THE DEVELOPING BRAIN Critical Periods of Brain growth 1 month
neural tube 4 th month All the lobes and major divisions complete 1
year post-natal 2/3 adult size 2 years age 75% adult size 5 years
90% adult size Potential for Neurogenesis [new brain cell
formation] (peaks in utero) and Synaptogenesis [new connection
formation] (peaks by 5 years) continues throughout life.
Slide 4
DEVELOPMENTAL MILESTONES FOR A NORMAL CHILD Primitive reflexes
(disappear by 3-4 months) Neck control 3-4 months (earlier in
African children) Sitting 5-6 months Rolls 7 months Crawls 7-8
months Stands with support 10 months Walks 12 months Climbs up and
down stairs 20 months
Slide 5
CEREBRAL PALSY (CP) A group of disorders of the development of
movement and posture, causing activity limitation that are
attributed to non- progressive disturbances that occurred in the
developing or infant brain.
Slide 6
This is often accompanied by disturbances of sensation,
cognition, communication, perception, behaviour or by a seizure
disorder. It is reported to be the most common cause of motor
deficiency in childhood both in developing and developed countries.
CEREBRAL PALSY (CP)
Slide 7
CAUSES General Premature babies particularly those who weigh
less than 3.3 pounds (1,510 grams or 1.5kg) have a higher risk of
CP than full-term babies. Falls and birth traumas occuring before,
around or shortly after delivery Nigeria and Developing Countries
Problems during labour and delivery that lead to difficulty in
establishing breathing at birth
Slide 8
Excessively high bilirubin/jaundice Infections (Intrauterine
and Perinatal) Metabolic such as Hypoglycemia or Low blood sugar
Developed Countries Extreme prematurity Inborn Errors of Metabolism
CAUSES
Slide 9
TYPES OF CP Spastic Cerebral Palsy: This causes stiffness and
movement difficulties Dyskinetic Cerebral Palsy: This can be either
Athetoid Cerebral Palsy leads to involuntary and uncontrolled
movements or Ataxic Cerebral Palsy causes a disturbed sense of
balance and depth perception
Slide 10
Mixed Cerebral Palsy: This is a mixture of different types of
cerebral palsy. A common combination is spastic and athetoid TYPES
OF CP
Slide 11
FURTHER CLASSIFICATIONS OF CP Clinical (spastic [too stiff],
flaccid [too soft], extra- pyramidal [moving without control or
abnormally positioned] and mixed). Anatomical (number body parts
[limbs] affected) The Gross Motor Function Classification System (
GMFCS ), a recently developed system, classifies children with CP
by their age specific motor activity.
Slide 12
Based on the assessment of severity of CP in children 0-12
years of age based on their functional abilities rather than their
limitations. It describes the functional characteristics in five
levels, from I to V, with level I being the mildest. FURTHER
CLASSIFICATIONS OF CP
Slide 13
ANATOMICAL DEPICTION OF CP
Slide 14
THE GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM (GMFCS) Before 2
years2-4 years4-6 years6-12 years Level I Manipulate objects with
hands and walk independently Gets up from sitting without holding
unto something Can climb stairsWalk indoors and outdoors, climb
stairs. Level II Belly crawls, pull to stand on furniture and
cruise Can assume sitting position without assistance, walk with
assistive device Sitting with both hands free, walk short distances
without assistive device Walk indoors or outdoors on level surface
only Level III Can roll and creep forward on stomach w sit and
require adult assistance to assume sitting Walk with assistive
device Walk indoors or outdoors on level surface with an assistive
mobility device. Level IV Can roll independentlyAble to roll and
creep, can sit when placed, but need both hands on the floor. Sit
independently in a chair but minimal hand function Rely on wheeled
mobility, may achieve self- mobility using assistive device Level V
Limited voluntary movements, no head control Requires adult
assistance to roll All areas of motor functions are limited.
Functional limitations in sitting and standing are not fully
compensated for through the use of assistive device.
Slide 15
DIAGNOSIS OF CP Delayed motor milestones Fisting after 5 months
of age Inability to sit with support by 8 months Inability to walk
at age 15-18 months Discrepancies between intellectual and motor
development Persistent or evolving increase or decrease in muscle
tone
Slide 16
Head lag beyond 6 months of age Poor trunk control and balance
Opisthotonic posturing and extensor thrusting Development of
Dystonia Toe walking/scissoring of feet Abnormal motor or gait
patterns DIAGNOSIS OF CP
Slide 17
MANAGEMENT OF CEREBRAL PALSY A MULTI DISCIPLINARY APPROACH
Slide 18
ISSUES IN MANAGEMENT The Stigma The Fears The Reality
Slide 19
STIGMA In African culture, children are highly cherished for
many reasons, principal amongst which is the hope that they will
bring prosperity in future. Thus when a child is diagnosed as
having a condition that diminishes such expectation, hopes are
dashed and parents often go through a process that can be
associated with grieving.
Slide 20
Next comes blame: Is it a curse Evidence of infidelity or
witchcraft Is it hereditary STIGMA
Slide 21
CONSEQUENCES OF STIGMA Denial of the child Neglect - A
significant number of children are severely malnourished Social
isolation: Many children are hidden away from other family members,
friends and the community. Some are shipped of to live with distant
relatives who are not in a position to provide proper care
Infanticide: There are numerous recorded cases.
Slide 22
THE FEARS Will it happen again? Who will bare the high cost of
care? What is the duration of care? What quality of life is the
child expect to have? What label will be placed on the child? i.e.
Impaired, Disabled, Handicapped.
Slide 23
THE REALITY No quick fixes or magic cures. Care is
multi-disciplinary. Process of care is long, requiring
determination, patience and faith in the in-born (often times
undiscovered) abilities of the child. Most therapies often require
prolonged periods before appreciable differences can be seen. It is
difficult to predict response to therapies.
Slide 24
THE REALITY Most families go through different stages of
grieving before finally accepting the diagnosis In Nigeria, without
social security, the complete cost of care for a child with CP is
borne by the parents In Nigeria and other African countries, most
causes of CP can either be prevented or considerably reduced with
improved Basic Health Care Services As stakeholders, we should all
be change agents and join in the advocacy for the rights of
children living with cerebral palsy and other childhood
disabilities
Slide 25
TREATMENT/MANAGEMENT OF CP Cerebral palsy cant be cured, but
early application of the right management options for the child
often results in a marked improvement in the quality of life of an
adult with CP. The earlier treatment begins the better chances
children with CP will have in overcoming developmental disabilities
or learning new ways to accomplish the tasks that challenge
them.
Slide 26
CP usually affects several areas of functioning and as a
result, there is a requirement for several disciplines to be
involved in managing the condition It is also preferable to have a
pediatrician coordinate the activities of the multi-disciplinary
care team in order to ensure an effective treatment outcome.
TREATMENT/MANAGEMENT OF CP
Slide 27
GENERAL PRINCIPLES OF TREATMENT/MANAGEMENT Determine severity
of the disorder in order to arrive at an appropriate level of
intervention that is required for proper management Establish clear
indications and goals for each therapy Ensure that therapists and
operators of intervention programs are well informed about the
childs condition and that they also inform the physician of their
activities
Slide 28
Details of local intervention programs with details of
eligibility, access and payment should be readily available Include
parents in therapy sessions and encouraged them to incorporate what
they learn into their childs daily activities. GENERAL PRINCIPLES
OF TREATMENT/MANAGEMENT
Slide 29
THE MULTI-DISCIPLINARY TEAM Pediatricians - provide general
care and coordinate the activities of other members of the
Multi-Disciplinary Care Team Surgeons provide specialist care and
perform corrective surgeries. Occupational therapists- help manage
fine motor activities Physiotherapists - help manage gross motor
movements
Slide 30
Speech therapists - help improve speech and swallowing.
Clinical Psychologists - provide emotional well-being as well as
cognitive evaluation for school placement. Special need educators -
provide the right kind of education for children with cognitive
impairment THE MULTI-DISCIPLINARY TEAM
Slide 31
OTHER MANAGEMENT OPTIONS The quality of life of children with
CP clients can be greatly enhanced through the use of the
following: Prosthetic devices such as braces and other orthotics
Wheelchairs and rolling walkers IT devices such as computers, voice
synthesizers and other accessories that can aid communication and
mobility.
Slide 32
WHAT PARENTS SHOULD DO Get diagnosis from appropriate
specialists. Get informed so as to be in a better position to
separate fact from myth Identify available options for intervention
Get involved with or start a support group. Get counselling.
Slide 33
WHAT GOVERNMENT SHOULD DO Provide facilities and trained
manpower for the effective management of CP and other childhood
disabilities Provide support for families in terms of funding and
affordable or subsidized medication Ensure a disable friendly
environment through the provision of accessible public
transportation and public buildings Enact laws to reduce stigma,
discrimination, abuse, neglect, and violations of rights
Slide 34
Train and deploy of a Medical Aids Corps of adequately trained
young adults to run awareness campaigns on childhood disabilities
and early detection/intervention techniques in rural communities.
Establish Special Care Units for Childhood Disabilities in
hospitals/health centers WHAT GOVERNMENT SHOULD DO
Slide 35
Establish Counseling Units in hospitals and health centers to
help families of children with CP to cope the realities of their
situation. Organize regular Seminars and Conferences on CP and
other childhood disabilities to serve as forums where affected
families and interested members of the public can get better
informed about CP related issues. WHAT GOVERNMENT SHOULD DO
Slide 36
Build capacity for all categories of Healthcare providers in
the area of early intervention and modern trends in the management
of CP and other childhood disabilities. Provide special medication
and other management options like physiotherapy, for children with
CP and other childhood disabilities. WHAT GOVERNMENT SHOULD DO
Slide 37
Train and deploy Special Needs Teachers and Careers in schools.
Identify and document affected families in rural communities.
Compile a register of relevant professionals for the management of
childhood disabilities in each community. WHAT GOVERNMENT SHOULD
DO
Slide 38
CONCLUSION CP is the most common cause of movement disorders in
children. It is also the most expensive childhood disability to
manage. Some causes of CP can be prevented through the provision of
adequate care for pregnant women and young children.
Slide 39
Families play a critical role in the provision of care for
children with CP and other childhood disabilities and should be
given the necessary financial, social and emotional support to
carry out that responsibility Effort should be made and facilities
put in place to help discover the hidden potentials of children
with CP and other childhood disabilities CONCLUSION
Slide 40
THE WAY FORWARD Healthcare Professionals need to listen more
and provide adequate as well as appropriate information to
families. Relevant agencies should support Benolas effort to raise
awareness about CP and other childhood disabilities to ensure that
discussions continue even at the highest levels.
Slide 41
There is need for families and NGOs to come together to form
larger support and advocacy groups for CP and other childhood
disabilities. There is need for Government at all levels to rise to
their responsibilities towards children with childhood disabilities
and their families. THE WAY FORWARD
Slide 42
REFERENCES Parameter: Diagnostic Assessment of the Child with
Cerebral Palsy: Report of the Quality Standards Subcommittee of the
American Academy of Neurology and the Practice Committee of the
Child Neurology Society". Neurology 62 (6): 85163. PMID
15037681.PMID15037681 Benola CPI, (2013). Group 3 Syndicate
Presentation at Benolas Two Day Round Table Meeting of Experts,
Lagos. Benola CPI, (2013). Report of Roundtable Meeting of Experts
on Effective Management of Cerebral Palsy in Nigeria, Lagos.
Cerebral Palsy Childrens Hemiplegia and Stroke Association Report,
(2012).
Slide 43
Ejeliogu, E. (2013) Management of Cerebral Palsy in Nigeria:
Paper delivered at Benolas Two Day Roundtable Meeting of Experts on
CP, Lagos. Lesi, F.E.A. (2013). Cerebral Palsy: The Stigma, the
fears and the Reality. A paper presented at Benola Cerebral Palsy
Initiative Family Forum, Lagos. National Institute of Neurological
Disorders and Stroke (2012). Cerebral Palsy: Hope Through Research.
Cerebral palsy information booklet compiled by the National
Institute of Neurological Disorders and Stroke (NINDS). Cerebral
Palsy: Hope Through Research REFERENCES
Slide 44
Odding, E. Roebroeck, M.E. Stam, H. J. (2006). The epidemology
of cerebral palsy: incidence, impairments and risk factors.
Rosenbaum, P. Paneth, N. Leviton, A. Goldstein, M. Bax, M. (2007a).
A Report. The Definition and Classification of Cerebral Palsy April
2006. Developmental Medicine and Child Neurology Journal
Supplement, 49:8-14. Saad, M. T. (2013) Early Detection and
Effective Management of Persons Living with Cerebral Palsy in
Nigeria: Paper presented at Benolas 2 Day Roundtable Meeting of
Experts on Cerebral Palsy, Lagos. REFERENCES
Slide 45
Saad, M.T. (2012). Efficacy of Cognitive-Behavioural Therapy on
Self- Concept of the Visually Impaired Students of Kaduna State
Special Education School. An Unpublished Ph. D Thesis Presented to
the Department of Counselling and Educational Psychology,
University of Abuja, Nigeria. Umeh, C. S. (2013). Management of
Cerebral Palsy: A Multidisciplinary Approach. Paper delivered at
Benolas CP Family Forum, Lagos. REFERENCES