GUIDE FOR TEACHERS DEALING WITH CHILDREN WITH MOTOR DEFICIENCY
FOREWORD
The consequences of motor deficiency are varied and so are its causes. Contrary to popular opinion, people with motor deficiency are not automatically confined to wheelchairs or limited by their physical problems.
Motor deficiency affects the educational as well as social and professional life. It requires careful observation and attention to the children or teenagers who are concerned, a regular dialogue with the parents and collaborations between the different professionals (teachers, nurses, educators, re-educators). These are for better integration of students in the schools, designed for the inclusion of all and for their future participation in a social, civic, economic and cultural life.
When we want to adapt the school to these children, we immediately think, in general, of easing the physical constraints, which can cause problems, for example, to access some parts of the school. Because we lack information, we are less aware of the obstacles motor-deficient children must overcome during their studies. In fact, the perceptive, cognitive or psycho-affective difficulties caused by the problems associated to motor deficiency are not obvious. But, they concern a large number of these students, particularly the ones with cerebral lesion.
The objective of this guide is to sensitize the teacher to these questions and to offer adaptations to solve the problems caused by these pupils. This supposes to present a large number of difficulties they might meet. The listing of these mustn’t let us think they are inescapable. When they exist, they can be great but in many cases, they are discreet or transitory and even more so when they have been taken into account at an early stage. In addition to the diversity of pathologies comes the diversity of people: each child or teenager is different, irreducible to a typical portrait.
Furthermore, the nature of the child’s problems doesn’t allow us to prejudice exactly his chances of success because they depend, for him as for the others, on his abilities, the situations he faces, the experiences he lives and the tasks he’s asked to do. It’s advisable to promote the possible adaptation to overcome the negative effects of motor deficiency and to favour the highest possible level of school success in ordinary schools for pupils with such deficiency.
Contents
Characteristics of motor deficiency ...... …p. 5
1. Motor attacks……………………………………………………….p.6
1.1 Motor-deficiencies with a cerebral origin………………………..p.6
1.2 Motor-deficiencies with medullar and/or neuro-muscular origin ………………………………………………………………………p.8
1.3 Motor-deficiencies with osteo-articular origin…………………..p.10
2. Problems linked to motor-deficiency……………………………....p.11
2.1 Epilepsy…………………………………………………………….p.11
2.2 Neuro-psychological problems……………………………………p.11
2.3 Psycho-affective aspects…………………………………………...p.12
Elements to take into account when planning school integration………p.14
1.Contributions to install……………………………………………p.14
1.1 Professionals in charge of care, rehabilitation and
specialised education…………………………………………………p.14
1.2 Specialised teachers in charge of supporting integration……...p.15
1.3 Integration auxiliaries and educational assistants……………..p.16
1.4 Other actors’………………………………………………………p.16
2. Developments to foresee………………………………………….p.16
1.1Transports………………………………………………………..p.16
1.2 Moving around the school……………………………………….p.17
1.3 Installation in the classroom…………………………………….p.17
1.4 Material used…………………………………………………….p.18
1.5 School time ………………………………………………………p.18
1.6 Testing……………………………………………………………p.18
2.Support through computers……………………………………..p.19
3.1 IT to increase the pupil’s autonomy……………………………p.19
3.2 IT to prepare adapted pedagogic documents………………….p.20
3.Elaboration of the individual integration project……………...p.21
3.1Characteristics of the individual integration project………….p.21
3.2Individual project and integration convention…………………p.21
3.3Questions to ask yourself before elaborating
individual project……………………………………………….p.21
Adaptation of the teaching…………………………………………..p.23
1. Common adaptations to teaching situations……………………….p.23
3.4Class activities needing skilled gesture………………………….p.23
3.5Complex visual information uptake…………………………….p.24
3.6 Work organisation………………………………………………p.25
2. Fundamental learning…………………………………………….p.27
2.1 Reading……………………………………………………………p.27
2.2 Writing. …………………………………………………………..p.28
2.3 Counting and calculating………………………………………..p.32
3. Physical education and fine arts…………………………………p.35
3.7Physical education……………………………………………….p.35
3.8Musical education………………………………………………..p.39
3.9Fine arts…………………………………………………………..p.41
Further information
1. Books
4.Specialised magazines
5.Pedagogic articles
6.Films
7.Associations
8.Internet sites
9.Other sources of information
10.Where to find material
CHARACTERISTICS OF MOTOR DEFICIENCY
Motorbility is the function, which maintains posture and produces movement: voluntary, automatic and reflexes.
Its alteration affects very diverse areas of activity. As a result the problems for a child with motor deficiency are not always limited to moving around, posture, the picking up and manipulation of objects, or writing. They can equally manifest themselves in important circumstances in education, for example, to explain orally or to look at someone or something attentively. In fact, motor activity is present when we speak. Speech engages a series of precise movements in the vocal cords, larynx, glottis, and the tongue and in the action of looking, because it is the eye movements, which allow the reading child to understand a text or an image.
The global prevalence of child motor deficiency seems to remain constant. It is estimated, in France, at 3.24 per thousand, but it only includes the deficiencies of children and teenagers who are dealt with by the Departmental Commission of Special education (CDES): ref. the educational guide for teaching handicapped children or teenagers. They do not therefore take into account mild deficiencies.
Motor deficiency is the loss or alteration of a mental or physical structure or function.
It can result from an attack on the nervous system, which can affect the central nervous system, comprising the encephalon and the bone marrow or the peripheral nervous system, which links the spinal cord to the organs, especially muscles via the peripheral nerves. Motor deficiency can be an attack on the muscles or the skeleton.
Disability, which is a consequence of deficiency, is the reduction, to a greater or lesser extent, of conscious and voluntary motorbility, causing a partial or total reduction in the ability to accomplish a task: for example, the inability to move around without a wheelchair, to read or write without a technical aid.
Disadvantage, caused by the deficiency and the disability, comes through the limitation or inability to achieve a normal social role: to work, to have leisure, etc.
According to the international classification of handicaps, the handicap is the result of three elements: deficiency, disability and disadvantage. But handicap isn’t independent of the environment to which the person with motor deficiency is confronted. Whereas rehabilitation, apparatus or surgical interventions reduce the inability, the teaching, by adapting the situations and pedagogic stages, contributes to reducing the child’s handicap.
1. Motor attacks
The attacks on the motor function are variable: sometimes unnoticeable, sometimes leading to impotence, can be present at birth or be noticed sooner or later, be changing or stable. We can add those that cause the deficiency, the diversity of the problems associated to motor attacks, as well as the peculiar way which each child or teenager lives and experiences his handicap.
Therefore, the different motor deficiencies constitute a heterogeneous group, which can be described by numerous criteria:
- According to when the lesion happened: genetic or acquired deficiency
- According to the cause: by malformation, traumatic injury, and illness...
- According to the changing or not character of the deficiency
- According to the nature of the attack. This criterion, which we retain here, allows distinguishing 3 major types of motor deficiency: The motor deficiencies with cerebral origins, those with a medullar origin and those caused by osteo-articular lesion.
1.1 Motor deficiencies with a cerebral origin
They are caused by very early lesions of the brain region which leads to motor disabilities with a brain origin properly called (IMC, IMOC), or they are due to attacks happening much later, through cranial trauma, brain blood clots or brain tumors.
Neurological attacks, once fixed, do not change anymore. Only the nervous command and the regulations are wrong at the beginning, leading to problems of muscle tone, of the automatic regulation of movements and their voluntary control- paralysis, involuntary movements. The motor performers (muscles and skeletons) are not affected but they can suffer from secondary deformation linked to growth. It is the prevention of the subsequent aggravations, which motivates numerous apparatus and surgical interventions until the end of the growth.
Cerebral motor disabilities:
According to a survey done by the Departmental commission on Special Education, cerebral motor deficiencies resulting from an attack taking place before, during or slightly after birth, have a rate of 1.12 per 100 births.
We can distinguish 3 clinical types: spasticity, athetosis and ataxic syndromes.
Spasticity:
It’s characterised by the lack of control of motor reflexes normally controlled by the pyramidal cortex which is damaged. Difficulties to stand, to contract or relax muscles lead to a greater or lesser slowness of movements. Passive stretching, the cold and the emotions worsen the inflexibility. There are 3 predominant spastic attacks:
- Quadriplegia: this is often a serious attack of the 4 limbs and the trunks.
- Diplegia: or LITTLE syndrome, often caused by premature birth. The motor disorder is predominantly on the lower limbs.
- Infantile cerebral hemiplegia: this is a unilateral cerebral attack- a leg and an arm on the same side.
Athetosis:
It results from an attack on the grey matter. It’s characterised by involuntary movements, low, rhythmic irregular and of small range. The movements are particularly problematic when they affect the face and disturb the speech.
On a disturbed muscle base, the athetosic subject has difficulties to develop an intentional adopted movement- the range is exaggerated or blocked by contractions.
Ataxia:
More rare, it is due to a lesion of the cerebellum. It’s characterised by problems of balance and walking as well as problems of co-ordination.
It’s necessary to add to the diversity of the categories usually described, the diversity of the individuals. Thus, the neuro-motor problems, which affect them, are sometimes intricate: spasticity and athetosy can for example join together in remarkable ways.
Equally, the term describing the type of attack can hide a more complex reality: the hemiplegia of a child can be accompanied by smaller problems on the other half of the body and the diplegia does not necessarily affect the 2 lower limbs in the same way. As a result, there are strong individual differences. One child can have little difficulty to walk while another has to use a wheelchair.
Neuro-motor problems are often associated with neuropsychological problems or even psycho-affective ones.
See pages 11 and 12.
Cranial trauma:
Every year, hundreds of children and teenagers are victims of serious cranial traumas, as a result of traffic, sport or domestic accidents. Because of the bone structure, the localised cerebral lesions by failures or contusions are less frequent than the diffuse attacks due to shock to the brain mass.
Violent shocks generally provoke a loss of consciousness and coma.
The prognostic for recuperation varies according to the severity of each diffuse lesion and their link but also according to the duration and depth of the coma.
Usually, there are four evolution steps:
- The coma itself: the child or teenager is in intensive care.
- The awakening: he’s then transferred to the rehabilitation service. His attention fluctuates; he’s tired and very easily tired. He usually shows problems with superior functions and motor difficulties.
- Recuperation: following rehabilitation, we notice a regression of motor problems, varied but still more important than that of neuropsychological problems.
- The check-up: done less than 2 years after the accident. After a period of progress, follows a phase where he doesn’t recuperate anymore: his situation is steady. The after-effects are established and he must learn again with them. The after-effects are very different from one person to another. In most cases, the motor recuperation is good. Psycho-affective problems often linked to neurological defects, can lead to behavioural and mood problems.
See page 13.
1.2. Motor disabilities with medullar and/or neuro-muscular origin
- Medullar lesions due to a trauma or an illness:
They can result from a spinal cord trauma or a lesion with an infectious, vascular or tumorous cause.
The defects are due to problems with the conduction of motor and sensorial impulses.
The paralysis of the limbs, which is the inability to make voluntary movements, increases when the level of damage to the spinal cord is high. If the subject is affected at the level of the upper limbs, he’s tetraplegic; in the lower limbs, he’s paraplegic.
When the spinal cord is completely damaged, the impulses from the brain to the muscle are blocked: paralysis of the muscles below the lesion is complete. If the spinal cord is not completely destroyed, impulses may pass to a greater or lesser extent depending on the severity of the lesion.
Sphincter problems, needing regular urinary catheters and problems of sensitivity, causing bedsores, are characteristics of disabilities with medullar origin.
- Medullar lesion due to genetic malformation:
This is an abnormality in the development of the spinal column present in 0.5 cases per 10,000 births in France.
It results in a bone malformation characterised by a fault in the closure of the rear part of the vertebra, dorsal or lumber, which leads to a hernia of the meninges and of the extremity of the spinal cord, which is called myelocele. We note that:
- The motor nervous fibres travel to the skin instead of going to the muscles of the lower limbs, which causes a paraplegic paralysis as well as of the sphincters, which can lead, more or less, to incontinence.
- The sensitive nervous fibres are not connected to the skin receptors or to the profound organ receptors. Someone who’s insensitive in the areas under the spinal bifid, is subjected to bedsores.
The abnormality located in the lower part of the spinal column frequently comes with another malformation situated at the base of the skull leading to a defect in the flowing of the spinal cephalon. This can lead to hydrocephalus if a catheter and a valve allowing circulation are not put in place at an early stage. In this case, cognitive disturbances can occur.
- Neuro-muscular illnesses:
Today, they gather a dozen diseases, which are mainly of genetic origins. They are changing diseases, which, for most of them, lead to a progressive reduction of the contraction force of the voluntary muscles, that is a loss of muscular strength. The affected children or teenagers are easily tired.
The motor deficiencies they lead to are associated to problems in the motor unit linking the motor neuron, the synapse and muscular fibre. (See figure below). There are attacks of the muscular fibres- myopathy- of the muscular junction- myasthenia- of the peripheral motor nerve- Charcot-Marie-Tooth diseases- and of the shaft of the motor nerve- motoneuron- situated in the anterior horn of the spinal cord- infantile spinal muscular atrophy.
If taken in hand early and using technical aids, it limits the vital and functional consequences of these diseases, which lead to various problems: orthopedic deformities, respiratory and sometimes heart failure, deglutition and digestive problems.
(Figure) The motor unit and neuro-muscular diseases.
Muscular distrophy of Duchenne de Boulogne
It’s a hereditary disease, which only attacks males. It’s the most severe and most frequent of muscular dystrophies- 1 cases per 3,500 male born.
It can be the result of a genetic mutation, but more often results from the transmission of a pathological gene carried by unaffected mothers to their son. The illness is characterised by an absence of a protein, the dystrophin, which normally consolidates the fibres of the muscular membrane. As a result, damaged muscles cannot repair and the muscles progressively atrophy.
Walking problems appear around the age of 3. The motor disability progressively worsens. Little by little, the child can’t get up by himself, climb stairs and walking becomes impossible at 10-12 years old. The muscle weakness, first limited to the root of the lower limbs, affects the trunks and the upper limbs. Movements must be by electric wheelchair and writing with the help of a computer. At an advanced stage, respiration is made possible by a respiratory rehabilitation and assisted pulmonary ventilation.
Treatment calls on medicines, appliances, and multiple rehabilitations, including physiotherapy to limit severe skeleton deformity.
Life expectancy is tied to cardiac complications more than to respiratory attack, which is maintained through care.
There is a very similar illness on a psychological and genetic scheme called Becker dystrophy, which appears later and develops at a slower pace.
1.3. Motor deficiencies with osteo-articular origin
They can result from malformation (absence or abnormality of a limb, malformation of joint), from a problem in the bone formation (imperfect osteogenesis...), from rheumatism lesion (rheumatoid arthritis), form infectious lesions (osteitis...), from spinal deviation (scoliosis, kypho-scoliosis), from accidents, leading to imputation, intra-joint hemorrhage for the homophiles. These motor deficiencies, sometimes severe and painful, don’t have neurological after-effects.
The imperfect osteogenesis
It’s a genetic disease characterised by brittle bones. It leads to early apparition of many spontaneous fractures with different after-effects. Imperfect osteogenesis has many names: glass-bone disease, Lobstein disease or Porak and Durante disease. It has many different forms of severity.
It affects girls as much as boys, 1 case per 15,000 births. It’s due to the absence of collagen, the main protein for the formation of the bones.
Sometimes, it occurs at birth. More often, it comes when learning to walk. The falls, due to these first trials and which have no consequence for other children, lead to repeated and severe fractures needing surgery, immobilisation and rehabilitation. The children are quite often thin and small, but their situation improves with their age as the frequency of the fractures decreases progressively with puberty. It’s estimated that 80% of the fractures happen before 18 years old.
Apart from these 3 types of motor deficiencies, with cerebral, medullar and/or neuro-muscular and osteo-articular origins, they are other motor deficiencies, which can’t be classified because linked to many origins, for example, multiple genetic arthrogryposis.
2. Problems linked to motor deficiencies
At school, the learning difficulties for motor-deficient children or teenagers are more linked to the deficiency than to the physical disability as such. These problems, which are not proportional to the visible motor attacks come mostly with deficiencies of a cerebral origin. Apart from slowness in schoolwork, there are problems due to epilepsy and also due to neuropsychological or psycho-effective