j UNE 1981 P H Y S I O T H E R A P Y 33 TH E “ HIGH RISK” INFANT C. D . M O L T E N O , B .A ., M .B .C h .B ., M .M E D ., M .D ., F .C .P . (S.A .), D .C .H .* S U M M A R Y T o d a y there is a fa r m o r e p o sitiv e a ttitu d e to w ards h a n d ica p p e d c h ildren. T o g e th e r w ith th is tre n d goes the necessity o f early d ia g n o sis a n d c o m p re h e n s iv e m a n ­ a g em ent. B y c o n sid erin g certain in fa n ts to be at risk fo r d e v e lo p m e n ta l d isa b ilitie s a n d b y in tr o d u c in g p o p u la tio n screening p ro g ra m m e s, early d e te c tio n b e c o m e s a p o s ­ sibility. In a d d itio n to d ia g n o sis, a d e q u a te tre a tm e n t fa cilities to c a ter f o r the c h ild re n a n d th eir fa m ilie s s h o u ld be e sta b lish e d in all areas o f th e c o u n tr y . D e v e lo p m e n ta l d isa b ilitie s a re c o m m o n in in fa n c y a nd c h ild h o o d a n d p re se n t a c h a lle n g e to a ll th o se c o n ­ c ern e d w ith c h ild h e a lth . W h e n th e d isa b ilitie s a re o f a c h ro n ic , n o n -p ro g re s siv e n a tu re , th e ch ild is de sc rib e d as being h a n d ic a p p e d . A h a n d ic a p p e d ch ild is defined by S h e rid a n (1968) as o n e w ho s u ffe rs fro m a n y c o n ­ tin u in g d isa b ility o f b ody, in te lle c t o r p e rs o n a lity w hich is likely to in te rfe re w ith n o rm a l g ro w th , d e v e lo p m e n t and th e c a p a c ity to lea rn . In a n e ffo rt to e ffe c t e arly diag n o sis o f su c h c h ild re n , S h e rid a n in tro d u c e d th e “ at risk ” c o n c e p t in 1962. T h is c o n c e p t w as n o t h o w e v er g e n e ra lly a c c e p te d b e c a u se it w as fo u n d th a t, in o rd e r to d e te c t m o st h a n d ic a p s , 60 - 7 0 % o f in fa n ts h a d to be c o n sid ere d “ a t ris k ” . T h is in v o lv e d excessive e x p e n d itu re of tim e a n d m o n e y as w ell as c a u s in g u n n e c e ssa ry m a te rn a l a n x ie ty . R isk re g is te rs h a v e th e re fo re b een replaced by p o p u la tio n s c re e n in g p ro g ra m m e s . A c c o rd in g to H o lt (1973), sc re e n in g p ro c e d u re s a re se nsitive to a n d sp e c ific fo r a p a r tic u la r c o n d itio n , c a p a b le o f b e in g p e rfo rm e d q u ic k ly a n d c h e a p ly a nd o f p ro v id in g a f a il/p a s s re su lt. T h e y m a y b e c a rrie d o u t in a G .P . c o n su ltin g ro o m o r a well b a b y clin ic by a p p ro p ria te ly tra in e d c o m m u n ity n u rse s w o rk in g u n d e r th e su p e rv isio n o f a c lin ic d o c to r. I f e v e ry in fa n t w as sc ree n e d in th e n e o n a ta l p e rio d by a d o c to r, a t 6 m o n th s a n d a g a in a t a y e a r by a c o m m u n ity h e a lth n u rse , m o st m a jo r h a n d ic a p s w o u ld be d e te c te d in in ­ fancy. In fa n ts p ick e d up by such sc re e n in g sh o u ld be re fe rre d to a d e v e lo p m e n ta l a sse ss m e n t u n it. T h e risk c o n c e p t does, h o w e v er, h a v e m erit. E a rly d e te c tio n o f c e re b ra l p a ls y g ives rise to b e tte r lo n g -te rm resu lts o f th e ra p y . F o llo w -u p c lin ics c a te rin g fo r in fa n ts m an a g ed in n e o n a ta l in te n siv e c a re u n its fo c u s on th o se a t p a rtic u la r risk f o r c e re b ra l palsy. S u ch c ases co u ld be id e n tifie d a n d th e ra p y c o m m e n c e d in th e firs t six m o n th s o f life. I t m u st be m e n tio n e d th a t th e ra p y can begin b e fo re a d e fin ite d ia g n o s is o f c e re b ra l p a lsy has been m ade. D e te c tio n o f n e u ro d e v e lo p m e n ta l a b n o r m a lity in d i­ c ates th e n e ed f o r n e u ro d e v e lo p m e n ta l th e ra p y . H igh- risk in fa n ts sh o u ld be e x a m in e d a t c e rta in key ages (c o rre c te d fo r p re m a tu r ity w h e re a p p lic a b le ) w hen p ro b lem s a re m o re e asily d e te c te d . T h e fo llo w in g is n o t in te n d e d as a c o m p le te c h ec k list o f a ll a b n o rm a l signs, b ut as a n in d ic a tio n o f th e m o s t c o m m o n ones. 6 w eeks: • F e e d in g d iffic u ltie s a s s o c ia te d w ith e x te n s o r h y p e r­ tonus, to n g u e th r u s t etc. S e n io r L e c tu re r a n d P a e d ia tric ia n , D e p a r tm e n t of P a e d ia tric s a n d C h ild H e a lth , U n iv e rs ity o f C a p e T o w n a n d R e d C ro ss W a r M e m o ria l C h ild r e n ’s H o s ­ p ital. R e ce iv e d 1 M a y 1981. O P S O M M IN G V a n d a g is die b o n d in g te e n o o r g e stre m d e k in d e rs baie m e e r p o sitie f. D ie neig in g gaan sa a m m e t die n o o d s a a k lik lie id vir v r o e i d ia g n o se en o m v a tte n d e b a n ­ tering. D e u r se k ere su igelinge as h o c r isik o vir o n tw ik k e lin g s g e s tr e m d h e d e te b e sk o u en d e n r b e v o lk in g s- s iftin g p r o g r a m m e in te stel, w o r d vroee o p sp o rin g 'n m o o n tlik h e id . B eh a i we d ia g n o se , b e h o o rt v o ld o e n d e be- h a n d e lin g fa silite ite v ir die k in d e r s en h u lle fa m ilie s in al (lie d ele van die la u d to t s ta n d g e b rin g te w ord. 4 months: • A s y m m e try o f to n e o r m o v e m e n t. • P e rs is te n t p rim itiv e re fle x es, e.g. M o ro , fistin g , o b li­ g a to ry a sy m m e tric to n ic n e c k re fle x (A T N R ). • H e a d lag in pull to sit d u e to h y p o to n ia o r e x te n s o r h y p e rto n u s . It is im p o rta n t to o b se rv e th e fe et d u rin g th is p ro c e d u re . T h e y sh o u ld lift o ff th e b ed w hen th e in fa n t is p u lle d up in to th e s ittin g p o sitio n . • F a ilu r e o f visual p u rs u it m o v e m e n ts (la te ra lly a n d up a n d d ow n). It is u se fu l to look f o r a n o b lig a to ry A T N R d u rin g la te ra l visual fo llo w in g . • A b s e n t h e ad rig h tin g o n la te ra l tiltin g . 8 m o n th s : • A b s e n t la te ra l p ro te c tiv e e x te n sio n . • F a ilu r e to g ra sp a n o b je c t e q u a lly well w ith e ith e r h a n d . 12 m o n th s : • By th is sta g e a ll c h ild re n w ith c e re b ra l p alsy s h o u ld h a v e b e en d ia g n o s e d a n d th e ra p y c o m m e n c e d . T h e tw e lv e -m o n th e x a m in a tio n is u se fu l, h o w e v er, in the case o f p re m a tu re in fa n ts w h o h a v e b e en th ro u g h a sta g e o f e x te n s o r h y p e rto n u s . By a y e a r it sh o u ld h a v e d o n e so if it is g o in g to resolve. T h e sc h e m e is c u m u la tiv e , i.e., if a n y o f th e signs listed a t a sp e c ific age a re p re s e n t a t th e n e x t, th e y a re a b n o rm a l. T h e d e cisio n to tre a t a c h ild d e p e n d s on th e p re ­ sence o f n e u ro d e v e lo p m e n ta l a b n o rm a lity . T h is d o e s n o t n e c e ssa rily in d ic a te a d ia g n o s is o f c e re b ra l palsy. Such a d ia g n o s is d e p e n d s on b o th th e n e u ro d e v e lo p m e n ta l p ic tu re a n d a fo rm a l n e u ro lo g ic a l e x a m in a tio n . T h e d ia g n o s is sh o u ld b e m a d e by a p a e d ia tr ic n e u ro lo g is t o r a d o c to r tra in e d in d e v e lo p m e n ta l p a e d ia tric s . T h e im p lic a tio n s fo r th e c h ild a n d fa m ily o f such a d ia g ­ n o sis a re g ra v e a n d it sh o u ld o n ly be m a d e w ith c o n ­ fid e n c e . O n th e o th e r h a n d , o n c e m a d e , th e p a re n ts a re e n title d to be in fo rm e d im m e d ia te ly . C e re b ro -m o to r d y s fu n c tio n is n o t th e o n ly ty p e o f a b n o rm a lity w h ic h m a y p re s e n t d u rin g in fa n c y . P ro b le m s w ith v ision, h e a rin g o r g lo b a l d e v e lo p m e n ta l d e la y o c c u r a n d s h o u ld be d e te c te d . V isio n a n d h e a rin g c a n be te s te d c lin ic a lly by th e S ty c a r m e th o d a n d if d e la y fo u n d to be p re se n t, th e ch ild is re fe rre d to th e re le v a n t sp e c ia list. It is im p o r ta n t to e sta b lish a d e v e lo p m e n ta l p ro file in all in fa n ts assessed. T h e a sse ss m e n t s h o u ld in c lu d e gro ss m o to r fu n c tio n , m a n ip u la tio n a n d social a n d la n g u a g e d e v e lo p m e n t. T h e m a n a g e m e n t, o n c e a d ia g n o s is o f so m e fo rm o f h a n d ic a p has b e en m a d e , m a y be d iv id e d in to th a t d ire c te d to w a rd s th e ch ild h im s e lf a n d th o se a sp e c ts c o n c e rn in g th e fa m ily as a w h o le . R e g a rd in g th e fo rm e r, sp a c e d o e s n o t a llo w f o r a fu ll d e s c rip tio n of th e te c h ­ n iq u e s o f n e u ro d e v e lo p m e n ta l th e ra p y . H o w e v e r, it is 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. ) a p p ro p ria te to c o n s id e r th e a im s of tr e a tm e n t o f c e re ­ b ra l p a ls y as d e sc rib e d by B o b a th (1967); “ I. T o d e v e lo p n o rm a l p o s tu ra l r e a c tio n s a n d p o s tu ra l to n e a g a in s t g ra v ity fo r s u p p o r t a n d c o n tro l o f m o v e ­ m e n ts. 2. T o c o u n te r a c t th e d e v e lo p m e n t o f a b n o rm a l p o s tu ­ ra l re a c tio n s a n d o f a b n o rm a l p o s tu ra l to n e . 3. T o g ive th e c h ild , b y m e a n s o f h a n d lin g a n d p lay , th e f u n c tio n a l p a tte rn s h e will u se la te r o n fo r fe ed in g , d re ssin g , w a sh in g e tc fo r se lf-h elp . 4. T o p r e v e n t th e d e v e lo p m e n t o f c o n tra c tu re s a n d d e fo rm itie s ” . I t is o b v io u s t h a t a c o m p re h e n s iv e a sse ss m e n t of e ac h c h ild , o u tlin in g b o th a b ilitie s a n d d isa b ilitie s, m u st p re c e e d th e ra p y . S im ila rly , p e rio d ic re a ss e s sm e n t fo rm s a n in te g ra l p a r t o f n e u ro d e v e lo p m e n ta l th e ra p y . M a n a g e m e n t o f th e fa m ily in clu d e s p a r e n t c o u n se llin g a n d e d u c a tio n , a n d a lso p ra c tic a l h e lp w ith d a y -to -d a y p ro b le m s. P a r e n t c o u n se llin g s h o u ld fo rm an in te g ra l p a r t o f th e m a n a g e m e n t o f e v ery h a n d ic a p p e d c h ild a n d sh o u ld b e o ffe re d as so o n as th e h a n d ic a p is d ia g ­ n o se d . I t m a y ta k e th e fo rm o f fo rm a l c o u n se llin g by a so c ial w o rk e r, o r p sy c h o lo g is t o r b e c o n d u c te d in ­ fo rm a lly b y th e th e r a p is t tre a tin g th e c h ild . M a c K e ith (1973) d e sc rib e s th e fe elin g s of a n g e r, g rie f, g u ilt a n d re v u ls io n f e lt b y p a re n ts fa c e d w ith th e sh o c k of le a rn in g t h a t t h e ir c h ild is h a n d ic a p p e d . P a r e n ts n e ed a n o p p o r tu n ity to disc u ss th e s e fe e lin g s in o r d e r to a d ju s t to w h a t h a s h a p p e n e d a n d c o m e to so m e so rt o r re a lis tic a c c e p ta n c e . W ith o u t a c c e p ta n c e th e p a re n ts w ill h a v e d iffic u lty fin d in g re so u rc e s w ith in th em se lv es to p ro v id e th e k in d o f lo v in g a n d se c u re e n v iro n m e n t th e ir ch ild n e e d s. 34 P a r e n ts sh o u ld b e g iven as m u c h in fo rm a tio n a b o u t th e ir c h ild ’s h a n d ic a p as th e y re q u e st. T h e d ia g n o s is a n d p ro g n o sis m u s t be in te rp re te d a n d d iscussed in te rm s w h ich th e y u n d e rs ta n d . T h e y a ls o n e ed to know w h a t fa c ilitie s a re a v a ila b le a n d h ow to use them T h e g re a te s t s o u rc e o f a n x ie ty in p a re n ts is u n c e rta in ty — n o t k n o w in g e x a c tly w h a t has h a p p e n e d n o r w hat c a n b e d o n e a b o u t it. P a re n ts a lso re q u ire p ra c tic a l h e lp w ith d a y -to -d a y p ro b le m s o f m a n a g e m e n t, e sp e c ia lly if th e ch ild is se v e re ly h a n d ic a p p e d . P ro b le m s o f fe ed in g , d iscipline, th e m o s t s u ita b le k in d o f p la y a n d toys, ho w to org a n ise the d a ily ro u tin e so th a t o th e r m e m b e rs o f th e fam ily a re n o t n e g le c te d , fre q u e n tly arise. T h e p re se n c e o f a h a n d ic a p p e d c hild in a fam ily re p re s e n ts a h u m a n tra g e d y . E v e ry e f fo r t sh o u ld be m a d e to p re v e n t such a situ a tio n fro m o c c u rrin g . H o w ­ e v er, w h e n it d o e s a ris e , e a rly d ia g n o s is a n d c o m p re ­ h e n siv e m a n a g e m e n t will lessen th e im p a c t, p ro v id e a m u c h n e e d e d s u p p o rt system a n d fa c ilita te a c c e p ta n c e b y th e p a re n ts a n d a lso p ro m o te th e d e v e lo p m e n t of th e c h ild . R e fe re n c e s B o b a th , B. (1967). T h e very e a rly tre a tm e n t of c ere b ral p a lsy . D e ve lo p . M e d . C h ild N e u r o l. 9, 373. H o lt, K. S. (1973). F u n c tio n a l a sse ss m e n t o f h a n d ic a p p e d c h ild re n : A n assessm ent. Proc. R o y . S o c . M e d . 66, 611. M a c K e ith , R . M . (1973). T h e feelin g s a n d b e h a v io u r of p a re n ts o f h a n d ic a p p e d c h ild ren . D e ve lo p . M e d C h ild N e u ro l. 4, 115. S h e rid a n . M . D . (1968). T h e d e v e lo p m e n ta l p ro g re s s of in fa n ts a n d y o u n g c h ild re n . M in istry o f H e a lth R e p o rt. 20. 102. L o n d o n . H .M .S .O . JUNIE 1981F I S I O T E R A P I E RESULTS OF EARLY INTERVENTION IN TH E BABY WITH CEREBRAL MOTOR DISTURBANCE S. H . IR W I N - C A R R U T H E R S , N a t. D ip . P h y sio . (P re t.), D ip . P h y sio . Ed. (P re t.)* S U M M A R Y T h e re su lts o f a stu d y c o m p a rin g the early a n d late tre a tm e n t o f b a b ies w ith cereb ra l m o to r d istu rb a n c e are d iscussed. C riteria f o r d ia g n o sis m u s t be e sta b lish e d b e fo r e tests can begin. I t w o u ld a ppear th a t early in te r­ v e n tio n re su lts in m a r k e d im p r o v e m e n t b u t m o r e su r v e y s are necessary to p r o v id e c o n v in c in g e vidence. In r e c e n t y e a rs m u c h h a s b e e n w ritte n on th e im ­ p o rta n c e o f e a rly in te rv e n tio n in th e tre a tm e n t o f c e re ­ b ra l m o to r d is tu rb a n c e s . T h e te rm “ c e re b ra l m o to r d is tu r b a n c e ” h a s re p la c e d c e re b ra l p a ls y a n d d e n o te s a m o v e m e n t d i s o rd e r w h ic h has d e v e lo p e d as a re su lt o f b r a in d a m a g e . B y “ e a rly in te r v e n tio n ” we m e a n t r e a t ­ m e n t s ta rte d as e a rly as p o ssib le w ith in th e firs t y e a r o f life a n d in a n y case a t less th a n six m o n th s o f age. I n th is c o u n try , w e h a v e n o t g o n e as f a r as in the U n ite d S ta te s w h e re n e u ro d e v e lo p m e n ta lly tra in e d * S e n io r le c tu re r a n d A c tin g H e a d o f D e p a rtm e n t, U n i­ v e rsity o f S te lle n b o sc h a n d T y g e rb e rg H o s p ita l, t P a p e r d e liv e re d a t S A S P C o n g re ss h e ld in P r e to r ia M a rc h 1981. R e ce iv e d 1 M a y 1981. O P S O M M IN G D ie resultate van ’n stu d ie w at vroe'e en laat b ehau- d e lin g van babas m e t sere b ra a l-m o to rie se v ersteu rin g £ v e rg elyk , w o rd b espreek. K rite r ia v ir d ia g n o se moet\^ vasgestel w o rd vo o r to etsin g begin. D it w il v o o r k o m d a t vroe'e beh a n d elin g d u id e lik e v e rb eterin g m e eb rin g , m a a r m e e r o n d e rso e k e is n o d ig o m o o rtu ig e n d e fe ite aan die lig te bring. th e ra p is ts a re in v a d in g th e in c u b a to rs in th e p re -te rm un its. E a rly in te rv e n tio n p re su p p o se s e a rly d ia g n o sis, w hich m a y b e e asy in th e se v e re ly a ffe c te d c h ild b u t very d iffic u lt in th e m o re m o d e ra te ly a ffe c te d y o u n g b a b y . S e v e ral w o rk e rs in th e field o f e a rly in te rv e n tio n h a v e b e e n c ritic ise d on th e g ro u n d s th a t th e ir c rite ria fo r d ia g n o s is m a y n o t e x c lu d e in fa n ts w hose sy m p to m s m ig h t h a v e c le a re d s p o n ta n e o u s ly . V o jta , in p a rtic u la r, h a s co m e u n d e r c ritic ism b e c a u se in h is c lin ic d ia g n o s is is m a d e o n th e g ro u n d s o f se v e n re fle x es, m o re th a n o n e o f w h ich b e a rs his n a m e a n d a ll ol' w h ic h a re assessed s u b je c tiv e ly fo r a d e g re e o f a b n o rm a lity . K o n g (1960, 1975) has su g g e ste d six in d ic a tio n s fo r e a rly tre a tm e n t: • A n o b lig a to ry a b n o rm a l p a tte rn — fro m b irth . • V e ry low to n e w ith n o h e a d c o n tro l b y th re e m o n th s . 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. )