HANDICAPPED CHILDREN: EMOTIONAL DEVELOPMENT AND ROLE OF THERAPIST R. S. JA C O B SO N , B.Sc. P hysiotherapy (W itw atersrand), D .S.E., C erebral Palsy (U .N .I.S.A .), M.A. Clin Psych. (W itw atersrand) pECEMBER 1979 P H Y S I O T H E R A P Y 91 G. ST R A K E R , Ph. SUMMARY The d evelo p m en t o f trust, pride and au to n o m y, initia­ tive and industry in the first ten years o f childhood is described. T he problem s encountered by the handicapped child and his parents are p o in ted out. T he role the therapist can play and the self know ledge necessary fo r this role are briefly discussed. This pap er is aim ed at prom oting an understanding of the em otional w orld and th e developm ental tasks (ring th e physically handicapped child. A discussion I this n a tu re is necessary fo r th e follow ing reasons: Firstly, th ere is a consistent finding in th e literature that a ch ild ’s em otional developm ent, b eh av io u r and reaction to his h andicap are n o t dep en d an t u p o n the extent of th e handicap itself, b u t u po n his em otional adjustment to it (F reem an, 1967). Secondly, the authors are of the opinion th a t, during the early m onths a fte r th e diagnosis o f th e handicap, it is of considerable im portance fo r b o th m o th e r and father to have ongoing em otional as well as medical support. T h e physiotherapist who has contact w ith th e child m ay find herself in a position w here she has to help the m o th e r contain h e r feelings of uncertainty, unsureness and insecurity at each stage o f th e child’s m aturation. In o rd er to do this, a physiotherapist m ust have an ability to em pathise w ith the plight of the parents, w ithout becom ing ‘sucked’ into th e fam ily system, as well as a basic know ledge of the em otional tasks the child m ust negotiate. DEVELOPMENTAL TASKS Any child is p a rt o f tw o sim ultaneously functioning worlds; the world of adults and th a t o f his peers. T h e physically handicapped child is necessarily d ependent upon adults fo r a period of tim e th a t fa r exceeds th at of his n orm al co unterpart. T h e p rim ary focus of this paper will be on the relevant aspects of n o rm al de- J opm ent th a t occur w ithin th e ad u lt w orld o f the Id. Special reference will be m ade to the p art played by the physiotherapist. D espite this narrow structure, it is necessary to re­ cognise th a t m otor, sensory, perceptual, cognitive, Janguage, social and em otional developm ent all go hand in hand and can n o t be isolated from one another. Im pairm ent in any area can affect overall developm ent. In addition to th e above, it m ust be stressed th a t Contents Handicapped Children: Emotional Development and Role' of Therapist — R. S. Jacobson and G. Straker ......................................................................... 81 Play in ;lrifancy and Application in Treatment — D. C o u rla n d e r...................................... .................... 93 Acupuncture — An Investigation — H. C. Watts 97 Ethics in Human Experimentation — ■ J. C. B een h a kker ... .................................................. ........... 100 Treatment Note — A Plea fo r Massage — (W itw atersrand) OPSOM M ING D ie ontw ikkelin g van vertroue, trots en outonom ie, inisiatief en vlyt in die eerste tien kinderjare w ord be- skryf. Die problem e wat deur die gestrem de kin d en sy ouers teegekom word, w ord uitgewys. D ie rol wat die terapeut k a n speel en die selfkennis benodig vir d i i rol w ord ko rtliks bespreek. negotiation o f any em otional crises fo r the handicapped child m u st be even m ore hazardous in a w orld th a t adm ires physical h ealth and em phasises normaility. T he child, as well as significant adults in his world (in­ cluding therapists), m ust deal w ith th e fact th a t he is n eith er h ealth y n o r to tally norm al. Bearing this in m ind, let us now exam ine th e possible vulnerable areas in th e em otional developm ent of th e handicapped child. T h e fram ew ork adopted fo r this discussion o f develop­ m en t fro m birth to ten years is th a t of E rik E rikson. A lthough in his book C hildhood and Society (1955) E rikson d e a lt extensively w ith developm ental crises fro m b irth thro u g h to old age, it is beyond th e scope o f the present p ap er eith er to discuss all these stages o r to deal w ith th em com prehensively. T hus, only a b rief o u tlin e o f th e stages from b irth to ten years of age will be m entioned below. T he fo u r basic developm ental tasks of childhood are the developm ent o f basic trust, pride and autonom y, initiative and finally industry (E rikson, 1955). W ithin the first year of life th e m o th er creates a sense of tru st in th e child by sensitively and consistently caring for and responding to th e b ab y ’s physical and em otional needs. P aren ts m ust n o t only have ways of satisfying th e child, b u t also convey to th e child a conviction th a t they “know ” how to handle and care fo r th eir new -born baby. In th e case of th e physically h a n d i­ capped child, th e parents m ay n o t be able to cater fo r th e child in this way. T his m ay be because the handicapped child m ay show alterations of developm ent th a t m ay be confusing and frightening for th e p aren t e.g. opisthotonus o r feeding problem s. T he m o th er of th e handicapped child m ay th erefore n o t be as sensitive o r as sure in th e handling of h e r child. T h e child m ay begin to experience th e w orld as painful, chaotic and capricious. T h e ability to trust th e world and p a rti­ cularly significant adults m ay th erefo re be im paired in th e physically han d icap p ed child and th e end result m ay be a child w ho is m istrustful of people and Inhoud P. Chatterton ............... ............................................. 100 National Executive Committee ................................... 101 Correspondence ................................................ ... ... 102 Branch News/Taknuus ................................................. 103 News from Special Interest Groups ...................... 105 News from A ffiliated Associations ... ................. 105 W.C.P.T. News ... ............... ....................................... 106 C la s s ifie d /V a c a n c y ....................................... ... ... 108,109 Book Reviews ............... .................................. ... ... 109 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 92 F 1 S I 0 T E R A P I E DESEMBER 1979 situations. T his is com m only seen in th e excessively dem anding, insecure and testing behaviour o f these children. E arly supportive help fo r th e m o th er o f any handicapped child th erefore is n o t a luxury b u t a necessity. L a te r in the first year of life the m o th er helps the norm al child to deal w ith fru stratio n an d so th e child develops the ability to delay im m ediate gratification of all his needs. In so doing, th e child develops his own resources fo r dealing w ith fu tu re frustrations. T h e paren ts o f a han d icap p ed child m ay n o t be able to provide the child w ith situations w here he will learn to deal w ith fru stratio n . A lthough the parents o f the h an d ica p p ed child m ay be acting o u t o f feelings o f guilt, overprotectiveness o r anxiety, the end p o in t is a child who can n o t to lerate any fru stratio n w hatsoever. T his can be seen in the child who d em ands im m ediate satisfaction o f his every w him and w ho throw s severe a n d frightening tem p er tantrum s. H ere th e professional can help p aren ts deal w ith th e ir own anxieties. W ith excessive anxiety u n d e r control and w ith em pathic support, th e p aren ts o f the han d ica p p ed child will be m ore able to provide “ o p tim al” fru stra tio n fo r th eir baby. In addition to increasing his fru stra tio n tolerance, the ten m o n th old n orm al baby is dealing w ith the anxiety th a t ensues fro m separating fro m his parents. T h e average p a re n t deals w ith this by briefly separating fro m th e child, never allowing th e p ro d uction o f an overw helm ing anxiety in the child. T h e norm al child thus learns to tru st th e paren ts’ com ings and goings, so laying th e groundw ork fo r th e separation th a t occurs w hen th e child becom es school-going. T h e h a n d i­ capped child, due to his extended an d excessive de­ pendency needs, m ay n o t be subjected to norm al separations fro m the p arents. T h e p aren ts, due to over­ protectiveness, guilt an d anxiety m ay n o t allow th e child to experience sh o rt separations an d th e h a n d i­ capped child m ay learn to control th e p aren ts’ comings an d goings. A vicious circle is set up as th e restraint placed o n th e parents leads to resen tm e n t and a n ­ noyance in the p aren t. T h e child m ay pick up these feelings o f resentm ent and this triggers feelings of insecurity in th e child w hich in tu rn m ay lead to increased efforts on his p a rt to m ak e his parents con­ fo rm to his dem ands. P aren ts o f han d icap p ed children n eed guidance a t a very early stage in dealing w ith th e ir ow n anxiety a t separating fo r sh o rt periods from th e ir child. T herapists should be able to deal w ith ’ssue‘ th e o th e r hand, m an y handicapped children are subjected to long separations from parents b y n u m erous hospitalisations. T h e overw helm ing a n ­ xiety p roduced on such occasions m ay prevent a child fro m m astering this developm ental task. C areful con­ sideration should th erefo re be given b efo re hospitalising a young child w ith o u t its m other. In sum , th e han d ica p p ed child m ay experience, w ith- ™ th e first year o f life, m an y interferences w ith his ability to form tru stin g relationships — tru st n o t only o f significant others b u t also o f him self. T h e second y ear o f life is the p erio d during w hich the child is establishing his own sense o f autonom y i.e. he repeatedly attem pts to establish control o f his ow n b o d ily functions. E rik so n (1955) draw s o u r atten ­ tio n to an im p o rta n t issue: “As his env iro n m en t en­ courages h im to ‘stan d o n his ow n fe e t’, it m u st p ro ­ tect h im against m eaningless and a rb itra ry experiences of sham e and early d o u b t” (p. 244). In light o f this statem ent, it is the a u th o rs ’ view th a t this stage o f developm ent is p a rtic u la rly difficult fo r th e handicapped child. T his is because th e body o f th e handicapped child m ay becom e a supervised object fo r others who m ay subject it to con stant o b serv atio n an d exercise absolute rig h t o v er it. In any attem p t to im prove the child’s functioning m arginally, b o th p aren ts and th era­ pists m ay drive th e child continuously, so prom oting an attitu d e of subm ission, dependence an d passivity. It is a t this p oint th a t therapists need to evaluate th e ir aim s, program m es and relationship w ith th e child. T h e child m u st be allow ed to experience auto n o m y over his ow n body by being allow ed th e freedom to explore his environm ent w ithout the constant “supervision” of his m ovem ents. T h u s th e im portance of allow ing the child to experience no rm al m ovem ent is the aim of th erap y , n o t th e c o n sta n t v erb al correction of posture o r m ovem ent. In th e early pre-school years (3 - 6 years) th e child m u st neg o tiate an o th e r d ev elopm ental crisis viz. the child m ust ‘grow to g e th e r’ b o th in h is person and his body. A t this stage th e child forgets failures quickly and tries again an d again to succeed at various tasks. T h u s the sense of initiative adds a qu ality o f being active and task-involved to th e sense of auto n o m y de­ veloped in th e previous stage. T he handicapped child faced w ith problem s gives u p an d so does n o t develop th e sense o f initiative. O ften it is easier fo r p a re n £ ~ a n d child if ad u lts com plete th e tasks ra th e r thS(^ allow th e child to go th ro u g h repeated failures. In o rd er to n egotiate th is stage, th e th e ra p ist needs to assess th e ch ild ’s capabilities com prehensively an d ad­ vise th e parents in th e p resentation of challenging tasks w hich a re n o t beyond th e ch ild ’s abilities. Success a n d challenge are im p o rtan t a t this stage fo r any child. A t th e sam e tim e, the child is m oving m ore into th e w orld of his peers. P eer in teractio n has been cited (H artu p , 1967) as an essential p a rt of th e socialisation process and socialisation is one of th e m ajo r aim s of h ab ilitatio n o f the handicapped. H a rtu p goes even fu rth e r in stating th a t a child who does n o t fit com ­ fo rtab ly into in teractio n w ith his peers is indeed at risk o f em o tio n al m alad ju stm en t. P e e r in teractio n at this stage u sually occurs thro u g h the m edium o f play. T h e im p o rtan ce o f p lay fo r all children is being u n d er­ lined in th e literatu re of all schools o f psychology (Singer, 1975; S inger & Singer, 1976). F a ilu re to play an d socialise w ith peers m ay co n trib u te to anxiety in social situations, excessive aggression and lack o f strong em o tio n al ties to others. M an y tim es th e play o f the h an d icap p ed child is replaced by adult-supervised “ con­ structive activities” . S ocialisation and play w ith peers m ay be a restricted area fo r th e handicapped child. In w orking w ith p arents, therapists should find ways to provide p lay experience. R esearch w ith regard play an d peer in teractio n am ongst han d icap p ed ch ild rf) is needed. T h e n o rm al child, a t this stage, is com m only ex­ periencing tra n sie n t fears w hich are usually o f no pathological significance. H ow ever, th e handicapped child m ay develop m u ltip le and persistent fears which are heavily im bued w ith anxiety. T h is anxiety m ay m anifest itself in dream s an d n ightm ares w ith central them es of persecution, ab an d o n m e n t and m utilation w hich indicate the im pact o f th e h andicap n o t only upo n th e ch ild ’s inter- an d intra-personal life but also upo n his body im age. C aught in these fantasies, th e child m ay try to m ake sense o f his h andicap by constructing fantasies, o ften based on his ow n w rong doing. T h e im p o rtan ce o f referral fo r psychological help can n o t be u n d erstate d in situations such as these. By th e tim e the n o rm al child reaches p rim ary school, he should have established tru stin g relationships, have a sense o f au to n o m y an d dem onstrate in itiativ e and interest in his environm ent. A fu rth e r developm ental task w hich th e child m u st accom plish at this age is th a t of establishing a sense of adequacy and industry. T h e sense o f industry is usually cultivated w ithin the m ilieu o f fo rm al schooling. F o rm al schooling also re- \ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) quiries th a t less allow ance be m ade fo r th e individual child who m ust now fit into group activities and obey group rules. In o th e r words, the child m ust b e aw are o f an d respect the wishes o f others. T his can n o t be accom plished w itho ut previous p eer p articip atio n which provides a child w ith opportunities to learn the con­ sequences of his ow n actions. A s alread y m entioned, the handicapped child m ay n o t have interacted success­ fully w ith his peers an d thus ad ju stm en t to form al schooling m ay be difficult. T he choice o f o rd in ary o r special school is a particularly stressful decision for m any p aren ts o f han d icap p ed children. T h e m a jo r issue th a t needs evaluation is th a t th e child be placed in a situation w here he will experience reasonable success and acceptance fro m his peers. T h e o ther psychological sequelae o f physical handicap, viz. learning problem s and difficulties w ith ab stract th o u g h t have b een well docum ented elsew here (R utter, G rah am & Y ule, 1970). T o sum m arise, th e em otional developm ent of any handicapped child is especially vulnerable. I t is im ­ p o rta n t th a t all professional w orkers dealing w ith the ih ild view him as a W H O L E dynam ic individual. T h ere f r e some salient facto rs w hich com m only prevent thera- 'pists from viewing th e child objectively. W hat these factors m ay be has as yet not been em pirically re­ searched. H ow ever one m ay m ake inform ed guesses as to w hat could prevent therapists from viewing h a n d i­ capped children objectively. W h at follow s is based on m any years of experience of the senior a u th o r as a therapist a t a school fo r cerebral palsied children. T herapists m ay be unaw are of, and tend to deny, th eir own feelings w hen w orking w ith th e handicapped. “R escue fantasies” m ay easily develop in therapists w ith a need to feel superior to paren ts an d other workers. If th e th e ra p ist is unaw are o f h e r own feelings, she m ay do th e child and fam ily a g reat disservice by not allowing them to com e to term s w ith th e limits o f professional help and u ltim ately th e d isability itself. T herapists can p ro m o te the belief in p aren ts th a t the child can becom e n orm al o r nearly so and this m ust be guarded against. T he parents m ust be supported and DECEMBER 1979 93 helped gently to see reality — n o t to ho p e fo r the im possible. T herapists also need to recognise th a t feelings of anger an d disgust m ay be problem s not only fo r the parents of th e handicapped child b u t also for th e m ­ selves. In our culture these feelings are regarded as unacceptable b u t they are ju st as n atu ral as positive feelings. O ften these angry feelings m ay be transferred onto a p articu lar th erap ist or institution. T h e th erap ist m ust understand th e dynam ics involved, refrain fro m retaliatio n , and accept th a t anger is a very n a tu ra l em otion. In conclusion, it is clear th a t th e th erap ist plays a crucial role in aiding the fam ily of a handicapped child in th e successful negotiation of th e m any em o­ tional hazards facing th e child. T h e present pap er has attem p ted to provide th erap ists w ith a w orking guide to the problem s w hich m ay beset a handicapped child and his fam ily. In o rder to assist any fam ily to accept an d deal w ith th e child, the th e ra p ist m u st be aw are n o t only of the problem s facing the chiH , b u t also of herself. References E rik so n , E. H . (1955). C hildhood an d Society. London. Penguin Books. F reem an, R. D . (1967). E m o tio n al R eactions o f H a n d i­ capped C hildren. R ehabilitation Literature, 28, 9. H a rtu p , W. W., G lazer, J. A . and C harlesw orth, R, Peer (1967). R einforcem ent and sociom etric status. C hild D evelopm ent, 38, 1017 - 1026. R u tte r, M ., G rah am , P., Y ule, W . (1970). A N e u ro ­ psychiatric study in childhood. T h e L avenham Press L td., L avenham , Suffolk. Singer, J. L. (1973). T h e C h ild ’s W orld o f M ake- Believe: E x p erim en tal Studies o f Im aginative Play. N ew Y ork. A cadem ic Press. Singer, 3. L. and Singer, D . G. (1976). Im ag in ativ e P lay and P retending in early C hildhood. In C hild P e r­ sonality an d Psychopathology. E d.: A. D avids. V ol. 3, N ew Y ork. W iley and Sons. P H Y S I O T H E R A P Y PLAY IN INFANCY AND APPLICATION IN TREATMENT* D. C O U R L A N D E R , B.Sc. kjM M A -R Y The theoretical principles o f play according to Piaget are described. Six stages o f play up to tw o years o f age are detailed, w hilst play relevant to the transition fro m infancy to childhood is m entioned. T he application o f play in assessment, parent counselling and treatm ent is discussed. T h e D evelopm ental A ssessm ent C linic a t th e R ed Cross W ar M em orial C h ild ren ’s H ospital in C ape Town, deals with children who are physically o r m entally handicapped as well as those who are socially dis­ advantaged. Som e w ho are considered to be ‘at risk’ in infancy continue to undergo com prehensive periodic assessm ent during th e ir pre-school years. In o rd er to m ake the assessm ent p rocedure pleasure- able a play situation, w hich served as a prelim inary to m ore form al assessm ent, was created w ithin th e clinic setting. D uring these observations it was fo u n d th a t * O riginally published in the N ew sletter of the S.A. N eurodevelopm ental T h erap y A ssociation, 2, 3, 2:11 and rep rin te d by kind perm ission o f th e editor. (Physiotherapy) R and OPSOMMING D ie teoretiese beginsels van speel volgens Piaget word beskryf. Ses stadia van speel tot op twee jaar w ord op- gesom , terw yl speel m et betrekking to t die oorgang van kleinkind to t kind (na twee jaar) genoem word. D ie toe- passing van speel in evaluering, raad aan ouers en behandeling, w ord bespreek. play could provide an altern ativ e form of assessm ent in its own right and, m oreover, serve a useful guide in plan n in g treatm en t an d fo r p a re n t counselling. T h ere are m any ways in which play m ay be defined. C hildren, adults an d anim als play, and different cultures h ave th e ir own form s o f play. S h erid an ’s definition, ‘P lay is th e eager engagem ent in pleasurable physical o r m ental effort to o b tain em otional satisfaction’, is ap p ro p riate to th e observations th a t will be discussed. N o rm s o f child developm ent used as instrum ents fo r observation and diagnosis reflect th e m atu ratio n of p attern s o f beh av io u r in infancy and th e integrity o f th e n eu ro -m o to r system. T hese provide a yardstick w ith w hich to m easure progress and a guide for tre a t­ m ent, b u t deal very little w ith play as a n a tu ra l and spontaneous function. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )