. These are not all of the objectives, but the teacher will write them in this way.

1) BEHAVIORAL OBJECTIVE
Given a list of 20 randomly selected words, Sasha will read then with 80% accuracy.

COMPONENTS OF THE OBJECTIVE
Condition: She is given 20 randomly selected words
Behavior Description: Sasha will read these words
Criterion: with 80% accuracy

2) BEHAVIORAL OBJECTIVE
Given required reading asasignments, Sasha will complete them 4 out 5 times without complaint.

COMPONENTS OF THE OBJECTIVE
Condition: She is given the required reading assignment.
Behavior Description: Sasha will complete the assignment without complaint.
Criterion: 4 out of 5 times.

Question:
6. Why do you write a plan for a child's rehabilitation?
(Select the best answer.)
a) to fill up paper and put in his file.
b) to make an impression on your supervisor.
c) to see if the objectives that you made for the child are accomplished.

 


 

A thorough evaluation for a school problem uses the following steps:

The Screening Test helps classroom teachers identify which students might need further testing. This could be in academics, vision, hearing.

A Pre-referral occurs when the classroom teacher asks the special education teacher for assistance with a student who is having difficulty learning in the classroom. The student's problems may be academic, behavioral, or health. During this time, the student is observed for the specific problem and approaches to the problems are worked out with the classroom teacher.

Referral is the formal process of asking the special education team to evaluate a child completely for a learning disability. For example, a child might benefit from the Preferral recommendations, but still is failing in a major area of education. This child is then referred for complete evaluation.

The next stage of Evaluating the student involves giving those tests that will provide a real measure of what the student knows and observation of the student in the classroom. Finally, all of the professionals that have given the tests, along with the student, the parents, and perhaps close friends of the student meet to discuss the results of the testing. We know if the child has a disability based on test scores. Testing and the environment of the testing are very important in the evaluation.

The Individual Educational Program for the student with a disability is designed to meet the student's educational needs. The evaluation information is the basis for measuring the current level of performance. Next is the Curriculum, which outlines the annual goals and short term objectives. The student is expected to achieve the annual goals by the end of the school year. The short-term goals are the intermediate steps between the student's current level of performance and annual goals. These objectives need to be observable and measurable and for that reason, they have three components:

  1. the conditions under which the behavior will occur
  2. the behavioral description
  3. the level of mastery that must be achieved for the student to advance to a new skill

A record is kept of these goals and are a guide for the school year to bring the student up to his/her learning capacity. These goals may be academic or social in nature. Placement and special services are those that cannot be provided by the classroom. The plan must state the service to be provided and the dates of service.

The same type of evaluation can be done for rehabilitation of a child. It will require medical knowledge of a doctor, but you can work with him to try various therapies to help a child.

Working with disabled children is an exciting experience because they are young and most have some ability to learn. To help them make the most of their abilities is rewarding work.