9 Physical Disabilities
Four-year-old Jayla is getting ready to start school for the first time. She is both excited and scared, but maybe not as excited and scared as her mom is. Jayla usually stays at home with her mom, but now that the new baby is coming, her parents think it might be good for her to go to school and meet some new friends.
Jayla has been to her new school once, on a visit with her mom, dad, and Ms. Lisa, the physical therapist who comes to her house to teach her how to walk using her new walker. All the classrooms are in a building that has no steps, which will make it easy for Jayla to get around by herself. She can’t wait to play with all the great toys she saw on her visit, especially the play kitchen and the dolls and doll clothes.
On the first day, her parents and Ms. Lisa go to school with Jayla. Ms. Lisa makes sure the furniture is out of the way so the wheels on Jayla’s walker don’t get stuck. Ms. Lisa also gently reminds some of the adults who are helping Jayla a little too much that she can do things herself. As the days go on, Jayla shows everyone that yes, she can do things for herself … most things, anyway.
The dramatic play area is the most popular with the children, and during center time it gets very crowded. All of the girls want to play with Jayla, but the center is so small that her walker is in everyone’s way. After a few days, some of the other children decide that when Jayla is playing there, they just will play somewhere else until she leaves. The teacher notices that Jayla often plays alone, but she doesn’t think it is because the other children don’t like to play with her—Jayla has plenty of friends during group time and outdoors. She concludes that there is just not enough room for other children to play in the centers with Jayla.
The teacher asks Ms. Lisa to come to school and brainstorm with her about how they can solve this problem. They ask all of the children how they think they could rearrange the centers, and after a lot of discussion, the class comes up with several suggestions that work great. Now, Jayla and her friends play in the dramatic play area at the same time, and they are all learning together.
A physical disability may affect a child’s ability to use his legs, his upper body, or both; he may have more difficulty using one side of his body than the other. Some children walk unaided, while others may have leg braces or use a wheelchair or walker some or all of the time. Many, like Jayla, require rather simple accommodations and modifications—and a little imagination on the part of teachers—to be fully included with children without disabilities. Others need an array of supports from different professionals to move, communicate, socialize, and learn. Understanding individual children’s strengths and needs and providing appropriate supports and therapies will enable children to actively participate to the greatest extent possible in the early childhood setting.
What Are Physical Disabilities?
Children with a physical disability have a medical condition that significantly impacts their ability to move from place to place, move specific parts of their body, and sustain energy. Several medical conditions can result in physical disabilities, including the following:
» Cerebral palsy: Also known as CP, cerebral palsy is one of the most common physical disabilities in childhood (Accardo 2007). It is not one specific disease or disability; the term indicates injury or damage to parts of the brain that control a person’s muscles. Injury can occur during pregnancy, delivery, or soon after birth. CP is discussed in more detail later in this chapter.
» Spina bifida: The term spina bifida means “open spine” and is a condition that occurs during prenatal development. The child’s developing spine fails to close all the way, and a sac of fluid—sometimes containing part of the spinal cord—may bulge through the opening. This can cause moderate to severe loss of feeling in the child’s lower half of the body, affecting her ability to walk and control bladder functions (March of Dimes 2014b). A child with spina bifida may also have hydrocephalus, a condition caused by excess fluid building up in the brain and causing pressure.
» Spinal cord injuries: Complete or partial spinal cord injuries may occur during the birthing process or in an accident after birth. Complete spinal cord injuries paralyze a child from the spot of injury and down the rest of the body. Partial spinal cord injuries will leave the child with some feeling and some movement from the spot of the injury and down the rest of the body (Hayes & Arriola 2005).
» Traumatic brain injuries: Traumatic brain injury (TBI) refers to damage to the brain caused by a child’s head hitting something very hard (like the ground, or a bat or ball when playing), or the child’s head being shaken violently, such as during a car accident or incident of physical abuse (shaken baby syndrome). The physical effects of TBI include paralysis, difficulty with balance and motor coordination, and stiffness or tightness of muscles used for movement and speech (BIAA 2017). Children may also have difficulty with memory, attention, reasoning, and other areas that impact learning and everyday functioning.
» Muscular dystrophy: A genetic disorder, muscular dystrophy weakens a child’s muscles over time. As the condition progresses, more muscles are affected, including those of the heart and respiratory system (MDA 2017).
Possible Reasons for Physical Disabilities
A physical disability can result from any of the following:
» Genetic conditions, such as muscular dystrophy
» Congenital disorders, such as spina bifida
» Injury to the brain before, during, or shortly after birth
» Serious illness, like meningitis
» Accidents later in childhood
Impact of Physical Disabilities on Development and Learning
Because physical disabilities are such a diverse group of conditions, they have different effects on each child’s motor skills, communication, ability to care for her own needs, and learning. Depending on their situation, children may need physical, visual, sensory, and/or cognitive supports from teachers, special education professionals, and therapists. Some conditions, such as spina bifida or CP, may require surgeries that interrupt a child’s school participation. Teachers and programs must understand each child’s capabilities and limitations and be flexible to meet the needs of the child and their family.
It is important for a child with a physical disability to become as independent as possible, as soon as possible. Many well-meaning adults and peers have a natural instinct to assist and protect a child with a physical disability, but this can inhibit the child’s development and make him unnecessarily dependent on assistance. Children who have learned to depend on others to do things for them will continue to do so. In some cases, children need extra motivation to keep trying because some actions are particularly challenging for them—moving around indoors or outside; writing, drawing, and other activities that require small motor control; and even making themselves understood. Your attitudes about a child’s ability to achieve and to do things herself and the support and encouragement you provide will go a long way toward fostering her independence.
Identifying Physical Disabilities
Some conditions, such as spina bifida, are noticed before or at birth, but often a disability is not identified until the first few years of life. A delay in a child’s physical skills, such as not crawling or walking on time, is one of the first signs of a potential problem that parents notice and seek help for. Large motor issues are easier to spot and diagnose than small motor issues since the large muscles needed for crawling and walking develop before the small muscles needed for writing (Gerber, Wilks, & Erdie-Lalena 2010). To diagnose a child’s disability, doctors use physical examinations, lab tests and imaging, and medical history.
In its “Learn the Signs: Act Early” campaign, the CDC (2017a) identifies specific milestones for families and caregivers to be aware of to recognize motor weaknesses, delays, and potential disabilities. While keeping in mind that there is wide variation in motor development, families should alert their child’s doctor if the child is not reaching typical developmental milestones (see the box).
If you have concerns about a child’s large or small motor skills, take the time to observe the child in different situations and write down what you see. This will make it easier for the family, the doctor, and other professionals to determine the child’s needs and design interventions to help the child be as successful as possible.
Therapeutic Interventions for Children with Physical Disabilities
Although many children have lifelong challenges with a physical disability, early treatment and interventions can help reduce its effects and enable children to be as independent as possible. Coordination among teachers, therapists and other specialists, and families is essential for determining what services best support a child, how those services will be provided, and how the classroom teacher can support a child when specialists are not in the room.
A child may receive different kinds of therapy and interventions. See the sidebar titled “Common Therapies in Early Intervention and Special Education Programs” for a more detailed look at the services provided by physical, occupational, and speech-language therapists. Assistive technology (AT) is technology specially designed to help a child communicate, gain academic skills, and acquire daily living skills. (Chapter 4 addresses AT more in depth.) Some children may undergo medical interventions, such as surgical procedures or muscle injections that assist with movement limitations (ADDM CP Network 2013).
Developmental Milestones, Birth–Age 5: Motor Skills
By the time the child is 2 months old, she
• Holds her head up and begins to push up when lying on her tummy
• Makes smoother movements with her arms and legs
By the time the child is 4 months old, he
• Holds his head steady, unsupported
• Pushes down on his legs when his feet are on a hard surface
• May roll over from tummy to back
• Holds and shakes a toy and swings at dangling toys
• Brings his hands to his mouth
• Pushes up to his elbows when lying on his stomach
By the time the child is 6 months old, she
• Rolls over in both directions (front to back, back to front)
• Begins to sit without support
• When standing, supports her weight on her legs and might bounce
• Rocks back and forth, sometimes crawling backward before moving forward
By the time the child is 9 months old, he
• Stands, holding on to a hand or furniture for balance
• Gets into sitting position
• Sits without support
• Pulls to stand
• Crawls
By the time the child is 1 year old, she
• Gets to a sitting position without help
• Pulls up to stand, walks holding on to furniture (known as cruising)
• May take a few steps without holding on
• May stand alone
By the time the child is 18 months old, he
• Walks alone
• May walk up steps and run
• Pulls toys while walking
• Helps undress himself
• Drinks from a cup
• Eats with a spoon
By the time the child is 2 years old, she
• Stands on tiptoe
• Kicks a ball
• Begins to run
• Climbs onto and down from furniture without help
• Walks up and down stairs holding on
• Throws a ball overhand
• Makes or copies straight lines and circles
By the time the child is 3 years old, he
• Climbs well
• Runs easily
• Pedals a tricycle
• Walks up and down stairs, one foot on each step
By the time the child is 4 years old, she
• Hops and stands on one foot up to 2 seconds
• Catches a bounced ball most of the time
• Pours, cuts with supervision, and mashes her own food
By the time the child is 5 years old, he
• Stands on one foot for 10 seconds or longer
• Hops; may be able to skip
• Does a somersault
• Uses a fork and spoon and sometimes a table knife
• Uses the toilet on his own
• Swings and climbs
Adapted from CDC 2017b.
Strategies for the Classroom
While a physical disability may mean that a child does some things in a different way than other children or uses special equipment, it should not prevent him from participating in routines and activities with other children or from accessing the same learning opportunities. In many ways, children with physical disabilities are much like any other child, and it is important to have social, behavioral, and academic expectations for them that are similar to those you have for other children. Get to know each child’s interests, abilities, needs, and personality so you can select the strategies that will best help that child learn and socialize. You may need to be creative! Strategies will not all be the same for every child with a physical disability.
The ADA and Supporting Children with Physical Disabilities
The Americans with Disabilities Act (ADA) addresses the needs of children with physical disabilities in early childhood settings (including family child care centers) with the following requirements:
Programs cannot say that a child with a disability cannot attend unless having the child there poses a direct threat to the health or safety of others or if having him attend the program requires fundamental alteration of the program.
Programs must try to make their building physically accessible to someone with a disability. Existing buildings must complete readily achievable changes to remove any barriers for someone with a disability, while newly constructed facilities and any reconstruction of existing buildings must be fully accessible.
Programs have to make reasonable modifications to the rules and regulations to make sure a child, parent, or guardian who has a disability can participate in the program, unless making those modifications would constitute a fundamental alteration.
Programs must provide appropriate ways to have effective communication with children or adults with disabilities, except when doing so would be an undue burden.
Evaluating the Physical Environment
Simple changes to indoor and outdoor spaces—such as rearranging furniture, removing throw rugs to minimize obstacles, and providing underinflated balls for outdoor play—go a long way toward enabling a child with a physical disability to independently participate in most of the daily routines. Many children, however, need further accommodations. As a child grows older and physically larger, the need for changes to the physical environment will continue.
Look at every physical aspect of each environment the child is in, from the moment he wakes up in the morning until the time he goes to sleep. This includes the way he gets in and out of his house and school, across the parking lot, on the playground, and in the classroom. Consider changes to these environments that may be needed. If there are stairs to enter the building or inside the building, is there a ramp or wheelchair lift as an alternative? Do toileting or changing facilities need to be enlarged or adapted? Can the child safely negotiate the outdoor play area and actively participate with other children? The IEP team, including the child’s parents, teachers, and program administrator, must consult with the child’s physical therapist and other professionals to determine whether any major changes to the physical environment are necessary and achievable.
Promoting Independence in the Environment
» Make sure that the floor is free of any hazards and barriers. If you do have area rugs, make sure they are secure and won’t cause a child to trip.
» Use furniture that is heavy and stable so nothing can be knocked over easily or unintentionally.
» Position furniture so that a child using a walker or a wheelchair can navigate the room independently.
» Make sure all seating arrangements are appropriate, comfortable, and safe for the child. Work with parents and/or the child’s physical therapist to plan for having the child sit in many different places—at the table, on the floor, and on outdoor play equipment.
» Make materials accessible and portable. If it is not possible to have some materials accessible at all times to a child with a physical disability, keep them in a clear container so they are visible and all children know they can use them. Set materials in a variety of places throughout the room where the child with a disability and his peers can play and work together.
» Have a place for any equipment (wheelchair, walker, crutches) the child uses for part of the day to be stored out of the way so they are safe but near enough to be accessible whenever the child needs them.
» Organize self-care activities so the child can be independent. If the children use cubbies, assign the child with a disability one on the end of the row so she has ample room to take care of her possessions by herself.
» Provide stabilization bars or other equipment in the bathroom so the child can take care of his toileting and handwashing needs as independently as possible. If the child cannot be independent with toileting, make sure a plan is in place that takes age-appropriate modesty into consideration and treats the child with dignity.
» Adaptive equipment needs repair or replacing from time to time. Keep an eye out for malfunctions and address them right away with the child’s therapist or family.
» Make sure the child with a physical disability is on the same visual level as everyone else throughout as much of the day as possible. If she must remain in her wheelchair during large group time, consider having everyone else sit in chairs instead of on the floor.
» Because a physical disability is visible, many peers are curious and want to know about it. Set up your class library with books that teach about the disability itself or show a character with the same disability.
Cerebral Palsy
Cerebral palsy (CP) is a group of disorders that affects posture and balance, muscle control and coordination (including speech and chewing), and even reflexes such as swallowing. It results from an injury to or lack of development in the area of the brain that controls movement of muscles. Cerebral palsy is not progressive. It is more common among boys than girls.
The effects of CP can be mild, moderate, or severe, ranging from having a somewhat clumsy gait to using a wheelchair or other special equipment all of the time. The extent of the injury to the part of the brain that controls the muscles determines how severe the CP will be. The more severe the CP, the more likely it is that a child will also have intellectual, language, visual, and/or hearing disabilities (ADDM CP Network 2013).
Types of Cerebral Palsy
Cerebral palsy is sometimes described based on where and to what extent parts of the body are impacted. Children with CP may be affected in only one limb (monoplegia), in the arm and leg on one side of the body (hemiplegia), in both legs (paraplegia), or in all four limbs (quadriplegia) (Pakula, Van Naarden Braun, & Yeargin-Allsopp 2009).
Cerebral palsy is also described by the way it affects a person’s movements (ADDM CP Network 2013). The most common type, known as spastic CP, causes stiff, jerky movements, making it very difficult or almost impossible for a person to be able to move in certain ways at will. This type impacts about 70–80 percent of all people with cerebral palsy. Athetoid, or dyskinetic, CP happens when the signal from the brain to the spinal cord is misinterpreted, and it is characterized by involuntary, uncontrollable movements. This makes it difficult for the child to walk or control a part of his body the way he wants to. Individuals with ataxic CP have balance and coordination problems that make their movements look unsteady or clumsy.
Facts About Cerebral Palsy
• More than half (58 percent) of children identified with CP can walk independently.
• Many children with CP also have at least one other condition, such as epilepsy, intellectual disabilities, or ASD.
• The rate of children born with CP has stayed relatively stable over the past 50 years, even as the number of babies born at risk for CP (because of conditions like premature birth or low birth weight) has dramatically increased.
• The number of children with CP who also have moderate to severe intellectual disabilities has decreased about 2.6 percent each year from 1985 to 2002. This suggests that improved medical care for mothers during pregnancy and for infants may be preventing more significant forms of CP. (Van Naarden Braun et al. 2016)
Promoting Independence During Activities and Lessons
» Hands-on learning experiences are important for all children, so make sure that the child with a physical disability has lots of opportunities to participate, even if he needs assistance. Let him do as much as he can, as independently as he can.
» Keep objects steady when a child is using them. If she is painting, stabilize the paper and the paint by taping the paper to the table or placing the paper on a no-skid surface or inside a shirt box.
» Provide choices for what the child can do or how he can participate. A sense of autonomy is important, and feeling that he can make things happen gives him a sense of accomplishment and control and makes an activity more meaningful.
» Give children enough time to explore, create, and discover. To actively participate in all activities, children whose movements are limited or difficult must know they have enough time. Older children may need additional time to complete assignments and tests.
» Remember that a child with a physical disability may tire more easily when participating in activities that require exertion. Alternate times when the child needs to be active with more restful activities, like reading a book with an adult.
» Make sure everything a child needs is within reach. Put puzzles and small manipulatives on a tray with sides or inside a shirt box so they are easy to reach and will not get lost.
» Provide materials and instructions in different formats and at different levels of difficulty. For a child who needs to work on using both hands together, offer toys that require the use of two hands. Have different types of blocks, some that connect easily and others that require more complex balancing skills.
» Use virtual materials and manipulatives on a computer that are easier to use than real objects.
» Use assistive technology so a child can complete her classwork as independently as possible, such as by typing or completing classwork on a computer that is specially designed for her.
» Work for success. Even if a child cannot be independent in all parts of an activity, he can do something by himself. Structure activities to provide some aspect of independence and success, even if for one small part of a task. Encourage him to try, even when activities are difficult.
» If a child has difficulty physically raising her hand in class to let the teacher know she has something to contribute, work together to find an alternative, like pressing a buzzer.
» If pencil and paper tasks are too difficult, consider having the child give a combination of written and oral responses.
Promoting Independence with Peers
» Brainstorm with the children ways they could include their classmate with a physical disability in their play activities.
» Answer children’s questions about a peer’s disability honestly and positively. Encourage the child with a disability to answer these questions as well, if she is comfortable doing so.
» Children with physical disabilities may have frequent absences for medical appointments, illness, and so on. Talk with the other children to explain and allay any fears that something might be seriously wrong with the child.
» Model how to respect a child’s personal space and boundaries. Teach peers not to crowd around a child with a physical disability or relegate him to the back of a group activity where he can’t readily participate.
» Teach peers to never push a child’s wheelchair. Moving a child’s wheelchair from place to place is always the job of the child herself or an adult.
» Teach children to ask the child with a physical disability if he wants help before doing something for him. Also, teach the child with a physical disability to identify his own boundaries and to respectfully tell others when he does not need help.
» Encourage all children to celebrate when anyone accomplishes something new on their own.
» Work with community agencies to adapt recreation and sports facilities to make them more inclusive of people with physical disabilities. When children with physical disabilities can participate in and enjoy the same activities and places as their peers, they are more likely to be included and accepted.
Summary
Physical disabilities can limit what a child can do, but it does not have to stop her from participating in high-quality programs and learning alongside her peers. Along with therapies and assistive technologies where appropriate, provide an environment where children learn to be as independent as possible.