12. Neurologic, Orthopedic and Other Impairments Exceptional children who are crippled, deformed, or physically handicapped and those who have held problems comprise the group labeled neurologically or orthopedically handicapped. Most of the children found in these special classes have problems of coordination, perception, cognition, or mobility resulting from the lack of proper development of, or injury, to the central nervous system. These children have been classified into three broad categories: (1) neurologically impaired, (2) orthopedically impaired, and (3) children with other health impairments. The neurological impaired are those children whose handicapping condition is due to a lack of complete development or injury to the central nervous system. An injury to the brain, or lack of development of the brain is likely to result in disabilities of various kinds including cerebral palsy, epilepsy, spina bifida, and other brain involvements. Of the four disabilities listed above, cerebral palsy is the most difficult to treat and requires a team approach by the members of various professions. The majority of cerebral-palsied children have associated handicaps of vision, hearing, and speech, as well as perceptual or behavioral handicaps. Cerebral palsy is not a disease, but a condition characterized by a group of concurrent symptoms. It is classified as to different forms of neuromuscular involvement including, (1) spasticity, (2), athetosis, (3) ataxia, (4) tremor, and (5) rigidity. The first two groups comprise about 75 to 80 percent of cerebral palsied. Spasticity makes up the largest group of the cerebral palsied, constituting 40 to 60 percent of the total. It can occur in one or more limbs with hemiplegia being the most common locus of involvement. The clinical picture is one of hyperactive deep reflexes, hypertonicity, and clonus. Athetoids make up the second largest group or about 15 to 20 percent of the total. Athetosis is characterized by uncontrollable, jerky, irregular, twisting movements. The head is frequently drawn back, the neck extended and tense, and the mouth held open, the tongue protruding and drooling often occurs. During sleep, however, the athetoid does not writhe or squirm. Ataxia is less prevalent than the others and is due to a lesion in the cerebellum, which normally controls balance and muscle coordination. The child is often unsteady in his movements, walks with a high step and falls easily. The eyes are uncoordinated and nystagmus is common. Tremor and rigidity are the result of injury to the extrapyramidal system. They occur in a small proportion of cerebral palsied children. The causes of cerebral palsy appear to be very similar to the causes of many forms of mental deficiency in children. Illingworth (1958) asserted: "...the causes of cerebral palsy and of mental deficiency are so interwoven, that with only a few exceptions research into the causes of one cannot and should not be separated from research into the causes of the other." Visual, hearing, speech, and perceptual disorders are substantial in a number of children (Hopkins, Bice & Colton, 1954; Denhoff & Robinault, 1960; Strauss & Lehtinen, 1947; Cruickshank, Bice, & Wallen 1957). Given the compounding nature of the these disorders, it is difficult to systematically prescribe one type of intervention for a child. Individualized remediation is essential. Spina bifida is one of the most common birth defects causing disability in infancy and childhood. It is a congenital condition in which the bony elements of the spine have not made a complete closure, leaving an opening in the neural tube. The myelomeningocele lesion is frequently accompanied by paralysis of the legs and lack of bowel and sphincter control. With physical therapy, bracing, and the use of crutches or walking frame the child can learn to walk and to great extent take care of his own needs. Incontinence presents the greatest social problem. Spina bifida is frequently accompanied by hydrocephalus which is an increase of cerebrospinal fluid in the cranial cavity causing pressure and enlargement of the size of the head. Children with spina bifida who do not have hydrocephalus do not deviate significantly in intellectual function from the normal population (Kirk, 1979, p. 366). Many orthopedically handicapped children acquire their crippling condition later in life as a result of accidents, infectious diseases, a congenital predisposition, or a disease which incapacitates the child. Poliomyelitis once accounted for the largest enrollment of crippled children in schools. The virus that caused this disease was almost completely eradicated in 1956 with the development of the Salk and the Sabine oral vaccines. Hemophilia, bleeder's disease, is a congenital hereditary defect of blood coagulation. There is currently no absolute cure for it. It is almost entirely in males with females as carriers. According to Katz (1970) the incidence of hemophilia in North America is 1 or 2 per 10,000 males. The average hemophiliac does not have sensory impairment, mental retardation, or other associated disabilities which would limit his academic success. He may need special attention, because of poor school attendance. His educational problems can be met by home teaching or help from a resource or itinerant teacher with the child remaining in the regular classroom. Muscular dystrophy is a progressive disease of the voluntary muscles such as the arm, thigh, and calf muscles. Muscle fibers are replaced by fatty tissue causing a weakness of the muscles but a continued healthy appearance of the child. It is found throughout the world, and its cause is attributed to an inherited characteristic coming from either parent. Males are affected from five to six times as often as females. Children afflicted with muscular dystrophy rarely live to adulthood. Working with the physically challenged, one of the most difficult tasks is fostering personality adjustment. The group as a whole shows a greater tendency toward a personalized, introspective view of life with concern over the effect of the disability. Barker et al (1953) surveyed the studies on the adjustment of physically handicapped individuals and found: 1. Physically disabled children, more frequently than normal children, exhibit behavior which is commonly termed, maladjusted. 2. The kinds of maladjusted behavior exhibited were not necessarily peculiar to the physically handicapped. 3. There did not seem to be much evidence of a relationship between the kind of physical handicap and the kind of maladjustment. 4. The person with a long history of physical handicap has a greater amount of maladjustment than the person with a short history of physical handicap. 5. The attitudes of parents toward their crippled children, whether rejecting or overprotecting, tend to be more extreme than their attitudes toward normal children. Kirk (1979) outlined the basic needs which crippled children experience: 1. Affection and recognition. 2. Self-realization. 3. Security. 4. Frustration. 5. Compensation. 6. Importance of home contacts. 7. The role of the school including special adaptations and modifications, school housing to meet their needs, transportation, special equipment, medical supervision, and individualized instruction. Educational procedures for the physically handicapped include (1) the organization of programs for different ages and levels; nursery and kindergarten, elementary and secondary school; (2) the adaptation and modification of physical facilities and plant to accommodate children with physical disabilities; (3) provisions for general educational activities offered to all children; and (4) special individual and small group remedial instruction for speech, language, reading, writing, and arithmetic disabilities (Kirk, 1979, p. 381).