[Narrator:] Challenge for habilitation: the child with the congenital rubella syndrome.
[Narrator:] A maternal viral infection during pregnancy,
especially in the first three months,
has the potential for producing a number of harmful effects
in the developing fetus.
An estimated 20,000 to 30,000 children
were born with the congenital rubella syndrome
as the result of the 1964-65 rubella epidemic
in the United States.
This group of one-and-a-half to four-year-old children
in the clinic reception area are all in the rubella program
at the Texas Children's Hospital in Houston.
When the 146 patients were reviewed in 1967,
90 had hearing loss, 39 were visually impaired,
and 50 had significant motor handicap.
Of these, there were 20 deaf-blind with impairment
of both hearing and vision.
The use of more definitive diagnostic studies
and clinical observation showed that the 17 considered normal
probably did not have the congenital rubella syndrome.
Comprehensive evaluations were done on 80 children
at age two and a half years in order to project
their educational needs.
Those with primarily an auditory or visual handicap
were eligible for existing preschool programs.
The staff of the child development clinic
initiated a diagnostic therapeutic nursery
for the 25 multiply-handicapped children.
Their arbitrary classification as mild, moderate, or severe
was based on physical, developmental,
and behavioral deviations.
The clinic offers interdisciplinary services
for the parents and child.
Individual sessions with the social worker
focus on current stresses produced by the presence
of a handicapped child in the family.
The persistence of rubella virus
may cause progression of known physical abnormalities
and development of new ones.
The pediatrician must therefore evaluate all systems
in his periodic examination.
During each regular eye examination,
the ophthalmologist looks for evidence
of congenital cataract, glaucoma, microphthalmus,
and rubella retinopathy.
Similar in-depth studies are done
by the cardiologist, otologist, audiologist, and orthopedist.
Maturation, cognition, and behavior,
while related to the degree of structural abnormality,
cannot be defined by physical examination alone.
Developmental and psychological profiles
are used by the psychologist to determine the mental age
and to identify specific areas of functional delay or deficit.
The psychologists have selected different test instruments
for three children of comparable chronological age
based on prior knowledge of their medical disability
and direct observation of their behavior.
Excitability and inattention, rather than
the severity of visual and hearing impairment,
prevent this deaf-blind girl from performing
on the Gesell Developmental Test.
The hearing-impaired, but otherwise normal child,
is being tested with the non-verbal
Leiter International Scale.
Her intellectual potential, as well as affect and behavior,
are appropriate.
Performance on the Stanford-Binet
indicates that this physically normal boy is also
of average intelligence.
At five years of age however, immunological tests
showed that his original diagnosis of rubella
was probably incorrect.
Motor skills, particularly creeping, crawling,
and walking, did not develop in an orderly progression
for most of the congenital rubella patients.
For some children, athetosis, spasticity,
or hypotonia resulting from central nervous system
involvement, was a significant handicap.
This girl with spastic diplegia, in addition to
correctable auditory and visual impairment,
has had individual physical therapy
and has been fitted with long leg braces and crutches.
Overcoming architectural barriers,
such as stairs at school, is a part of her gait training.
The earlier motor handicap of the boy at the table
is not evident since he no longer needs a short leg brace.
Both of these children have progressed
from the multi-handicapped program
to a pre-school deaf class.
Their functional vision and auditory amplification
allow them to interact and to respond with pleasure
to the sight and sound of the barking toy dog.
An area of baldness is seen on the back of the heads
of many rubella children.
This resulted from the type of bizarre movement
and self-stimulatory activity demonstrated
by this 18-month-old deaf-blind motor-delayed child.
The multi-handicapped girl in the parallel bars
has only minimal muscle weakness and is at a readiness stage
for walking.
Her distractibility, short attention span,
and her poor vision, even with contact lenses,
are preventing her independent locomotion.
She later progressed to walking alone
with one hand on the wall, but would not cross an open doorway
until provided with a yardstick with which to maintain contact
with the floor or wall.
Hypotonia and muscle weakness, although initially
present in many of the children, usually improved
by the age of two and a half years.
This severely hypotonic boy is still unable
to hold his head erect at age four years.
The physical therapist is positioning him so as
to utilize his minimal muscle power
to help develop motor function.
The therapist attempts to stimulate head control
by holding his attention with a flashlight
and a spinning musical top.
Head control would have to be established
in the normal neurodevelopmental sequence
before he could coordinate movements of his arms, legs,
and trunk.
His inability to maintain a given posture
is fatiguing and soon results in loss of motivation.
Although this little girl has normal vision
and aided hearing within the speech range,
coordinated upper extremity movement
is extremely difficult for her due to severe spasticity
and athetosis.
The occupational therapist is demonstrating an activity
which requires the child to use the fine muscles of her hand
and forearms for grasping, and the gross muscles
of her shoulders and arms for reaching and placing
the block on the pedestal.
This demands a great effort from the child,
who is rewarded by an approving facial expression
and verbal praise from the therapist.
Psychomotor retardation and maladaptive behavior
prevent establishment of the oral mechanisms of sucking,
chewing, and swallowing,
the essential antecedents of eating and drinking.
The occupational therapist is attempting to teach this
three-and-a-half-year-old boy each step in the hand-to-mouth
progression of self-feeding.
First, he must learn to grasp the spoon or cup, hold onto it,
and then move it through space from the table to his mouth
with increasing dexterity and minimal spilling.
He rejects not only the utensils, but any interaction
with the therapist herself.
Even in children who are attentive,
upper extremity weakness, lack of motor control,
and poor eye-hand coordination may delay the acquisition
of self-help skills.
The speech therapist must consider
both mental and chronological age in programming
for multiply-handicapped children.
She teaches the mothers of children
under three years of age how to provide language stimulation
through daily activities.
A bell is used by this mother to make her 18-month-old girl
aware of environmental sounds.
Such awareness is a forerunner to comprehension
of the spoken voice.
This three-year-old boy prefers to sight
through the hole in the plastic ring
rather than use the ring appropriately.
When his mother has his attention,
he can comprehend her directions.
A standing board is used for positioning and total body
support of the hypotonic boy shown previously on the mat.
This allows him to participate in a small group conducted
by the speech therapist.
He responds appropriately by laughing at the barking dog
and attempts to use his arms and hands to grasp the color rings.
On the other hand, the deaf-blind girl
shows no more interest in auditory stimulation
than she did in independent locomotion.
The nursery groupings for peer interaction
are based on the degree of impairment
and the cumulative effect of multiple handicaps on behavior.
Those classified as severe are immature
and have inappropriate emotional responses,
lack of environmental awareness and self-stimulation,
which prevent optimal group participation.
Many of these deaf-blind children
are absorbed in stereotyped activities frequently referred
to as blindisms.
Waving their hand in front of their eyes
seems to produce a hypnotic flicker effect.
Jabbing the thumb or forefinger into the globe of the eye
appears to be pleasurable rather than painful for them.
The therapeutic program is designed
to develop the child's attention span, his awareness of others,
and his own self concept.
This goal-directed activity is most difficult
to achieve with these autistic-like children
who do not interact with the group.
For this reason, one-to-one behavior modification
techniques are a more successful training method.
Children in the moderate group function
at about the one-year language level
by Gesell developmental norms.
Although they are able to understand and execute
a verbal command, their attention span is short.
Distraction by pleasurable visual stimulation
often prevents completion of the task directed by the therapist.
Sighting through the translucent cup into a direct light results
in amplification of the child's existing
nystagmus and represents another example
of a pleasurable blindism.
The children in the mild multi-handicapped group
are able to comprehend directions and carry out
a fine motor activity emphasizing color matching
and number concepts.
This represents a level of function
which approaches their chronological age.
They have a longer attention span and watch and interact
with the other children.
Most have a moderate to severe neurosensory hearing loss,
but have adequate vision to lip-read
and make maximal use of visual clues given by the teacher.
Imagery play is used by the nursery teacher
to initiate group interaction with three children.
They are over three and a half years of age
but are still at the parallel play
stage of social development.
The little boy was placed in the nursery program
for habilitation of multiple handicaps
resulting from head injury.
Although his physical appearance and combination of handicaps
is somewhat different from the children
with congenital rubella, the therapeutic approach
is essentially the same.
Over the past three and a half years,
the parents and professional staff
have mutually benefited from the discussion
and educational groups focused on the management
of these handicapped children.
The nursery teacher is demonstrating
how to make an edible play dough from flour, water, and food coloring.
The speech therapist then shows the parents
how they may use the play dough for language stimulation
by the use of simple phrases such as "take it," "roll it,"
and "pull it," which are clearly enunciated so that the child can read their lips.
Continuous monitoring and discussion
of each child's progress at interdisciplinary staffings
provides the basis for projecting short and long-term
functional and educational goals for optimal habilitation.