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WHAT
CAUSES CEREBRAL PALSY ? |
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We
do not know the cause of most cases of cerebral palsy.
That is, we are unable to determine what caused cerebral
palsy in most children who have congenital CP. We do know
that the child who is at highest risk for developing CP
is the premature, very small baby who does not cry in
the first five minutes after delivery, who needs to be
on a ventilator for over four weeks, and who has bleeding
in his brain. Babies who have congenital malformations
in systems such as the heart, kidneys, or spine are also
more likely to develop CP, probably because they also
have malformations in the brain. Seizures in a newborn
also increase the risk of CP. There is no combination
of factors which always results in an abnormally functioning
individual. That is, even the small premature infant has
a better than 90 percent chance of not having cerebral
palsy. There are a surprising number of babies who have
very stormy courses in the newborn period and go on to
do very well. In contrast, some infants who have rather
benign beginnings are eventually found to have severe
mental retardation or learning disabilities. |
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CEREBRAL
PALSY IN THE NEWBORN ? |
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Many
children with cerebral palsy have a congenital malformation
of the brain, meaning that the malformation existed at
birth and was not caused by factors occurring during the
birthing process. Not all of these malformations can be
seen by the physician, even with today's most sophisticated
scans, but when CP is recognized in a newborn, a congenital
malformation is suspected. When a diagnosis of CP is made,
the mother and father often feel guilty and wonder what
they did to cause their child to have this disorder. While
it is certainly true that good prenatal care is an essential
part of preventing congenital problems, it must be stated
that congenital problems, or "birth defects,"
often occur even when the mother has strictly followed
her physician's advice in caring for herself and the developing
infant. Though the causes of "birth defects"
are usually unknown, we do know that the developing brain
can be affected by several factors. When the fetus is
exposed to certain chemicals or infections through the
expectant mother, for example. |
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The
developing brain can be injured if the expectant mother
suffers severe physical trauma, the fetal brain can be
injured, too, but this is rare. Finally, prematurity and
a low birth weight have been shown to be related to an
increased incidence of specific disorders. Many chemicals
are known to adversely affect the developing brain, alcohol
being the most commonly used. The term Fetal Alcohol Syndrome
describes the long-term, multi-system effect of alcohol
on a child whose mother abused alcohol during the pregnancy.
When a fetus is exposed to large amounts of alcohol, several
body systems, including the neurological system will almost
certainly suffer damage. Cigarette smoking by the mother
has been shown to decrease birth weight, and low birth
weight is associated with several disorders, including
cerebral palsy. Severe malnutrition in the mother can
adversely affect brain growth in the fetus, and it, too,
can result in a low birth weight. The use of cocaine or
crack by the expectant mother is associated with blood
vessel complications, and these complications affect many
organs as well as the central nervous system. Cocaine
use is increasing and thus becoming more prevalent as
cause of brain damage in infants. Most infants whose mothers
used cocaine during pregnancy develop mental retardation
rather than cerebral palsy, however. Infections such as
rubella (German measles), toxoplasmosis, and cytomegalovirus
(CMV), ( if a woman has them during pregnancy), also may
injure the brain of the fetus. Rubella can be prevented
by immunization, prior to becoming pregnant, and the chances
of becoming infected with toxoplasmosis can be minimized
by not handling the feces of cats and by avoiding raw
or uncooked meat. |
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Congenital
infection with human immunodeficiency virus (HIV, the
virus that causes AIDS) also causes brain damage in children,
though it usually causes mental retardation rather than
CP. It is likely that many other infections in the expectant
mother injure the developing fetus, but they are not recognized
as causative factors because the woman who has the infection
either does not recognize the symptoms of infection or
is symptom-free. Premature infants are at a much higher
risk for developing cerebral palsy than full-term babies,
and the risk increases as the birth weight decreases.
Between 5 and 8 percent of infants weighing less than
1500 grams (3 pounds) at birth develop cerebral palsy,
and infants weighing less than 1500 grams are 25 times
more likely to develop cerebral palsy than infants who
are born at full term weighing more than 2500 grams, any
premature infants suffer bleeding within the brain, called
intraventricular hemorrhages, intracranial hemorrhages.
Again, the highest frequency of hemorrhages is found in
the babies with the lowest weight: the problem is rare
in babies who weigh more than 2000 grams (4 pounds). This
bleeding may damage the part of the brain that controls
motor function and thereby lead to cerebral palsy. If
the hemorrhage results in destruction of normal brain
tissue (a condition called periventricular leukomalacia)
and small cysts around the ventricles and in the motor
region of the brain, then that infant is more likely to
have CP than an infant with hemorrhages alone. Does prematurity
"cause" cerebral palsy, or do some infants who
are born prematurely have abnormal brains from the beginning,
leading to their premature births? We do not know the
answer to this question. |
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CEREBRAL
PALSY FROM THE BIRTHING PROCESS ? |
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There
are no specific events that, if they occur during pregnancy,
delivery, or infancy, will always occurring at birth or
right after birth). This is apparently why the incidence
of CP in undeveloped and poverty stricken areas of the
world, where infant mortality is very high, is the same
as in northern Europe, where infant mortality is the lowest.
It also explains why modern obstetrical care, including
monitoring and a high rate of Cesarian section, has lowered
infant mortality rates but not the incidence of cerebral
palsy. One large study, for example, has shown that more
than 60 percent of all pregnancies have at least one complication,
and that most of these complications cause no problems.
For instance, 25 percent of all newborns have the umbilical
cord wrapped around their neck, and 16 percent passed
meconium (had the first bowel movement) at the time of
birth. These "birth events" and the development
of CP have only a small correlation. In other words, the
chances of a child developing CP were nearly the same
whether the child was born with a cord wrapped around
her neck or not. On the other hand, newborns in this study
who had very low Apgar scores (less than 3 at 20 minutes)
had a risk 250 times greater than infants with normal
Apgar scores of developing cerebral palsy. An Apgar score
at this level suggests that the infant suffered severe
asphyxia (lack of sufficient oxygen to the brain) during
birth. Half of the infants who suffered severe asphyxia
during birth did not develop cerebral palsy, however.
When CP is diagnosed in childhood, it is often discovered
that the child suffered asphyxia at birth, but the asphyxia
is usually considered the symptom of an otherwise sick
baby with a neurological problem, and not the primary
cause of CP. In two different large studies, only about
9 percent of children with CP were thought to have CP
directly and exclusively related to asphyxia at delivery.
Ninety-one percent of the babies had other inherent causes
which led to prematurity or perinatal or neonatal problems
(problems In the nineteenth century, Dr. William John
Little described cerebral palsy and stated that the condition
was due to birth injury in most cases. Cerebral palsy
is also known as Little's disease and static encephalopathy,
but the term cerebral palsy is most widely used. Dr. Sigmund
Freud (who was a prominent neurologist before he founded
the field of psychiatry) also investigated the causes
of cerebral palsy. Freud thought that the condition was
due to something which occurred before the child's birth.
He argued that the problems seen at birth were often due
to an abnormality present in the baby before birth, rather
than being caused by the birthing process. This view of
Freud's was greatly ignored in the first half of this
century, but recent research has lent support to the idea
that cerebral palsy is more often a result of a congenital
abnormality than to an injury sustained at birth. Nevertheless,
the birthing process can be traumatic for the infant,
and injuries occurring during birth do sometimes cause
cerebral palsy. Modern prenatal care and improved obstetric
care have significantly reduced the incidence of birth
injury, but it is unlikely that it will ever be completely
eliminated. |
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CEREBRAL
PALSY IN THE INFANT AND CHILD ? |
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During
infancy and early childhood, the child is completely dependent
on others for his or her safety and protection. Protecting
the child from injury is one of the most important responsibilities
of the child's caregivers. One such injury is asphyxia,
which can damage the brain in a variety of ways, and is
the number one cause of CP in this age group. The three
most common causes of asphyxia in the young child are:
choking on foreign objects such as toys and pieces of
food (including peanuts, popcorn, and hot dogs); poisoning;
and near drowning. The brain may also be damaged when
it is physically traumatized as a result of a blow to
the head. A child who falls or is involved in a motor
vehicle accident or is the victim of physical abuse may
suffer irreparable injury to the brain. One form of child
abuse is the shaken baby syndrome, in which the caretaker
is trying to quiet the baby by shaking too vigorously,
causing the brain to strike repeatedly against the skull
under high pressure. |
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Severe
infections, especially meningitis or encephalitis, can
also lead to brain damage in this age group. Meningitis
is inflammation of the meninges ( the covering of the
brain and the spinal cord), usually caused by a bacterial
infection, and encephalitis is brain inflammation which
may be caused by bacterial or viral infections. Either
of these infections can cause disabilities ranging from
hearing loss to CP to severe retardation. |
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WHAT
ARE SOME DISORDERS WHICH ARE NOT CEREBRAL PALSY BUT RESEMBLE
CEREBRAL PALSY ? |
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Children
with disabilities have many problems in common, especially
problems involving interactions with family members and
society at large. The physical and medical problems of
children with disabilities vary widely, however. Some
of the problems caused by various disorders resemble those
affecting children with cerebral palsy, but on closer
inspection the medical issues turn out to be quite distinct.
Children with spinal cord dysfunction, for example, face
medical problems such as insensate skin and bowel and
bladder dysfunction, which differ markedly from the medical
problems faced by children with cerebral palsy. Spinal
cord dysfunction may be a result of spinal cord injury,
spina bifida (meningomyelocele), or a congenital spinal
cord malformation. Another large group of children who
at time may look similar to those with cerebral palsy
are children with temporary motor problems resulting from
closed head injuries, seizures, drug overdoses, or some
brain tumors. The medical issues for this group of children
are also different from the medical issues for children
with cerebral palsy, because these injuries can occur
at any age and the severity of the problems caused by
these injuries canges over time. We can also say that
disorders that are primarily of muscle, nerve, and bone
are not cerebral palsy by definition. Such conditions
include muscular dystrophy, peripheral neuropathies such
as Charcot-Marie- Tooth disease, and osteogenesis imperfecta.
All of these conditions are associated with specific medical
problems. Children with progressive neurologic disorders
(including Rett's syndrome, leukodystrophy, and Tay-Sach's
disease) also have medical needs which are different from
those of children with cerebral palsy. |
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Some
children with chromosomal anomalies (for example, trisomy
13 and 18) or congenital disorders (hereditary spastic
paraplegia, for example) may appear similar to children
with cerebral palsy; others, such as children with Down's
syndrome, appear very different from children with cerebral
palsy. Children with these disorders have some problems
in common with children who have cerebral palsy; they
also have problems that are unique for children with that
specific disorder. |
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HOW
IS A DIAGNOSIS OF CEREBRAL PALSY MADE ? |
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Many
of the normal developmental milestones, such as reaching
for toys (3-4 months), sitting (6-7 months), and walking
(10-14 months), are based on motor function. A physician
may suspect cerebral palsy in a child whose development
of these skills is delayed. In making a diagnosis of cerebral
palsy, the physician takes into account the delay in developmental
milestones as well as physical findings that might include
abnormal muscle tone, abnormal movements, abnormal reflexes
and persistent infantile reflexes. Making a definite diagnosis
of cerebral palsy is not always easy, especially before
the child's first birthday. In fact, diagnosing cerebral
palsy usually involves a period of waiting for the definite
and permanent appearance of specific motor problems. Most
children with cerebral palsy can be diagnosed by the age
of 18 months, but eighteen months is a long time for parents
to wait for a diagnosis, and this is understandably a
difficult period for them. Making a diagnosis of cerebral
palsy is also difficult when, for example, a two-year-
old has suffered a head injury. The child may immediately
appear to be severely injured, and three months after
the injury he may have symptoms that are typical of a
child with cerebral palsy. But one year after the injury
such a child may be completely normal. This child does
not have cerebral palsy. Although he has a scar on his
brain, the scar is not permanently impairing his motor
activities. After injury, waiting and observing are necessary
before the diagnosis can be made. |
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DO
X-RAYS OR OTHER TESTS HELP IN DIAGNOSIS CEREBRAL PALSY
? |
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As
noted above, in making a diagnosis of cerebral palsy the
most meaningful aspect of the examination is the physical
evidence of abnormal motor function. A diagnosis of cerebral
palsy cannot be made on the basis of an x-ray or blood
test, though the physician may order such tests to exclude
other neurologic diseases (such as those mentioned above).
Blood tests and chromosome analysis are helpful in diagnosing
hereditary conditions that may influence the parents'
future child-bearing decisions. When the tests indicate
that a child's condition is something other than cerebral
palsy and that the condition is inherited, family members
will benefit from genetic counselling. Cerebral palsy
is not a hereditary condition, however, and these tests
will neither establish nor rule out a diagnosis of CP. |
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Magnetic
resonance imaging (MRI) and Computed Tomography (CT) scans
are often ordered when the physician suspects that the
child has cerebral palsy. These tests may provide evidence
of hydrocephalus (an abnormal accumulation of fluid in
the cerebral ventricles), and they may be used to exclude
other causes of motor problems. These scans do not prove
whether a child has a cerebral palsy; nor do they predict
how a specific child will function as she grows. Thus,
children with normal scans may have severe cerebral palsy,
and children with clearly abnormal scans occasionally
appear totally normal or have only mild physical evidence
of cerebral palsy. As a group, though, children with cerebral
palsy do have brain scars, cysts, and other changes which
show up on scans more frequently than in normal children.
Therefore, when a scar is seen on a CT scan of the brain
of a child whose physical examination suggests he may
have cerebral palsy, the scar is one more piece of evidence
indicating that the child is likely to have motor problems
in the future. |
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WHAT
ARE THE DIFFERENT TYPES OF CEREBRAL PALSY ? |
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Cerebral
palsy may be classified by the type of movement problem
(such as spastic or athetoid cerebral palsy) or by the
body parts involved (hemiplegia, diplegia, and quadriplegia).
Spasticity refers to the inability of a muscle to relax,
while athetosis refers to an inability to control the
movement of a muscle. Infants who at first are hypotonic
wherein they are very floppy may later develop spasticity.
Hemiplegia is cerebral palsy that involves one arm and
one leg on the same side of the body, whereas with diplegia
the primary involvement is both legs. Quadriplegia refers
to a pattern involving all four extremities as well as
trunk and neck muscles. Another frequently used classification
is ataxia, which refers to balance and coordination problems.
The motor disability of a child with CP varies greatly
from one child to another; thus generalizations about
children with cerebral palsy can only have meaning within
the context of the subgroups described above. For this
reason, subgroups will be used in this book whenever treatment
and outcome expectations are discussed. Most professionals
who care for children with cerebral palsy understand these
diagnoses and use them to communicate about a child's
condition. |
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As
noted above, a useful method for making subdivisions is
determined by which parts of the body are involved. Although
almost all children with cerebral palsy can be classified
as having hemiplegia, diplegia, or quadriplegia, there
are significant overlaps which have led to the use of
additional terms, some of which are very confusing. To
avoid confusion, most of the discussion in his book will
be limited to the use of these three terms. Occasionally
such terms as paraplegia, double hemiplegia, triplegia,
and pentaplegia may occasionally be encountered by the
reader; these classifications are also based on the parts
of the body involved. The dominant type of movement or
muscle coordination problem is the other method by which
children are subdivided and classified to assist in communicating
about the problems of cerebral palsy. The component which
seems to be causing the most problem is often used as
the categorizing term. For example, the child with spastic
diplegia has mostly spastic muscle problems, and most
of the involvement is in the legs, but the child may also
have a smaller component of athetosis and balance problems.
The child with athetoid quadriplegia, on the other hand,
would have involvement of both arms and legs, primarily
with athetoid muscle problems, but such a child often
has some ataxia and spasticity as well. Generally a child
with quadriplegia is a child who is not walking independently.
The reader may be familiar with other terms used to define
specific problems of movement or muscle function terms
such as: dystonia, tremor, ballismus, and rigidity. The
words severe, moderate, and mild are also often used in
combination with both anatomic and motor function classification
terms (severe spastic diplegia, for example), but these
qualifying words do not have any specific meaning. They
are subjective words and their meaning varies depending
on the person who is using them. |
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WHAT
ARE THE RIGHT WORDS TO USE WHEN REFERRING TO CHILDREN
WITH CEREBRAL PALSY ? |
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Cerebral
palsy is the term used to describe the motor impairment
resulting from brain damage in the young child regardless
of the cause of the damage or its effect on the child.
Impairment is the correct term to use to define a deviation
from normal, such as not being able to make a muscle move
or not being able to control an unwanted movement. Disability
is the term used to define a restriction in the ability
to perform a normal activity of daily living which someone
of the same age is able to perform. For example, a three
year old child who is not able to walk has a disability
because normal three year old can walk independently.
Handicap is the term used to describe a child or adult
who, because of the disability, is unable to achieve the
normal role in society commensurate with his age and socio-cultural
milieu. As an example, a sixteen-year- old who is unable
to prepare his own meal or care for his own toileting
or hygiene needs is handicapped. On the other hand, a
sixteen-year- old who can walk only with the assistance
of crutches but who attends a regular school and is fully
independent in activities of daily living is disabled
but not handicapped. All disabled people are impaired,
and all handicapped people are disabled, but a person
can be impaired and not necessarily be disabled, and a
person can be disabled without being handicapped. In the
past there has been a disturbing lack of awareness and
sensitivity, both among the general public and in literature,
with respect to the words used when people with disabilities
are discussed. But an increasing amount of attention is
being paid to such language in our society along with
issues f education, employment, and public access for
disabled individuals. Certainly, the use of obviously
pejorative expressions has always been inappropriate,
and the formerly accepted practice of referring individuals
by their disability ("the epileptic," "the
spastic," "the retarded child") is no longer
acceptable. While it may take years for our language to
catch up with our changing views, the current acceptable
terminology stresses the individual person and then mentions
the disability that person has, therefore, we refer to
a girl with spastic diplegia or a boy with mental retardation.
Clearly, this language acknowledges that there is much
more to this individual than his or her disability. Other
terms that have recently come into use represent an even
more enlightened view. For example, the child who is mentally
challenged, rather than the child who is mentally retarded.
In this book, we have chosen to use language that reflects
the appropriate current societal goal of employing respectful
terminology and that also reflects our concern with presenting
information in a way that can be understood by the general
reader. We fully realize that there may be newer, even
better terms to use, but we will not use them when there
is a significant risk of introducing confusion into our
discussion. |
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WHAT
IS THE PROGNOSIS FOR THE CHILD WITH CEREBRAL PALSY ? |
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The
first questions usually asked by parents after they are
told their child has cerebral palsy are "What will
my child be like?" and "Will he walk?"
Predicting what a young child with cerebral palsy will
be like or what he will or will not do (called the prognosis)
is very difficult. Any predictions for an infant under
six months of age are little better than guesses, and
even for children younger than one year it is often very
difficult to predict the pattern of involvement. By the
time the child is two years old, however, the physician
can determine whether the child has hemiplegia, diplegia,
or quadriplegia. Based on this involvement pattern, some
predictions can be made. It is worth saying again that
children with cerebral palsy do not stop doing activities
once they have begun to do them. Such a loss of skills,
called regression, is not characteristic of cerebral palsy.
If regression occurs, it is necessary to look for a different
cause of the child's problems. In order for a child to
be able to walk, some major events in motor control have
to occur. A child must be able to hold up his head before
he can sit up on his own, and he must be able to sit independently
before he can walk on his own. It is generally assumed
that if a child is not sitting up by himself by age 4
or walking by age 8, he will never be an independent walker.
But a child who starts to walk at age 3 will certainly
continue to walk and will be walking when he is 13 years
old unless he has a disorder other than CP. |
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It
is even more difficult to make early predictions of speaking
ability or mental ability than it is to predict motor
function. Here, too, evaluation is much more reliable
after age 2, although a motor disability can make the
evaluation of intellectual function quite difficult. Sometimes
"motor-free" tests which can assess intellectual
ability without, the person being tested, needing to use
his hands are administered by psychologists who have expertise
in their use. Overall, the intellectual ability of the
person, far more than their physical disability, will
determine the person's prognosis. In other words, mental
retardation is far more likely than cerebral palsy to
impair a child's ability to function. |
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WHAT
CAN THE PHYSICIAN TELL THE PARENTS EARLY ON ? |
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Parents
are naturally concerned when their newborn child has problems,
and physicians need to evaluate the child's condition
and prognosis as well as they can. For example, evidence
of a bleed in the child's brain should be discussed with
parents, although the outcome of such a bleed cannot be
predicted. As we've discussed, the diagnosis of cerebral
palsy cannot be made at birth and, most assuredly, the
extent and severity of involvement that an individual
child might eventually have is impossible to assess at
birth. Many neonatologists, aware of the interaction that
generally occurs between the newborn and parents, avoid
discussing the child's problems in detail because they
want to permit this interaction to take place. The presumption
of a bleak future for a child sometimes causes parents
to withdraw from the child and this can have a significant
negative effect on the child. Physicians usually communicate
their concerns in terms of the child's symptoms, such
as muscle problems, and prepare parents for the possibility
of neurologic damage. Clearly, it is part of the physician's
role to inform parents, but the variability of outcome
makes it virtually impossible for the physician to predict
the future, and so the physician must weigh the need to
inform (and the imprecision of information) against the
need for the parents to have hope for, and to become close
to their child. |
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HOW
AGGRESSIVE SHOULD TREATMENT BE GIVEN A SICK NEWBORN ? |
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Many
times when a child is a few years old and severely disabled,
parents begin to wonder whether treatment should have
been less aggressive than it was. Given the tremendous
uncertainties in outcome, physicians and parents usually
choose to treat newborns and preserve life with the hope
that the outcome will be a good one. There are clearly
exceptions, such as when the baby has a known chromosomal
defect (such as trisomy 18), where the poor prognosis
is known and where very aggressive treatment may not be
used. However, in the majority of cases the information
regarding ultimate outcome is not available, and families
and physicians do the best they can with he limited information
they have. Often the prognosis is based on information
from studies of a large number of babies with a similar
birth weight. The chance of an individual baby having
cerebral palsy or mental retardation(expressed as a percentage)
is derived from these studies. Nevertheless, it is impossible
to know whether an individual infant will fit into the
70-90 percent group that has a good outcome or the 10-30
percent group with a poor outcome. |
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The
role of the physician is to gather as much information
about the child's condition as possible and to convey
this information to families along with the best information
available about chances for outcome. The role of the family
is to help in the decision-making process when there are
decisions to be made about further aggressive treatment,
though ultimately it is the physician's responsibility
to decide what should or should not be done. Most physicians
will take into consideration a family's wishes, but physicians
cannot give up their legal and moral obligation to do
what is best for their patient, nor can a physician withhold
treatment without the family's permission. The problem
is trying to figure out what is best. At the time the
decisions must be made it is often very difficult to know
what will ultimately be best. A decision to treat aggressively
usually involves the use of sophisticated equipment, although
availability of such technology does not mean that it
must always be used, and there are clearly times when
it is more humane to withhold or withdraw aggressive treatment.
These are never easy decisions to make. Clergy, social
workers, ethicist, and other health care workers who have
come to know the patient and family often help in making
a decision about what is best. |
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HOW
CAN REALISTIC GOALS BE DESIGNED FOR THE CHILD WITH CEREBRAL
PALSY ? |
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When
it comes to expectations and questions of what the future
holds for the child with CP, it is important to maintain
a combination of optimism and realism, just as one would
with any child. Suppose, for example, that the parent
of a non-disabled three year old has hopes and expectations
that the child will go to college and law school, enter
politics, and eventually become President of the United
States. Some of these expectations are realistic and are
likely to be met, while others are extremely unlikely
to occur to the point of being clearly unrealistic. Regardless
of these realistic and not realistic expectations, however,
the parent needs to care for the child as a three year
old and not as a college student or as a politician. It
is equally important for the parent of a child with cerebral
palsy to understand the child's present and future abilities.
That parent's expectations are also probably a combination
of realistic and unrealistic goals for the child, but
in time, with professional help, the parent will develop
a set of mostly realistic goals and it is to these goals
that the parent, child, and professional will dedicate
their effort. Occasionally, difficulties in communication
arise when the parents, educators, and medical care providers
discuss present abilities. As stated in the Preface, a
significant goal of this book is to., improve this communication
so that parents, educators, and medical care providers
can communicate their impressions to each other regarding
a specific child and in this way help the child function
at his or her maximum ability. An attempt to define future
expectations is usually most important in the teenage
years and beyond, when function is better defined and
the future looks more clear to everyone involved. |
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WHAT
MEDICAL PROBLEMS ARE ASSOCIATED WITH CEREBRAL PALSY ? |
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Children
with cerebral palsy have many problems, not all of them
related to the brain injury. Most of these complications
are nevertheless neurological. They include epilepsy,
mental retardation, learning disabilities, and attention
deficit-hyperactivity disorder. These problems are discussed
in chapter 3, as are problems that occur less commonly,
such as swallowing problems in children with spastic quadriplegia.
In the next chapter, we look at normal pediatric development,
to establish a basis with which to compare the development
and behavior of a child with cerebral palsy. Children
with cerebral palsy may also develop hip subluxation or
have problems with the gait. |
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