I CIIILDREN WITH CEREBRAL RALSY

A REPORT ON THE PROBLEM IN CALIFORNIA
AND A SUGGESTED PROGRAM FOR THEIR CARE

SUBMITTED TO THE

ElETY—SIXTII SESSION OE TIIE CALIFORNIA LEGISLATURE

PURSUANT TO

ASSEMBLY CONCURRENT RESOLUTION NO. 60

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CIIILDREN WITH CEREBRAL RALSY

A REPORT ON THE PROBLEM IN CALIFORNIA
AND A SUGGESTED PROGRAM FOR THEIR CARE

SUBMITTED TO THE

EIEW-SIXTII SESSION OE TIIE CALIEORNIA LEGISLATURE

PURSUANT TO

ASSEMBLY CONCURRENT RESOLUTION NO. 60

BY THE

STATE DEPARTMENTS OF PUBLIC HEALTH AND EDUCATION

DECEMBER 1944

TABLE OF CONTENTS

Page

CHILDREN WITH. CEREBRAL PALSY ______________________________ 3
Report on the Problem in California and a Suggested Program

For Their Care _____________________________________ 3

RECOMMENDED PROGRAM _____________________________________ 13
For the Care and Education of Cerebral Palsied Children in

California _________________________________________ 13
Recommended State-wide Program for the Care and Education

of Children with Cerebral Palsy__________--.._____ ..... 18
SUMMARY OF 'A STUDY OF THE EDUCATION OF CHILDREN WITH Cm-

BRAL PALSY IN THE STATE OF CALIFORNIA ___________________ 20

BIBLIOGRAPHY ______________________________________________ 35

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PUBLIC
HEALTH
HER/(CY

CHILDREN WITH CEREBRAL PALSY

REPORT ON THE PROBLEM IN CALIFORNIA AND A
SUGGESTED PROGRAM FOR THEIR CARE

Of all handicapped children, those afl‘licted with cerebral palsy are
the most neglected, the least understood and in the greatest need of
attention in California at this time. The purpose of this report is to
indicate the nature and extent of the problem, to show that present
facilities are woefully inadequate and to recommend a reasonable state-
wide program of care and education'for these children.

On April 23, 1943, the California State Legislature passed the fol-
lowing resolution:

WHEREAS, It is the desire of the Legislature to provide in every way
possible for the treatment and education of spastic and crippled children
within the State; and

WHEREAS, It is necessary in making such provision that the Legis-
lature be fully informed on the problems relating to the treatment and
education of such children; now, therefore, be it

Resolved by the Assembly of the State of California, the Senate
thereof concurring, That the Department of Public Health is hereby
requested and directed to investigate the problem of spastic and crippled
children, having particular reference to the number of such children in
the State who are in need of and can be benefited by special treatment
or education; and be it further

Resolved, That the Department of Education cooperate in making:
the investigation, and that each department be given full access to the
findings of the other, and that each department report to the Fifty-sixth
Session of the Legislature the result of its investigation and make recom-
mendations as to the treatment and education of such children, together
with the facilities required for such purposes and the costs thereof ; and
be it further

Resolved, That the Governor and the State Planning Board be
requested to include a study of such as a part of the postwar planning:
and be it further

Resolved, That the Chief Clerk of the Assembly shall transmit copies
of this resolution to the Governor, to the Department of Public Health,
to the Department of Education, and the State Planning Board.

What Is Cerebral Palsy1

Cerebral palsy, popularly but erroneously called spastic paralysis.
in a condition in which muscular control is impaired or lost. The dis-
ability may be severe or very mild; many muscles or groups of muscles
maybe affected, or only a few, or a single group. The lack of control
may be in the arms, legs, tongue, speech mechanism, eyes, or it may

‘Adapted from Children with Cerebral Palsy, Illinois Commission for Handi~
capped Children, June 1943.

 

(3)
790

_4_

affect the hearing. The extent of the disability varies widely and may
affect the entire range of normal muscular activity“

Most cases of cerebral palsy are caused by injury to the brain during
birth or by faulty development of the brain. Injury or disease during
the first years of life may also produce the condition Such diseases
as encephalitis or meningitis may result 1n cerebral palsy by producing
scar tissue in the brain.

The damage which has been done to the brain tissue by injury,
mal- development, or disease can not—be repamedrliut it is possible to
retrain the patient In the use and control of affected muscles. Each case
requires intensive diagnostic investigation which will disclose the extent
of the disability, the muscles affected, and the mental capacity orpoten—
tiality of the patient.

Loss of muscular control in cerebral palsy has been likened to the
situation which would exist in a telephone switchboard if the electrical
impulses traveling in the wires were to be uncontrolled because the insu-
lation had been worn through. In such a case if a plug were‘to be
inserted in the switchboard, instead of one phone ringing or one light
flashing, there would probably be many phones ringing continuously
and many lights flashing. In a somewhat analogous manner, the
impulses which the brain of the cerebral palsied person sends to his
muscles are uncontrolled and may result in exaggerated movement, a
variety of undesired movements, or no movement at all.

Determining the mental capacity of children with cerebralnpalsy
requires special skill and experience. Cerebral palsied children have
been incorrectly judged as feeble-minded in many instances because of
facial grimaces, drooling, lack of coordinated speech, partial visual or
hearing losses, and a- multitude of similar cOnditions so often present in
such cases. For many years feeble-mindedness was believed to be char-
acteristic of cerebral palsy, but it has been definitely shown in recent
years that about 75 per cent of the children with cerebral palsy have
intelligence quotients of 70 or higher, which indicates that most of them
are unquestionablv teachable. 2 Many of these children are of superior
mental capacity.

There are three main types of cerebral palsy: ( 1) spasticity, (2)
athetosis, and (3) ataxia. These conditions may exist in the same case,
but cerebral palsy patients can generally be characterized by one of the
three conditions, depending upon which one is the predominating
reaction.

“Spastic paralysis” has been used incorrectly as though it were
synonymous with “cerebral palsy. ” Spasticity is only one of the three
forms which cerebral palsy may take. Spastic muscles are hypersensi-
tive to stimulation, and when either voluntary or involuntary muscle
movements are attempted, the spastic muscle which is in opposition to
the muscle being contracted, itself contracts instead of remaining idle
or relaxing as it should. This disorder causes even the slightest move-
ment of the spastic muscle to result 1n exaggerated activity.

In the second group, the athetoid, there are constant involuntary
movements of the afiected muscles. Emotional states such as fear and.
anger increase the nervous tension of the patient and cause correspond-
ing increases in the athetoid movements. Usually athetosis is accom-

" ’1 he Far thést Comer, National Society for Crippled Children, 1944.

.__5_

panied by a constant tension of the muscles which is apparently caused
by an effort to control the athetoid movements. This tension may exist
for so long that patients can release it only after prolonged training.

The third general type of impaired muscular control in cerebral
palsy is ataxia. This condition, which is due to the inability of the
patient to select the proper force to cause a muscle to contract, results
in a disturbance of the ability to retain balance and to hold the posture.
Ataxia occurs less frequently than spasticity and athetosis but is fairly
common.

Treatment of cerebral palsy is a long and difficult process invariably
involving far more than surgery. There may be a group of handicaps
instead of a ‘single disability. Motor handicaps and sensory disturb-
ances, such as impaired hearing and vision, may be present in the same
individual. ‘ ' —

In addition to the physical factors inherent in cerebral palsy, there '

are many’ secondary factors which have important bearing upon the
adjustment of the handicapped child to his family and community, and
upon the family and community acceptance of the child. Some of these
factors are the frequently present facial grimaces and drooling, the
awkward speech, the need for confidence, the inability to relax tensed
muscles, and the awkward or stumbling gait of many cerebral palsied
children. These factors may cause the family and community to reject
the child. The family may become embittered and may even, in extreme
cases, hide the child. Parents or friends may be unduly fearful of the
child ’s welfare and become over-indulgent, thus preventing him from
achieving an adjustment.
7 In summary, the needs of the cerebral palsied child include all of
those of a normal child plus additional training in learing how to supply
his own particular needs. The problem has many facets—~the medical,
the psychological, the educational, and the social. All of these factors
are interactive and each child requires balanced attention to all, often
concurrently.

What Can Be Done for These Children

Knowledge and skill in the diagnosis and treatment of the cerebral
palsied has increased rapidly during the last 15 years. Despite the fact
that the damage done to the brain itself can not be repaired, there is
much which can be done for these handicapped children. There is per-
haps no other group for whom rehabilitation to even a slight degree
makes so much difierence and is so important. The range of possibility
for physical improvement of these children is extremely wide. As a
result of treatment and a coordinated program of education and re-edu-
cation, some may at best be able to feed and dress themselves; some may,
in addition, be able to carry on some work even though they are home-
bound; others may benefit from training to the point where they can
get around the community by themselves and be employed; still others
may be rehabilitated to such a degree that they can be completely inde-
pendent individuals, carrying on a normal life and participating in
activities that might be expected of anyone.

This last achievement is of course the optimum and is what one
would Wish for every cerebral palsied child—as well as for every other
child—but the importance of achievement to a lesser extent should not

—6—-

be underestimated. It is of great value to the individual, his family,
and the community for the child to be able at least to feed and clothe
himself and to be able to move about. Even this limited degree of
independence is a tremendous advance over lying helpless in bed, wholly
dependent upon the services of others.

Not every child with cerebral palsy is able to benefit from intensive
care; neither does every one of them require such care. Only by skilled
diagnosis can the extent of damage and the prognosis be judged. One
of the most important phases of diagnosis is that which saves the child
from being unjustly considered feeble-minded. This happened all too
often in earlier days and still occurs too frequently. There are data
available which point out the proportion of severely physically handi-
capped cases who have sufficient mental ability to profit from physical
rehabilitation and education. There are also diagnostic procedures
available which assist in determining which children may be benefited
by present techniques for their care and education. The common belief
(which is not based on evidence) that children afflicted with cerebral
palsy are mentally deficient is probably responsible for the failure in
development of adequate facilities for the care and education of these
children.

There is no consistent and precise relationship between the apparent
degree of the handicap and the possible results to be obtained through
treatment. Many of the cases appearing most severe have responded
out of all proportion to their apparent promise. Since more than 70
per cent of all cases are of mild or moderate severity and since most of
these have intelligence quotients of 70 or above, it is clear that con-
siderably more than half of all cerebral palsied children can be expected
to profit materially from a thorough program of care and treatment.
The fact that many of the more severely handicapped cases can also
profit to some extent by rehabilitation thoroughly justifies the expense
and time of treatment. 0‘

Number of Cerebral Palsied Children in California

There are between 8,000 and 10,000 persons under 21 years of age
with cerebral palsy in California according to conservative estimate.
Because of the nature of the condition and the inadequate provisions
for diagnosis, care, training, and education of cerebral palsied children,
many cases remain unregistered. At the present time, only 1,426 are
known to the Crippled Childrens Services of the State Department of
Public Health. It has been found through intensive local surveys in
other States that there are about six persons per 100,000 total population
for each age group and that there is no important variation according
to locality. Furthermore, there are no essential differences in incidence
by race or according to residence in rural or urban areas. The figure
six per 100,000 population has been arrived at from the fact that there
is an annual increment of seven per 100,000 population and about one
death occurs among these seven before they reach the age of six.3
During later childhood and adolescence, the death rate of cerebral palsied
children, like that of normal children, is low. Upon these factors the

 

aPhelps, W. M.: Recent Trends in Cerebral Palsy. Archives of Physical
Therapy 23 (6) : 332 (June) 1942.

_7_

assumption is made that the greater numbers in the lower age groups
counterbalance the smaller numbers in the older groups.

0f the estimated 8,000 to 10,000 afllicted children, about 75 per
cent are teachable. As many as 2,000 to 2,500 are candidates for cus-
todial care.

In addition to the children themselves, cerebral palsy has serious
effects on the families of which the children are a part. Oftentimes in
attempting to meet the needs of the handicapped child, the expense is
so great that all members of the family have greater financial burdens
than they can bear. Assuming that the families in which there is a
case of cerebral palsy are of the same average size as that for California
as a whole (3.2 persons per family according to the 1940 census), there
are no less than 25,000 to 30,000 persons directly affected by some of
the problems associated with cerebral palsy.

Typical Cases

In order to determine as accurately as possible the unmet needs of
cerebral palsied children in the State, a questionnaire was sent to the
parents of 1,632 persons with cerebral palsy. The names were obtained
from the register of the Crippled Children Services of the State Depart-
ment of Public Health, plus additional names known to the Spastic
Children’s Society of Alameda, that of Los Angeles, and to the Cali-
fornia Society for Crippled Children.

Replies from 426 parents of persons under 21 years old indicate
that children under age five tend to remain unregistered and that most
of them are not receiving the muscle training and special care which
are so urgently needed by preschool children. The special problems of
these younger children will be discussed further below.

According to the reports of the parents, the types and extent of
handicaps vary widely. About one-half require assistance in feeding,
less than half speak well, and one-fourth do not walk at all, while one-
fifth require assistance in walking. Sensory impairments are less
common than motor handicaps among this group of cerebral palsied
children but nevertheleSS occur frequently. Vision is impaired in one-
fifth, hearing in about one-twentieth. Far more significant in revealing
the difficulties with which these children and their parents have to cope,
is that many of them suffer from multiple handicaps, such as inability
to use their hands or to walk, impaired hearing as well as crippled
hands, defective vision or speech.

The human side of the problems of cerebral palsied children and of
their parents, their teachers and their friends is far more vividly shown
by the letters written to the Crippled Children Services in response to
the questionnaires. The overwhelming majority of the parents wanted
to keep their children with them, even though the physical burden to
the mother is in many instances enough to severely encroach on her other
homemaking duties. However, practically all parents expressed the
great need for special treatment and educational facilities for their
children.

A few families who could afford to do so have taken their children
to one of the centers in the east. A very small number have been able
to take advantage of one of the very few institutions in this State accept-
ing these children. But the majority have sought such facilities in vain.

_3_

As illustrations of the frustrations met by parents of spastic chil-
dren who are vainly seeking both medical and educational opportunities
for their children, there are quoted below some of the replies received
in answer to the questionnaires sent in connection with this survey.
They also serve to illustrate the frame of mind that is reached by parents
who find themselves blocked at every turn in their search for assistance.
The children’s names are disguised, but the situation and the parents’
remarks are reproduced accurately. Many of the messages from the
parents of these children show great optimism in spite of the frustra-
tions they have met in their search for treatment and education of their
children. Some of these are children whose handicap is such that while
their normal activities and participation in social groups are hampered,
they nevertheless have shown some ability for partial achievements—
have been “living on the fringes, ” as it were. Their parents have been
tantalized by the progress their children have made under the limited
facilities available. They are only too cognizant of the now unfulfilled
potentialities that would blossom forth under the proper training and
guidance.

 

Joe is 14 years old. He has fair use of his hands and has been
walking and talking for the last few years, and improving right along.
Joe is not attending school now. He attended a public school from
February to June last year, but was not allowed to return this year
because the principal felt he had not made sufficient progress. Joe’s
mother says, “I felt they never gave him a fair chance because four
months was not a long enough time for a child who had never been in
school before " ‘ " I feel he should have some schooling and be
among other children.” -

 

Hugo is 11 years old. He has good use of his hands and walks
unaided, although he has some difliculty with his balance. He speaks
fairly well now. Hugo’s mother reports, “My child has made a remark-
able recovery due to the fine help 1 was able to secure for him. Our
expenses were very heavy for many .years and it is only the past year
that we have been able to reduce them. At one time and for several
years, the therapy was costing us $80 a month ‘ ' ’ ”

 

Another family has a 12-year-old daughter who is moderately
handicapped and who has been attending the public schools. Her father
states, “I feel that if there were a center which understood and spe-
cialized in the needs of the spastic child, a great step toward complete
rehabilitation of these children as useful citizens would be accomplished.
I am especially interested in a school of speech training and also physio-
therapy treatments, as ____________ County lacks adequate facilities
to accomplish much in this particular field.”

 

Another parent of an 18-year-old girl.—-“I would give my interest
in Hell to have her walk in some fashion. I have done all I could as
far as my finances would permit without breaking me, and never had
the assurance of her walking. So my judgment was, better not spend

_9_

all and not walk ' ° ° I will not place her in an institution as
she is too lovely a child ° ' ° to bury alive. These children need
assistance more than any other types of afflicted ° ° " they have
been put out in the barn so to spec .” In reference to the Flack case,
‘ ‘ " ° ' the public are starving these same innocent children’s minds
and bodies by not recognizing their needs due to no fault of their parents.
There should betwo schools and training centers for these children in
the State, one in the north and the other in the south near large towns.”
The letter continues, recommending provision of temporary residence
facilities for the parents, so they could participate in the educational
program for the purpose of continuing it at home.

Further samples are given of replies to the questionnaire, setting
forth the need for and the desire to participate in any program which
may be developed.

“I believe we should have schools for handicapped children' 1n all
towns of any size, especially schools for the educatiom and speech training
of these children. I know of a good many children in a town of over
100,000 people, and we have no school fer these children. No child
can get an education with only one-half hour a day from the visiting
teacher. They should have at least one-half a day. It could be handled
by the public schools. There is a great need for such.”

 

“Our child has come a long way and each year has brought added
accomplishments. Like all parents of spastic children, we want to see
everything possible done for these children. Like the blind, etc., they
are with us as crosses from‘heaven and we should carry them Witlr
Christian charity. It is just another work of mercy that in the past
has been shelved and kept in the background " " " I do think it
is time to recognize this worthy cause, which has always been in Our
midst ' ' ' ”

 

The following are examples of cases Where adequate custodial care
is the only answer. It is urgently needed in order to relieve the parents
from the burden of caring for these children and to permit them ‘to
turn their efforts to other children in the family. A program of cus-
todial care which focuses on the particular needs of these children and
is instituted in their early years could aiford sufficient training to develop
to the full their very limited capacities so they at least could tend to
their more rudimentary needs.

Many of these bear a significant resemblance to a letter written
to a private institution by Mrs. Louise Flack in her search for facilities
for the care of her child and introduced as evidence by the defense at
her trial for the “murder” of her 8-year—old spastic daughter. This
was the much publicized case of a previously devoted mother who broke
under the strain of caring for her completely invalided and mentally
retarded daughter. Her neglect of the child led to its ultimate starva-
tion and death. Her letter, written a year to the day before the child’s
death in December 1943, read in part as follows:

“I am very much interested in finding a school or home for her
(daughter) where she could receive good care in every way and what
educational training she could receive and learn ‘ "

._10_

“I have been told by doctors that it is the best and only thing to
do. It breaks my heart to think of not having her with me, but if it is
for her good I try to tell myself it is what I must do ' ' ' ”

 

Ellen is 11 years old. She has poor use of both hands and can not
walk. She speaks well if not too excited. Her family has found it
necessary to" go as far as West Virginia to find satisfactory facilities
for Ellen, and are incurring monthly bills for her care, which are a
constant drain on their resources. Her mother, who lives in a northern
county, says, “ I am sure that only the mother of a spastic would know
how much it would mean to have a desirable place for her child, with
the hope that some improvement could be made. I looked for a good
many years to find a place Where Ellen could receive the proper training,
but could find nothing in California. Of course our main idea and
hope is to have her near us, as West Virginia is too far away. The costs
are great and I work in order to help my husband keep her there. We
have not been able to see her for two years now. ”

 

Johnny is 13 years old. He is badly paralyzed on one side. His
mother states, “Crippled children do better away from home, because
at home they learn to depend very much on having things done for
them. Away from home they try to learn to do things for themselves.
As I am a mother of ten more children besides Johnny, I don’t have
very much time to give him for his exercises " ’ " He needs more
attention than I can give.”

 

Jacky is 5 years old. He has poor use of both hands, needing com-
plete assistance in feeding. He does not speak, but makes noises like a
young infant. He can not walk, but stands on his toes with aid. His
parents state that he is so helpless they have been unable to find a school
that would take him. “Spastics seem to be children considered unworthy
of attention and care, and really they need more care since most of them
are so badly handicapped. Because of mother love, or whatever it is,
it is hard for parents to be strict and unyielding where their children
are concerned.”

 

Eddie is 5 years old. He has fair use of his hands and can feed him—
self, although he is awkward about it. He can speak single sentences
now, but only his family can understand him. He does not walk and is
unable to stand alone. He has been examined by several doctors but
has never been hospitalized. He has only received home treatment.
His mother would like to find a wheelchair for him “as he now lies in
bed all day long or has to be carried around by an adult.”

 

Helen is 10 years old. She has fair use of her hands but can not
walk. She speaks well and her mother says she has a high I. Q. However,
she can not go to school because she can not walk and there is no avail-
able transportation. Her mother feels that “ " ' * a proper school
with systematic muscle training would give her more than an even
chance for a happier future. Having three other children I don ’t feel
sufficiently capable of helping her enough myself. A proper custodial

__11_

home would be the answer to every dream any parent of a spastic child
could ask for.”

 

The above illustrations are only a sample of scores of similar cases
reported to the Crippled Children Services in response to its survey.
These are the cases of the more severely handicapped children who all
their lives will need constant care for even their ordinary daily wants.

Present Facilities for Treatment and Care
As They Now Exist

Adequate provision for the treatment and care of cerebral palsied
children requires specialized diagnostic facilities, followed sometimes
by surgery, and usually by prolonged physical, occupational, and speech
therapy. In order to determine what facilities are available in Cali-
fornia, an inquiry was made by the Crippled Children Services of the
State Department of Public Health to hospitals, convalescent homes,
and other institutions which might offer some help to these children.

Of the 370 hospitals which take children, only one reported facilities
for meeting 'the needs of cerebral palsied children in a coordinated
program of surgery, physical therapy, speech training and occupational
therapy, combined with an academic program. Six hospitals reported
facilities which include some elements in a coordinated program, and
eight'hospitals reported physical therapy facilities available for such
children. Several of these hospitals also provide orthopedic surgery for
cerebral palsied as well as other crippled children. A number of the
hospitals indicated above, stated that although they had physical therapy
departments and accepted cerebral palsy patients, they did not feel that
their physical therapists were equipped to give the specialized treatment
needed by cerebral palsied patients. A total of 98 children, out of the
estimated 10,000 in the State, were reported to have received some type
of care during the first 10 months of 1944. The hospital in which the
type of coordinated program referred to above is functioning, is East
Bay Children’s Hospital in Oakland. The cerebral palsy unit includes
muscle training, speech training, academic education, and adjustment
to group living. This program has been in effect since 1939. The
hospital-school came into existence through the efforts of the Alameda
Spastic Children’s Society, an organization composed of parents and
friends of spastic children. The Cottage School, as it is called, is operated
by the Oakland public schools on the hospital grounds, providing a coor-
dinated treatment and educational program for 14 preschool chil-
dren between the ages of three and six years. The average length of
attendance in the hospital—school is from one to three years. Admission
to the school is possible only after a complete medical, neurological and
orthopedic examination in the hospital. Daily physical therapy is pro-
vided by the hosptal at rates within the parents’ capacity to pay. Indi-
vidual specialized training is provided by the Oakland Board of Edu-
cation. Mothers of children attend school one day each week in order
to learn techniques for carrying out the recommendations of the special-
ists in the school. Although this program is unquestionably the best in
the State so far, it is obviously inadequate to meet the needs of the
known cases even in the immediate area. Inquiries were also made of

._.12__

94 other institutions, such as convalescent homes, boarding homes and
sanitariums. Of these, 10 reported that they accepted mentally normal
spastic children for care. Only four of these 10 institutions have medical
supervision and facilities for physical therapy ; the remaining six provide
custodial care only. Three of the four institutions which accept the
children are privately operated; the fees range from $75 to $150 a month.

Cerebral palsied persons who are mentally retarded are accepted
at Sonoma State Home where they are about 350 at present, and at Pacific
Colony, where there are 162. There are 27 private institutions accepting
mentally retarded children, which are licensed by the State Department
of Institutions. In only two of these are cerebral palsied children specifi-
cally listed as being eligible for admission.

RECOMIMENDED PROGRAM

FOR THE CARE AND EDUCATION OF CEREBRAL PALSIED
CHILDREN IN CALIFORNIA

In order to provide adequate care and education for children with
cerebral palsy and to give their families the help which is essential for
developing the capacities of these handicapped children, expansion of
existing public health and educational services is needed. The State
Departments of Public Health, Education, Institutions, and the Uni-
versity of California Hospital and School of Education all have some
facilities now for serving these children, but there is need to coordinate
these and to fill in certain major gaps. By building on these existing
facilities, it will be possible to provide care to a far greater extent and
at a lower cost than might be expected for dealing with so complex a
problem. The accompanying diagram shows the functional units of
the departments which can provide treatment and education for cerebral
palsied children and the proposed interrelationships of those depart-
ments. The structure and functions of the individual units of service
in the overall program are as follows:

HOSPITAL-SCHOOLS. The nature of cerebral palsy is such that med-
ical care, physical training and academic education must be carried on
simultaneously so that the child may develop in all respects at a cor-
responding rate. Therefore, it is recommended that two hospital- schools,
one in San Francisco serving northern California, the other in Los
Angeles serving southern California, be established. Each hospital-
school should be composed of two divisions working as a closely knit
unit. One of these divisions would be primarily medical and the other
educational.

The diagnostic and treatment division 1n San Francsico could well
be developed as an integral part of the University of California Hos-
pital. This hospital already has departments of pediatrics, orthopedic
surgery, psychology, psychiatry, neurology and physical therapy, with
trained personnel. The University School of Education is concerned
with the training of teachers for exceptional children and 1s stafied with
educators who can administer the education division of the proposed
hospital-schools. ’ With some additional personnel specially trained in
the treatment and education of cerebral palsied children and with some
additional space and equipment, excellent diagnostic treatment and
educational services can be developed.

In establishing the hospital-school to serve southern California, it
is recommended that the State enter into a contract with an existing
hospital having facilities for crippled children for the establishment of
the diagnostic and treatment unit and with the School of Education of
the University of California at Los Angeles administering the special
school in conjunction with the medical unit.

Diagnostic and Treatment Division. The child’s diagnosis and
recommended treatment must be based not only on physical examination

(13)

__14_

requiring time and highly specialized skill, but also on expert psycho-
metric and personality studies to determine the type of treatment which
is most likely to produce the desired result, namely, that of teaching
the child to become as nearly independent physically as his individual
capacities and current knowledge and skills make possible. Treatment
should include medically supervised training in systematic relaxation
and muscle re-education, physiotherapy, psychotherapy, and occupa-
tional therapy. In some instances, surgery will also assist a child to
walk or use his arms more effectively.

In addition to the diagnosis and treatment of individual patients
in this branch of the hospital-school, opportunity would be afforded for
research into the causes, prevention, and most effective treatment of
cerebral palsy. An added value would be that of training much needed
professional personnel to aid cerebral palsied children and their families
in their own homes to which most of the children will be returned after
their stay at the hospital—school. Such personnel would be afforded
excellent opportunities for education and experience in the diagnosis,
treatment and instruction of the victims of cerebral palsy. _

Residence and Day Schools. At the same time that the cerebral
palsied child is being given treatment for his physical handicap, a spe-
cial education program adapted to the evidenced capacity of each indi-
vidual should be provided. A special school should be established
adjacent to and closely coordinated with the diagnostic branch of the
hospital—school. This school should combine special motor and speech
education with a regular education program geared in tempo and specific
experiences to the characteristic tension and excitability of the cerebral
palsied child. Such a school should serve children who will be return-
ing to their homes and to the special education program of their local
school district during the period of diagnosis at the diagnostic center;
it should also serve as a resident school for children from less populous
school districts where no program of special education can be main-
tained; and finally, it should serve as a residence school for children
whose families are unable to provide the necessary physical care.

Such a specialized school would serve three other important func-
tions. It would become a center for the education of parents in the
home care of the cerebral palsied child. It would be a demonstration
and practice center for the education of teachers. It would make pos-
sible much needed research in the education of such children.

FIELD CLINICS. Already functioning throughout California under
the auspices of the Crippled Children Services of the State and local
health departments are clinics which are responsible for case-finding,
preliminary diagnosis, and follow—up of cerebral palsy cases as well as
other crippled children. Cerebral palsy cases found by the workers
attached to these clinics would be referred to the medical division of the
hospital-school for diagnosis and treatment. At present, the State
Crippled Children Services has little to offer cerebral palsied children
because of the lack of the combined medical and educational facilities
which are so urgently needed. In addition to their case-finding func-
tions which the field clinics are already organized to carry out, follow—up
Services on children whose treatment has been begun in the hospital
schools, can be rendered. Physical therapists will be needed to continue
treatment of those children returning to their home communities. Some

_15__

additional medical social workers and public health nurses will be
required to assist in the continuing development and adjustment of the
child in relation to the local public schools and to his own home.

CUSTODIAL CARE FOR. THE SEVERELY HANDICAPPED.
Although most cerebral palsied children can be helped sufliciently that
they can return.to live with their own families in varying degrees of
independence, some 30 per cent of the cases are usually found to require
custodial care because their capacities are so limited. These severely
handicapped persons are more efficiently cared for in institutions
separated from mentally defective persons who sufier no physical handi-
cap. This responsibility lies with the State Department of Institu-
tions, which has included in its postwar planning a separate institution
for physically handicapped mentally retarded children.

SPECIAL CLASSES IN PUBLIC SCHOOLS. As the work of' the hos-
pital-schools progresses, larger numbers of children will be enabled to
live successfully in their own homes and to attend the public schools if
special classes are provided for them, where education and physical
therapy can be provided concurrently. Some such classes have been
established, but the work needs to be greatly extended and correlated.
A supervisor of special education should be added to the staif of the
State Department of Education to give local school districts assistance
in the development of special classes and to coordinate this program
with the work of the hospital-schools. In addition to appropriate non-
competitive education in the usual school subjects, arrangements for
physical therapy carried out in the schools under the direction of the
State or local Departments of Public Health will be needed.

VOCATIONAL REHABILITATION. In the group of at least 70 per
cent of the children with cerebral palsy who can learn to care for them-
selves, some will be able to overcome their handicap to the extent of being
wholly or partially self-supporting. The Bureau of Vocational Rehabili-
tation in the Department of Education is already organized to work with
the handicapped, but some expansion of their services to work with the
highly specialized problems of the cerebral palsied may be necessary to
provide opportunities for the fullest development of those older children
who are helped toward independence by the other units of the cerebral
palsy program.

How the Program Would Work

Any child in the State suffering from cerebral palsy may attend the
nearest field clinic for preliminary diagnosis. If the parents wish to
take advantage of the facilities offered, they will be referred to the
hospital-school. In this center, after careful study, each child will be
classified as to his present and potential capacities and a plan of treat-
ment and education outlined with the parents. Some of the children
can return to their own homes where a simple muscle re— education plan
can be carried out by the parents under the supervision of a physical
therapist. Those children if of school age, can attend regular public
school or special classes as their condition warrants. Other children
more severely handicapped will require periods of intensive treatment
and education in the hospital-school before returning home. Another

—16——

group will be so severely handicapped physically that prolonged periods
in the hospital-school will be required. Some children will be recom-
mended to remain in the residence school because of social problems in
the home or because the family lives in an area where it will not be
possible to develop local physical therapy and special school facilities.
The children who require custodial care will be referred to the State
institution for physically handicapped mentally retarded, if the parents
so wish.

The progress of all the children accepted for care will be followed
by the staff of the hospital-school and those who will benefit by vocational
rehabilitation will be referred to that agency.

Financial Participation by the Parents

The parents or guardians of children accepted for care under the
program should be expected to pay for the costs of treatment and care
to the full extend of their ability to do so. Procedures would be estab-
lished along the lines now existing in other phases of the Crippled Chil-
dren Services for careful consideration of each family’s financial circum-
stances and resources in order that plans for such financial participation
might be worked out. This, of course, would involve all costs exclusive of
education and attendance at diagnostic clinics which are now available
without cost to the family and would continue to be so.

_...17_.

RECOMMENDED STATE-WIDE PROGRAM FOR THE CARE AND
EDUCATION OF CHILDREN WITH CEREBRAL PALSY

 

 

 

FIELD
HOMES (-—+ CLINICS 4—) SCHOOLS

 

 

 

 

 

 

 

 

 

HOSPITAL SCHOOL

 

 

 

 

RESIDENCE SCHOOL DIAGNOSTIC AND TREATMENT
CENTER
DAY SCHOOL ..........................................
¢ PHYSICIAN

 

NURSERY SCHOOL

PSYCHOLOGIST
PSYCHIATRIST
PHYSICAL TH ERAPISTS
OCCUPATIONAL THERAPIST

SPECIALLY MEDICAL SOCIAL WORKER
TRAINED TEACHERS

SPEECH THERAPISTS

HOSPITAL FACILITIES

i I i

 

 

 

 

 

 

 

 

 

 

SPECIAL
INSTITUTION FOR CLASSES VOCATIONAL
CUSTODIAL CARE PUBLIC REHABILITATION

SCHOOLS

 

 

 

 

 

 

-——18—

RECOMMENDED STATE-WIDE PROGRAM FOR THE CARE AND
EDUCATION OF CHILDREN WITH CEREBRAL PALSY

Administration and Functions of the Various Units
A. Field Clinics

State and Local Departments of Public Health (Crippled Children
Services)

Case-finding and follow-up, Field physical therapy, orthopedic
nursing and medical social services.

B. H ospital-Schools
Two Centers—San Francisco and Los Angeles

1. Diagnostic Center

University Hospital

Functions—Medical diagnosis and treatment
Psychometric Study
Social Study
Physical Therapy
Occupational Therapy
Training of Personnel
Research

2. School

University of California

Functions—Speech Therapy and Academic Education
Residence School for Selected Children
Day School and Nursery School
Parent Education
Teacher Training in Special Education
Research in Special Education

C. Institution for Custodial Care for Severely Handicapped Children
State Department of Institutions

Custodial Care for Those Who Are Not Candidates for the Hos-
pital-Schools

D. Special Classes in Public Schools

State and Local School Departments
For Children Able to Live at Home and Attend Public School

E. Vocational Rehabilitation

State Department of Education
Bureau of Vocational Rehabilitation for Older Children

_ 19 _
ESTIMATED COSTS OF PROGRAM

Hospital-Schools

Medical Units (University of California. Hospital)
Equipment---_________-______--_.__-_____-;_-$5,000 per school
Personnel and Operating Expenses _____ $36,000 per year per school

School-Units (University of California—School of Education)

Personnel and Operating Expenses _____ $70,000 per year per school
Construction and Equipment of School Building- _$200,'000 per unit

Field Services (State Department of Public Health)
Personnel and Expenses _____________________ $40,000 per annum

Coordination of Education of Physically Handicapped in Public
Schools (State Department of Education)

Personnel and Expenses ______________________ $20,000 per annum

SUMMARY OF A STUDY OF THE EDUCATION OF
CHILDREN WITH CEREBRAL PALSY IN THE
STATE OF CALIFORNIA4

Following the passage of Concurrent Resolution No. 30 by the
California State Legislature on April 23, 1943, the Department of Edu-
cation undertook a study designed to secure basic data concerning the
education of crippled and spastic children Within the State.

Education of Physically Handicapped Children

Under existing lawsf' the Superintendent of Public Instruction is
required to apportion to each elementary or high school district addi-
tional amounts equal to the excess cost of educating physically handi-
capped children during the preceding school year as reported by the
county superintendent of schools. The apportionment may not exceed
two hundred dollars ($200) for each unit of average daily attendance
of physically handicapped children in the district during the school year.

Under the provisions of Chapter 9, Education of Physically Handi-
capped Minors,6 school districts may make such special provisions as
in their judgment may be necessary for the education of physically
handicapped minors. Such physically handicapped minors may be
instructed in special schools or special classes, in hospitals, sanatoriums,
or preventoriums, in the home through the employment of home teachers,
by cooperative arrangement with the Bureau of Vocational Rehabilita—
tion of the State Department of Education, or by any other means
approved by the State Department of Education.

In the elementary schools of California, service to' physically handi-
capped children has increased from 2.910 children in 1934—35 to 4,493
in 1943-44, the last year for which figures were available in the State
Department of Education. In the following table (Table I) the excess
cost apportionments and average daily attendance of physically handi-
capped pupils in elementary Schools by types of classes are shown for
the 10-year period from 1934—35 to 1943-44.

4 A comprehensive study of the education of children with cerebral palsy in
(‘ulifornia is presented in a 165-puge typewritten manuscript prepared by Lois R.
Schulz and available in the otfice of the Division of Elementary Education, California
State Department of Education.

5 Education Code of California, 1943, Sections 6954, 6976, 7106, 7138.

0 Ibid, Sections 9601-96-14.

(20)

 

 

_21_

TABLE I

Excess Cost Apportionments and Average Daily Attendance of Physically
Handicapped Pupils by Typea of Claeeea and by Years in
Elementary Schools

,1 reraye Daily Attendance of Previous Year
In Elementary School

, Harem 0031' Individual Remedial Special

Year apportionment instruction classes day classes Total
1 943-44 __________ $756,279.64 848 931 2,714 4,493
1942—43 __________ 806,465.44 1 ,051 817 3,068 4,930
1941-42 __________ 810,859.04 97 3 818 3,144 4,945
1940-41 __________ 773,030.72 890 682 3,300 4,878
1939-40 ___________ 667,241.36 839 533 2,860 4,232
1938-39 __________ 627,094.42 717 595 2,77. 3,991
1937-38 __________ 598,214.78 609 _-- 3,220 3,829
1936-37 ___________ 558,774.34 618 _ _ _ 3,073 3,804
1935-30 __________ 594,769.24 558 __ - 2,870 3,428
1 934-35 __________ 424,750.22 380 _ _ _ 2,530 2,910

In the secondary schools of California, service to physically handi-
capped children has increased from 343 children in 1934-35 to 1,704 in
1943-44. In the following table (Table II) the excess cost apportion-
ments and average daily attendance of physically handicapped pupils by
types of classes in secondary schools are shown for the 10-year period

from 1934-35 to 1943-44.
TABLE II

Excess Cost Apportionment: and Average Daily Attendance of Physically
Handicapped Pupils by Type: of Classes and by Years in
High School:

Average Daily Attendance of Previous Year
In High School

I'cheur roxf Indii idual Remedial Special

Year apportionment instruction classes day clanxcs Total
1943-44 __________ $276,786.98 554 137 1,013 1,704
1942-43 __________ 3302,3041 DO '55 1 49 .‘l ,054 A 1,858
1941 ~42 __________ 283,349.64 6.95 1 34 1 .093 1,922
1940-41 __________ 232,615.46 549 148 905 1,602
1939-40 __________ 186,943.52 325 140 693 1 ,058
1938-39 __________ 177,9 18.98 284 91 603 978
1937-38 __________ 91 210.48 163 _ _ _ 369 532
1936-37 __________ 83,0953 123 _ - _ 382 505
1935-36 __________ 67,123.70 107 _ _ _ 327 434
1934-35 __________ 60,949.44 81 _ _ _ 282 343

It is apparent from the foregoing figures that steady growth is being
made in California in meeting the educational needs of physically handi-
capped children in the elementary and high school either through special
day classes, remedial classes, or in cases of extreme disability through
individual instruction given by teachers in the home of the physically
handicapped pupil.

Survey of Children With Cerebral Palsy (Spastics)

Inasmuch as Concurrent Resolution N o. 30 made special reference to
the problem 0f cerebral palsied children, the Department of Education
undertook a state-Wide survey. A preliminary questionnaire was sent
to city, county, and district superintendents. to high school principals,
and to directors of private schools. This preliminary inquiry served

_22_

as a device for locating the children with severe cerebral palsy. Detailed
questionnaires were then sent to all respondents who stated that spastic
children were in the school or resided in the community. One question-
naire was designed to obtain information regarding the educational
procedures followed by the school; the other, to procure information
about each child. It was anticipated that this procedure would yield a
state-wide picture of the educational facilities available for cerebral
palsied children which might be evaluated as to adequacy in meeting
the needs of such children between the ages of three 7 and sixteen years.

Personal visits were made to 15 schools, and information gained
from observation and conferences with school personnel was incorporated
into the data obtained from the questionnaires.

Nature of Cerebral Palsy

The treatment and prognosis of cerebral palsy are complicated by
the varied manifestations of the disorder. The severity of involvement
ranges from a slight to an incapacitating extent; it may involve one
limb, one side of the body, or all four limbs.

The physical appearance of the spastic child and his aimless gestures
contribute to the impression of mental as well as physical incompetence.
Involuntary motion which takes place in the muscles of the face as well
as the muscles of the arms and legsproduces contortions and grimaces
which on first sight appear to mark such children as definitely feeble-
minded. The characteristic of cerebral palsy is for the muscles to
respond maximally to any stimulus applied to them. The basis of this
response is motor, however, and is not due to emotional imbalance or
feeble-mindedness.

The basic movements—reciprocal kicking to walking, reaching or
grasping to self help, vocalized breathing to speech—are almost inherent
in the growing process of the normal infant but have to be taught to the
child with cerebral palsy. Abnormalities of the neuromotor system may
interfere with these basic learnings so that the spastic child can not learn
them or can only acquire very limited skill with them. The more compli-
cated m0vements are dependent upon these primary ones. If, however,
the basic movements have been learned by the spastic child, it may be
possible to teach him the more complicated ones. The primary goal
toward which the training of the spastic child should be directed are the
normal activities of walking, eating, dressing, and speaking. To the
degree that these can be acquired, the cerebral palsied child is educable.

The Incidence of Cerebral Palsy in School Children

Statistics show the incidence of cerebral palsy to be second in the
diagnostic classification of all crippling conditions. For several reasons
the public has not been cognizant of this large incidence. The inade-
quate medical resources to treat cerebral palsy patients have discouraged
parents from bringing their children to a clinic or hospital. The physical
inadequacy of the individual with cerebral palsy has made him socially
unacceptable, and families have therefore endeavored to shield him from

7 Education Code of California, 1.943, Section 9609 provides that minors
“suffering the efiects of spastic paralysis may be admitted at the age of three years
to special schools or classes established for such minors."

 

 

_23_

the unsympathetic attitude of people who misunderstand both the
etiology of the lesion and the mental status of the individual. Educa-
tional facilities have been available, for the most part, only to those
spastics whose degree of physical involvement is mild. Finally, there has
not been compulsory State registration because the disease is not
communicable.

The most reliable nationwide statistics indicate that there is an
annual increment of 7 cerebral palsied children for each 100,000 of the
population. Of these 7, one dies before reaching the age of six, thus leav-
ing six for every age group. In this way it is assumed that there are 96
cerebral palsied children under the age of 16 for every 100,000 of the
general population.

Applying this ratio to California, the number of children with cere-
bral palsy in the State would be about 7,680 on the basis of the present
8 million population. Authorities estimate a ratio of 54 educable cere-
bral palsied children under'sixteen years of age for each 100,000 of the
general population, which for California would mean a school responsi-
bility for 4,320 children with cerebral palsy.

The reports from the questionnaire of this survey do not locate this
number of children. There are several reasons to account for this dis-
crepancy: (1) inflated state population, (2) census limited to school
records, (3) compulsory school attendance beginning at age eight, (4)
children with mild degree of involvement adjusted to the school and not
reported, (5) severe cases not publicized, (6) schools without medical
service, (7) school personnel not qualified to diagnose. The ratio previ-
ously stated of 96 for each 100,000 of the population included ages 1 to
16; while those reported by California school authorities would include
for the most part only those within the compulsory school age of 8 to 16.

The survey in California yielded reports for 798 individual children
of school age with cerebral palsy from the following groups:

Public schools ______________________________________ 556
Children in school ___________________________ 457
Children not in school _______________________ 99

Private schools _____________________________________ 54

State schools _______________________________________ 2

State institutions ___________________________________ 186

Total _____________________________________ 798

The detailed data from 798 records form the basis for the further
study of the educational facilities for children With cerebral palsy in
California. A census of 798 spastic children under 16 years of age can
not be considered the total number of spastic children in the State, but
needs, rather, to be recognized with the limitations attendant a first
school census obtained from records not primarily compiled for that
purpose. This was a significant factor in reducing the number reported
by the preliminary inquiry. The number, 798, is further reduced, how-
ever, by the 186 feeble-minded patients Who are cared for by the Depart-
ment of Institutions. The minimum of the size of the school problem,
with regard to number of spastic children may be considered, therefore,
as one providing for 500 pupils. The experience of the crippled chil-
dren’s services in regard to other handicapped groups has been that

_24__

when more adequate programs are provided, these “hidden children”
quickly appear. It can safely be predicted that under an active state-
wide medical-educational program the known number of spastic children
in California will increase rapidly.

Problems Involved in the Education of the Cerebral Palsied Child

The survey revealed the areas of physical malfunctioning which
made each child a deviate in the school situation. For some children the
disability was noted in one or more areas, such as speech, locomotion, and
self-help, whereas for others it was shown only by disturbance in locomo-
tion. The three major areas of physical deviation were speech, self-
help, and locomotion. Impairment in vision was noted in 21 cases; in
hearing in 4 cases.

Locomotion. More than 200 children were reported with marked
difficulty in locomotion. Numerically, this is first in occurrence in all
types of motor disorder. The significance of independent locomotion to
school attendance is obvious. In general, the children who can not walk
are enrolled in special schools, taught by a home teacher, or are lacking
in school opportunity. Some typical examples of this locomotive
difficulty may be noted from the report.

An 8-year-old boy in a special school; completely dependent.
9-year-old X7 is just learning to walk with cane after using
wheel chair.

A 9-year-old girl who is able to walk in a framework with
wheels.

The abnormality of response of the leg muscles is conspicuous by
the scissor gait or by toe walking. The teachers report on some of these
as follows:

An 11—year-old has a “shuffling gait.”

A 7-year—old now can “stand on toes when supported.”

Girl. age 4-4, “is unable to take steps as she has a severe scissor
gait; can be assisted to walk with ski shoes.”

The difficulty of maintaining balance makes falling an ever present
danger. Examples of this were reported in various degrees of severity
and indicated an influence on the child’s participation in school
activities :
An 8-yearoold boy falls easily and has difiiculty in getting up.
An 11—year-old boy is “unsure of himself when walking, falls
more than the ordinary child does. ”
R8, age 10-7, “was unable to take more than two steps without
support at 8 years of age. He had a skinned nose which never
healed because he was always falling on his face. Can now
walk and run some.”

Self-help. Second in number of times reported were physical dis-
turbances involving the arms, hands, or both. The following examples
from reports in this study are typical :

Girl, 13 years old, right hand is helpless.
Ten-year-old girl eats fairly well alone and manages to dress
herself partially.

 

_25_

A 14-year-old girl who does walk but only short distances, is
unable to use her hands but writes and feeds herself with her
feet, has a good mind and reads on a level with children of
her age.

Speech. Various parts of the speech mechanism may be involved in
cerebral palsy. Reverse breathing is characteristic of many spastic
children. As a result only soft sounds can be made. One of the most
handicapped children reported in this study was a six-year-old boy who
had what may be called “silent speech.” Although he is able to direct
his tongue muscles to the proper movements, it is only very occasionally
and when he is completely relaxed that any sound can be heard.

Speech is further disturbed by muscular difficulties. The posterior
portion of the tongue may interfere with swallowing. The difiiculty
experienced by the spastic child in swallowing his saliva is a common and
distressing symptom in this respect. The case is reported by a special
school in a city school system of an eight—year-old girl who constitutes a
true schoolroom problem. The teacher writes:

X3 is a schoolroom problem. She is extremely difficult to
understand. She drools on people and whatever she is near,
paper, furniture. books. She wears a bib all day because of
excessive drooling.

Difficult Areas in Learning Situations. The. following problems
were reported as typical in the teaching of cerebral palsied children:
1. Speech
Uses a sign language with various grunts
Makes series of dilferent pitched tones
Good mind but unable to speak through lack of coordination
Nervous and stutters, when checked in his reading will slow down,
loWer his voice, and read almost without stuttering
Unable to speak clearly or rapidly
. Writing
Difficult to write legibly
Uses typewriter slowly with many errors
Very shaky and finds it difficult to write

3. Motor Control

Diificult to handle materials and tools

Difficult to hold materials

Difficult to see blackboard because of position of head

Difl‘icult to move to classes

Difficult to move about easily; unable to do laboratory experiments
4. Emotional Control

Dismissed from school because of problems of discipline

Very emotional; a behavior problem probably due to poor vision

Hard to deal with ; highly nervous

Too nervous to attend regular classes; was assigned a home teacher

Has given evidence of high temper in the past but seems to have

achieved better control
More nervous than he used to be; cries easily

lO

—26—

5. Slowness
Is incapable of movement if hurried
All movements slow
Needs to move at a slower pace than that afiorded in regular classes
Slow in oral expression
A slow writer

6. Reading
Eye coordination seems poor
Spasticity has affected eye muscles
Seems to have no fusion ability
No readiness for reading
7. Influence of group
Spasticitjr increases when child is in group and learning becomes
slower
Restless in a crowd and demands much personal attention
Reacts with increased nervousness to group stimulation

8. Arithmetic
No apparent conception of the meaning of number
Slow in all work involving number

9. Art
No ability to draw
Can use only large motions

10. Spatial relations
Unable to judge distances accurately
Unable to grasp and hold objects

It is evident from the many reports from teachers that the spastic
child experiences great difficulty in learning and requires a great amount
of individual attention from specially trained teachers to enable him to
make his maximal progress.

Evaluation of M ental‘Startus. A difierent type of problem, but one
upon which academic success is dependent, is the determination of the
educable potentialities of these children. The professional literature
is convincing in regard to the complications which confront the indi-
vidual Who attempts to measure the mental status of the child with
cerebral palsy. Because the present instruments of measurement empha-
size verbal or motor responses, the evaluation of the intelligence of the
cerebral palsied child is one of the major problems in planning education
for him. In testing the cerebral palsied child, tests should be used
which have the following characteristics: (1) few verbal responses
required, (2) fine muscular coordination not required, (3) the time
factor should not be important, (4) the degree of difficulty should chal-
lenge the subject, (5) some indication of the subject’s ability to appre-
hend a variety of relationships should be indicated, (6) testing periods
should be flexible in regard to time and number of tests, (7) the situations
used in the tests should be within possible experiential limits of spastic
children.

Information regarding the educability of the children in the schools
reporting in this survey was given in various ways. Intelligence quo-
tients were given for 113 children in the public schools. These were
obtained from different tests; for 41 children, from either form of the

_27__

Binet; for 89 children, from a combination of the Binet and some indi-
vidual performance test; and for 33 children, from either the Otis,
Kuhlman, California Mental Maturity, or some other form of group test.
The frequency and range of scores of these 113 children is shown in
Table III, Evaluation of Educability as Based on Tests.

TABLE III
Evaluation of Educability as Based on Tests
Test Used
Binet and Group
Intelligence performance test of

quotient Binet test intelligence Total

30« 40 ___________________ 0 2 0 2

40- 50 ___________________ 1 5 2 S

50- 60 ___________________ 2 6 3 11

60- 70 ___________________ 6 8 5 1!)

70- 80 ___________________ 7 3 (i 16

80- 9O ___________________ 8 7 4 1!)

90-100 ___________________ 8 5 8 21

100-110 ___________________ 2 2 4 R

110-120 ___________________ '3 1 2 8

120-130 ___________________ 1 0 0 1

130-140 ___________________ 0 0 0 0

140-150 ___________________ 0 0 0 0

130-160 ___________________ 1 0 0 1

Total __________ 41 39 33 113

Further light on the educability of spastic children was supplied by
the teachers ’ estimates in cases where the results of tests were unavailable.
The teachers reported that 13 children had reached the limit of educa-
bility; 33 were unable to achieve a passing grade; 16 were classified as
“passing for ability”; 55 were classified as poor in academic achieve-
ment; 30 were average; 103 were fair; 79 were good; 21 were “good but
retarded,” and 30 were excellent. Reports concerning the educability of
spastic children were received on 62 cases as follows: 23 were considered
educable, 19 were noneducable, and 20 were questionable.

From the data the inference seems justifiable that the majority of
children known to the school personnel have educable potentialities. Con-
sidering the 74 children who are reported to have intelligence quotients
above 70, the 290 whose performance level of school work is above passing,
and the 16 who were rated educable, there are 350 or more children of the
490 reported by the public schools who may be considered entitled to
school opportunity. In any event, the results of these inquiries indicate
the importance of some definite plans of psychometric examination of
cerebral palsied children by expert psychologists in order that the best
possible educational planning may be done for each individual child.

In summary there are several points which stand out as important.
Low mental capacity is not necessarily a concomitant of a cerebral lesion.
Because the mental status cannot be measured with present methods, it
cannot be assumed that mental deficiency exists. Evaluation of intel-
lectual capacity should not be confused with judgment of physical inade-
quacy. In many cases the child’s ability to learn is a better index of his
mental status than any evidence of speech or motor skill. Because of his
deviation, the cerebral palsied child’s progress should be measured in

 

_23__

terms of his own rate rather than compared,withrnorms on nonspastic
groups.

Programs of Other States for the Cerebral Palsied Child

The present concept of social welfare for the physically handicapped
child extends beyond medical care to a comprehensive program provid-
ing for educational, vocational, and social adjustment of the child. The
problem of the education of the child with cerebral palsy is a complicated
one in which the resources for care have not kept pace with the research
findings relative to his needs. The crux of the problem has been the diffi-
culty in integrating a program of muscle re-education- with the standard-
ized school routine. For no other group of handicapped children is the
problem of integration of care more significant than for cerebral palsied
children.

Reports from the few established cerebral palsy centers in the United
States, all in the eastern states, stress this integration in the program.
Four outstanding centers exist in the country: the Children’s Country
Home, Westfield, New Jersey; the Children’s Rehabilitation Center,
Cockeysville, Maryland; the James Whitcomb ’Riley Hospital, Indian-
apolis, Indiana; and Dr. Earl R. Carlson ’s School of Corrective Motor
Education, Long Island, New York. In these centers the focal point has
been medical research. The results indicate the importance of adjusting
the educational experiences to the children’s abilities and disabilities.

Outstanding among the state projects is Maryland’s method of
referral of cerebral palsy patients to a special diagnostic clinic with
opportunity for treatment and care at the Children’s Rehabilitation
Institute which admits only children with this type of handicap. A child
is accepted for a probation period of 3 months, and if he continues to
show progress, he is retained as a pupil. The criterion of progress is the
ability to learn, to improve mentally and physically. The expense of such
an institution is high because there is a staff-child ratio of one to one.

The aims of the James Whitcomb Riley Hospital have been set forth
as follows:

To correct deformities

To re-educate muscular control

To stimulate and.re-educate undamaged cortical cells

To improve rhythm of movements

To develop better neuro-muscular co-ordination and balance
To improve the tone of weaker muscles

To liberate the personality of the child

To develop the power of co-ordinate and articulate speech
To determine and guide educable possibilities

10. To stimulate mental as well as physical development

9973????”N!‘

This program does in reality attempt to treat the whole child as well as
his disease. An important feature of this plan is to continue in the home,
the treatment begun in the hospital.

Twenty-seven states now have limited programs under public and
private operation for the education and treatment of children with
cerebral palsy. These programs are suggestive for California’s planning
for the education of the cerebral palsied child. They demonstrate the need
for a distinct legislative and educational category for the cerebral

_29_

palsied; they indicate the value of an integrated program that correlates
physical training to develop motor skill with academic learnings; they
constitute a challenge to education to function positively in the formu-
lation of methods and techniques appropriate to the developmental devia-
tions reported for these children.

Recommendations for Educational Program

It is necessary in planning an educational program for children with
cerebral palsy to consider the physical and the mental deviations conse-
quent to the cerebral lesion. The educational prognosis is in many cases
confused by the interrelationship of the motor and the mental defect.
Wide variations of these conditions as regards degree or type of manifes—
tation may be considered as symptomatic 'of cerebral palsy.

Educational experiences which can be used by the spastic child will
show Wide variation. This necessitates defining educational expectations
for each child. The educational facilities previously discussed were in
relation to the spastic child who was in school. The educability of those
children was, therefore, in relation to ability for academic learning. Edu-
cability of the spastic child may, however, be considered in relation to
motor learning—that degree of mental ability which will enable the child
to learn the basic physical skills. An emphasis is placed on the spastic
child ’s acquisition of physical skills as a prerequisite for making academic
learning a functional asset to him. Some academic success, even though
a limited amount would be considered a criterion for the child’s con-
tinuing in any long-time educational program. There are spastic children
for whom the final goal may be limited to those basic skills of self-help,
but it is contended that there is a social obligation to assist the child to the
level of accomplishment that is possible for him. This variability in final
goal as well as in symptoms has complicated the formulation of an edu-
cational program because no single type of instructional program may
be considered appropriate for all children with cerebral palsy.

, The present practice of including the children with cerebral palsy
in the school program of the crippled child has served eifectively for some
spastic children. There needs to be a distinction, however, in the think-
ing and the planning for spastic children because there are many for
whom the regime of a school for children with all types of handicap is
too demanding. The program, planned for the orthopedic cripple who
shows a zero response to stimuli, will not be appropriate to the spastic
child who gives a maximal response to stimuli. Or in another situation,
the crippled child will be passively helpless whereas the spastic child’s
helplessness may. be superimposed with confused, tense, or involuntary
movements.

Fundamental to a program in which all spastic children may share
is a separate legislative and educational category such as at present exists
for the deaf and the blind. A beginning has been made in the permissive
legislation admitting children with cerebral palsy at the age of three
years to such special schools or classes as may be available to him.8

The evaluation of the educational facilities in California for chil-
dren with cerebral palsy indicated that the modifications now made in the
school program facilitated school attendance for a number of spastic
children. There were other spastic children, however, who were con-

" Education Code of California, 1943, Section 9609.

_3o_

sidered to have academic ability but whose degree of physical disorder
prohibited school opportunity under present conditions. In relation,
therefore, to the total group of spastic children, three services appear
essential in a plan designed to give all children with cerebral palsy edu-
cational opportunity commensurate with their physical and mental abil-
ity: (1) formulation of a state-wide cerebral palsy program with educa-
tional services having an integral function in the total plan; (2) continu-
ation of the special education program in public schools for those spastic
children for whom it is suitable or for whom adjustment can be made
through the regular channels; and (3) establishment of additional edu-
cational facilities necessary for a correlated program for children with
cerebral palsy.

State Program for Children With Cerebral Palsy

The major emphasis in any State program must be on the coordina-
tion of medical, surgical, neurological, educational, and social services.
It is apparent from a review of programs reported by other States that
an experimental approach is consistent with the present stage of the
problem in relation to diagnosis, prognosis, or treatment.

The educational program must be an integral part of the total State
program for spastic children and may therefore be considered in rela-
tion to the field services as well as to the diagnostic centers.

First in the consideration of any State plan are the field services.
The function of the field services should be twofold: (1) to recommend
treatment and educational placement for those children who can be cared
for through the existing facilities of the community; and (2) to locate
cases needing referral to a diagnostic center. The field services, now
functioning under the Crippled Children’s Division, Department of
Public Health, are organized to serve all sections of California. Exten-
sion of the service, to provide special clinics for children with cerebral
palsy would benefit a large number of this handicapped group. Educa-
tion should have the responsibility of recommending school placement
and making arrangements for the child’s admission to the appropriate
unit. The facilities of the State’s program of special education should be
used by this group. It is evident that for social and economic reasons,
adjustment within the regular school channels when it can be arranged,
is the recommended procedure. For the most part this group would be
composed of children similar in type of disability to those 431 who were
enrolled in the schools reported in this study.

The survey of State services emphasized the importance of family
education in the care and treatment of the spastic child. Such an
emphasis has the advantage of being an economy measure but the greater
advantage is in keeping the child within the family group.

A second unit in the State organization designed to serve the spastic
child would be a diagnostic center. For a State the size of California, it
would seem feasible to propose two such centers. There may be noted a
concentration of the numbers of spastic children in' two sections of the
State: one around San Francisco and the San Francisco Bay area; and
another around Los Angeles and San Diego. The preschool and school
age load is seen to be in similar geographical locations. The numbers of
spastic children in these areas reflect, to an extent; the development of the
facilities for diagnosis,'for treatment, and for special education which
have. served to draw the spastic children to these sections.

._31_

It should be anticipated that every child with cerebral palsy would
have the privilegeof referral to such a center for the services of special-
ists who would diagnose and recommend treatment. The establishment
of the child ’s status of educability would constitute one of the diagnostic
services. Educational placement would be recommended on the basis of
the physical and mental status of the child, the social aspect of the home
environment, or the location of the home in relation to needed school
facilities.

A short term of residence in the center would be necessary so that
the child could be studied under ditferent conditions. A six months
trial period and final placement of the child on his ability to learn, to
improve mentally and physically seems defensible. Three factors would'
determine treatment: degree of handicap; mental status of patient; and,
evidence of the condition as static or showing possible retrogression.
From a specific diagnostic analysis, considering these factors, treatment
may be planned to meet the extent of the injury.

A diagnostic center would offer opportunity for research. The
greatest obstacle in the development of adequate programs for these
children is in the lack of information regarding the whole field of cere-
bral palsy. Present methods of measuring intelligence, because they
place an emphasis on motor or verbal ability of the patient, are not
appropriate to the child who has no speech or who can not control or
direct his movements. Investigation is needed in such areas as adapta-
tion of teaching techniques in'the various subject—matter fields, adjust-
ment of physical facilities and equipment, and formulation of methods
and requirements for training teachers of spastic children. A very large
emphasis of the total program must be placed upon research.

Educational Program

The formulation of an educational program on the basis of an
analysis of the individual reports of spastic children suggests certain
areas as major points of emphasis. There must be an integration of
services so that the children may have the necessary physical training
to develop those motor skills without which academic learnings are not
functional.

There must be an emphasis on early training as an integral part of
the total program. The very young Spastic child is totally dependent
for care, and although his needs and desires approximate his chrono-
logical age, his motor skills are in conflict with them. The admission age
to a school program, according to present law, would be three years, but
medical and neurological findings are in agreement that diagnosis and
treatment should be instituted at as early an age as evidences of the
cerebral lesion are observed.

A program of training teachers to work with cerebral palsied chil-
dren is greatly needed. The skilled teacher is one trained in many
techniques. The teacher training program may be considered from
three approaches : requirements which should become legal considerations
and thus need to be written into the education code; programs to be
introduced into teacher training institutions; and, general policy of
requirements for teachers of cerebral palsied children.

Family education is needed in the care and treatment of the spastic
child in the home. Teachers of spastic children emphasize the importance

__32_

of a parent education program planned to aid parents in the care of the
handicapped child so the entire family may lead a reasonably normal life.
It 1s often dificult for the members of the family to maintain an objective
yet understanding attitude toward the cerebral palsied child and his
problems. He must receive help but not constant solicitude. He needs
to have some things done for him, yet he must learn to do for himself even
though the task 1s more difi'icult for him than for others. These distinc-
tions are not easy for parents to make, but are essential to the child’s
learning process.

Essential to the whole program is the recognition of the relation of
the cerebral lesion to a mental defect. In many cases of cerebral palsy,
motor disorders reflect mental deficiency and no amount of motor training
will compensate for the basic lack.

If the educational placement is to be recommended by specialists in
the diagnostic centers and in the field services, an increase in types of
school facilities and in modification of instructional services would seem
to be indicated. It is proposed that children with cerebral palsy be
classified in four categories on the basis of physical and mental develop-
ment and educational programs planned which will be adapted 1n facili-
ties and In techniques to the characteristics of each group. The follow-
ing four categories were suggested from a grouping of the cases referred
to in this study: Group 1, children who can be served by the facilities of
the special education programs as they now exist with added ‘services for
instruction in motor education and by establishment of special spastic
units' 111 schools for crippled children; Group 11, children of preschool age
who manifest varying degrees of my o;lvement Group III, children who
require custodial care because of mental deficiency, and Group IV,
children who have a severe physical involvement or multiple handicap but
who evidence mental capacity greater than those children committed to
institutions for the feeble-minded. Educational opportunity for these
children may be considered as education which will result in personal
satisfaction, and have little social or economic value.

It 1s not expected that arbitrary divisions of these groupings will
easily be made nor will it be essential A feature of the total program
would be that of flexibility to permit transfer from one unit to another
if the child’s condition shows change.

Group I. The children classified 1n this group would be those for
whom educability status is established and whose degree of physical
involvement varies. These children can profit by school experiences.
14‘01 those with a moderate physical handicap, the highly developed facil-
ities of the special education program can prOV ide suitable school opp01-
tunities and a wide range of adjustment can be made within the
organization of the public school. A basic principle of the planning of
the school program for spastic childl e11 should be one of adaptation. If
the spastic child has the regular educational facilities adjusted to his
needs, he is placed in an em 1ronment where he can have experiences
similar to those of other children

A favorable prognosis might be expected for the majority of the
group when provided with a program of physiotherapy treatments com-
bined with special education. Since this is the group for whom the
greatest gains would be noted in physical and mental accomplishments,
caution must be exercised in regard to the final goal. Research studies

__33__

have shown that arrest of development and even retrogression may be
expected, but the democratic philosophy of education justifies effort
toward giving these children educational opportunity commensurate with
their evidenced capacity.

For those children with a lesser degree of muscular co-ordination,
emphasis is placed on an enlargement of facilities by the establishment
of a spastic unit in the schools for crippled children. The techniques of
the classroom in which only spastic pupils are enrolled could be better
adapted to the motor and speech disability of these children.

One advantage of a special unit for spastics in a crippled children ’s
school is its proximity to other groups of children Who are more compe-
tent physically, emotionally, and academically. Complete segregation
of all spastic children is not desirable and is not recommended. Particu-
larly in relation to speech it may be advantageous for a child to have
association with children who do not exhibit speech abnormalities. This
loses its value, however, when the pattern observed daily is too remote
from the child’s ability of attainment. The aim thus would be to provide
school experience from which the child could profit so that by a gradual
process he may move from the special unit to the classes for all handi-
capped children or to the regular school when such becomes possible.

Group II. Group II would be composed of those children below
6 years of age with emphasis on the early preschool years. On the theo-
retical basis of teaching new motor pathways when the growth impetus
is high and before motor habits have been learned, and on the practical
basis of the results reported by workers in the field, this is the period
which training may be expected to be the most effective. From long
observation, administration of many tests, and the combined services of
specialists from several fields, a diagnosis, treatment, and prognosis may
be formulated for each child. The educational program may then be
planned for the child, consistent with his physical and mental abilities.

Preschool units such as these might be thought of in the total plan
as day schools similar, for example, to Cottage School in Oakland, or the
nursery unit in the Sunshine School in San Diego, and as hospital schools
providing 24-hour care. The primary distinction would appear to be in
the degree of severity of physical involvement. Location of the home to
other preschool units or suitability of the home environment might also
be important considerations.

The number of these children reported to the study was afiected by
the source of the data. The report of 109 spastic children below 6 years
of age may be considered only suggestive since for certain large areas as
San Francisco, the report was limited entirely to children'in the elemen-
tary grades. This figure includes those for whom reports were received
as well as some for whom name and age only was reported so that it is
larger than the group included in the tables in other sections of this study.

Group III. Though this study is concerned primarily with the
problems of educable children with cerebral palsy, the numbers of non-
educable ones can not be ignored. If the national statistics apply to
California’s present population, there are in the State more than 3,000
individuals under 21 years of age who are not educable in the sense that
they evidence ability in academic work. The reports to this study indi-
cated more than 200 such children including those committed to institu-
tions for the feeble-minded.

__34_

There is at the present time considerable public concern regarding
the commitment of spastic children to institutions for feeble-minded
patients. It is difficult to evaluate the mental status of a child who has
not had opportunity to acquire those physical skills by which he may
evidence intelligence. A very strong emphasis is needed in the total
program toward the development of techniques to determine educability.
This is a primary challenge to research. For cases difficult to diagnose,
a period of residence in the diagnostic center is recommended so that
adequate observation and suitable tests will make possible an evaluation
of mental capacity which will not be confused with physical inadequacy.

Group III would, therefore, be composed of children whose mental
capacity is not equal to the demands of the school. Acquisition of motor
skills would not be expected. These children should be cared for in an
institution for feeble-minded patients where they may receive general
care necessary for the physically handicapped. Special academic educa-
tion would not be indicated since improvement could not be expected.

Group IV. There are in addition to these three groups of spastic
children, a number for whom both academic and motor learnings are
questionable. These are the children who evidence severe physical
involvement both as regards area and extent, or. a multiple handicap.
Physical improvement may be expected to a very limited extent. The
mental capacity of these individuals is doubtful but the reports of such
cases suggest a level above that used as a criterion for commitment to an
institution for the feeble-minded. The disposition of this group of chil-
dren constitutes a serious problem since the cost of their care will be
extremely high in proportion to the degree of improvement that may be
expected. One such case reported to this study is that of A9:

A9, aged 14, is partially paralyzed on her right side,
has less than 25 per cent vision and has seizures at
- intervals. She carries the right hand in a typically
spastic manner, but limps only slightly. She has a
home teacher for 5 years but last year was in a special
school for handicapped children. She benefitted
greatly from her social contact with other children but
because of the seizures, she was removed. She is able
to look after herself almost entirely, can do much in
assisting around the house, can read and write Braille.

Conclusion

There is no factor resulting from the cerebral lesion which of itself
reduces the life span. Therefore, a correlated program of education
and training should continue as long as improvement is noticed in skills
of self-help and social competence. The establishment of criteria of
progress during the educative process should be a goal of projected
research.

There is reasonable hope, according to authorities in the field, that
at least some of the efiects will be overcome through the processes of
growth. Early, persistent, and long-continued programs of muscle
training supplemented by judicious use of special therapy and educa-
tional methods will go far toward helping the child to obtain a happy
and useful if not wholly competent place in the world about him.

"13%;:

I":

._ 35 _
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Children, Elyria, Ohio. August, 1943. 19 pp. Free (Copy sent under separate cover
to all persons on mailing list of Bulletin on Current Literature.)

VVhitncr, Chauncey H. A program for spastics in California. Spastic Children’s
Society of Alameda County, 4120 Sequoyah Road, Oakland, California. Mimeo-
graphed.

Whitner, Chnuncey H. Spastic Children’s Society—report of the president for
the year ended December 31, 1940. Issued by Spastic Children’s Society of Alameda
County. 915 Portal Avenue, Oakland, California. January, 1941. 6 pp. Mimeo-
graphed.

 

 

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