Cerebral Palsy (CP) is a group of non-progressive, permanent disorders that affect the development of the foetal or infant brain. The disturbance to the immature brain results in disturbances to the development of movement and posture which causes daily activity limitations. Motor disturbances are often accompanied by other impairments such as disturbances to sensation, cognition, communication, perception and behaviour (Rosenbaum et al., 2005). Children with CP have a significantly higher prevalence of experiencing behavioural and emotional problems such hyperactivity, conduct problems, peer difficulties and emotional symptoms. Such behaviours are a reflection of the child’s mental health and can have a wider impact upon school and family systems (Whittingham et al., 2010).
I have been working at a school for children with intellectual and physical impairments. Many of the children at the school have CP, each with varying degrees and impairments. There is one particular teenage boy at the school with CP, he is unable to walk and is therefore in a wheelchair, he struggles to communicate clearly with words and he has some behavioural problems. His peer interactions are not very good; many of the other learners are scared of him as he can be aggressive. If someone stands close to him he will grab your hand or clothes and hold on very tight and not release your hand. These behavioural problems are associated with his diagnosis of CP (Sipal et al.,2009).
Due to this boy’s behavioural difficulties with the other learners he is often isolated from the rest of his class and peers his age during class, break times and from group activities. He is placed in the back of the classroom clear from any other learners and with a broom stick through the wheels of his wheelchair to prevent him from wheeling himself around the class to interact with the other learners. He is therefore wheelchair bound, isolated and immobile as his ability to wheel himself around is taken away. Although he cannot communicate well with words he often looks agitated and distressed throughout his day at school as he sits remotely in the playground and classroom.
The school has been isolating and disabling the learner due to his behavioural problems and their concern for the fellow learners in the school, however is this right? The learner has CP and multiple associated impairments as a result leaving him in a wheelchair. He has the function of his arms to be able to wheel himself in his wheelchair however his freedom to do so is taken away from him and restricted. This poses the question of whether this exclusion is ethically correct? The learner comes to school however he is denied many of the benefits of the school program that the school prides themselves on.
According to the South African constitution (1996) everyone has the right to a basic education and everyone has the right to freedom of movement. In this boy’s case are his rights being compromised? Is he getting the best out of his school program by being seated remotely in the classroom? Behavioural problems should be dealt with appropriately within the school’s discipline rules. However if a behavioural problem is challenging to change and the learner cannot understand what he is doing is wrong the question of whether it is acceptable to isolate the child and take away his ability to move freely is raised.
Seeing this boy in this situation made me feel heart sore for him. From an outsider’s perspective, as a visitor at the school and a student physiotherapist, the boy looks unhappy and aggravated. My initial instinct was to do something to change that or to help him. However this is not as easy as I had thought being an outsider and a student to the school. Once I brought up my concerns with the clinician and some of the other staff they said nothing could be improved and that is the way they were handling the situation. This was difficult to hear as being a physiotherapy student my first instinct is to want to help. Looking at it from the school’s perspective they are compromising one child’s rights for many other children. By isolating him they are minimising fear among other learners and decreasing any possible conflict situations. The other learners may fear the boy as he is isolated this may lead the learners to think there is something to fear due to his separation. His speech is compromised and he often shouts out of agitation, this is scary for some learners however it may be reduced if he was included into school activities more as he may feel left out and agitated however he can’t clearly communicate that.
A key aspect of improving behavioural problems is understanding why the child is behaving the way they are. However this process can take time and is difficult when the child has speech and communication impairments (Whittingham et al., 2010). Techniques such as picture boards could be an option for the child as a means of communication at school. The child may be agitated and aggressive as he cannot communicate what he wants and changing his behaviour is a way to catch someone’s attention. For the school isolation of the learner is the easiest option as resources and time is limiting in a school environment. The boy may not be getting the attention he may need to improve his behaviour as there are many other learners who need to be managed and the facility does not allow for one on one attention all the time. Although the child spends a couple hours of his day at school, he spends predominantly most of his time at home.
Having a child with CP can put strain on a family system however that family system can have a positive impact on the child’s behaviour too (Whittingham et al., 2010). Implementing some behavioural management methods at home could improve this child’s situation. The family may have more time and attention to give the boy than that of the school staff. However this is not always straight forward as families have many other stresses and daily chores (medication administration, assisting with mobility and daily activities etc.), to be completed with a child with CP as well some parents having other children (Whittingham et al., 2010). This leaves minimal time in the day for any new intervention/activities for the family.
This is a challenging situation where one learners behaviour has lead him to be treated differently to help create a more conducive calm school environment for the fellow learners. The boy may not understand why he is treated differently and he cannot communicate how he is feeling therefore making this a complicated situation. A child should be dealt with appropriately if they are behaving badly, however this is challenging when a child cannot understand or cognitively process that what he is doing is socially unacceptable. Family systems are a vital part in CP management however implementation and time management problems arise in reality. Therefore changing or improving the child’s behaviour is challenging and controlling the environment becomes the next best option for the school.
References:
Rosenbaum, P. et.al. (2005). Proposed definition and classification of cerebral palsy, April 2005. Developmental Medicine and Child Neurology,47(8), 571-576. Retrieved from https://www.cambridge.org/core/journals/developmental-medicine-and-child-neurology/article/proposed-definition-and-classification-of-cerebral-palsy-april-2005/E74085EC032F818F14A5A1C1C2A30CD0
Sipal, R. et.al. (2009). Course of behaviour problems of children with cerebral palsy: the role of parental stress and support. Child: care, health and development,36(1),74-84. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2214.2009.01004.x
South African Government. (1996). Constitution of the Republic of South Africa, 1996. Retrieved from https://www.gov.za/documents/constitution-republic-south-africa-1996
Wittingham, K. et.al. (2010). Responding to the challenges of parenting a child with cerebral palsy: a focus group. Disability and rehabilitation, 33(17-18), 1557-1567. Retrieved from https://www.researchgate.net/publication/49653111_Responding_to_the_challenges_of_parenting_a_child_with_Cerebral_Palsy_A_focus_group
3 thoughts on “Behavioural management of children with Cerebral Palsy”
Great job Emma. I really enjoyed your piece. It is sad to read how the school is treating this boy who can’t even defend himself. I understood your dilemma of should one boy be kept isolated to ensure the safety of others. Your argument was clear, but I want to know are you going to stand back and say or do nothing about the situation or say something to thoses involved. I see you spoke about from the school’s perspective and what about your perspective. You can maybe talk about more about your feelings on the situation and how you would approach the situation as a physiotherapy student. You can maybe talk about by looking at literature of a better soultion as how to deal with a child with a behavioural problem. As one child can turn into more children. Hence, the school can’t do the something for every child that enters the school with behavioural problems. You have good referencing. Have you considered to look at literature that looks at how to “handle” or approach a CP child with behavioural problems so he can be included in school activites. Once again great topic, it makes one wonder, should one child’s rights be violated in order to protect the rights of the other children.
Hey Emma-Leigh. I thought your topic as well as your writing was excellent. I think it is such a difficult situation to be a part of, even if you were just observing the situation as a student physiotherapist. I thought you used the literature well in the first paragraph to give the reader a nice introduction into the topic. You set the scene nicely in the 2nd and 3rd paragraph, so it remained easy to follow exactly what was happening.
You gave a good account on the schools perspective of why they are doing what they are. However, I do understand that you are not able to give a personal “yes I agree with what they are doing” or a no “I’m not agreeing”, but I would have liked to hear more about how did you feel about the situation, without necessarily picking a side.
Also, I think you can look at what the literature say about solutions to cases where one needs to think about the individual as well as the majority. I know you referred to what the constitution says about limiting a person’s movement, but maybe adding more literature regarding this topic will give the reader a better understanding on whether something can be done about this situation or that what they are doing is in the best interest to the specific child and the majority of other children.
I hope these comments helps you but in general I thought your piece of writing was great.
Well done, Emma! This is an excellent piece, I like the fact that you consider each and every aspect of the situation. I particularly like the fact that you considered the actions of the pupil yet also brought forward the school’s policy and what they pride themselves on and how that ultimately results in some form of violation. It is however a very complex situation that does indeed require careful consideration. The piece is well written, and quite detailed. It is evident that you made use of quite a few references to explore the situation from various perspectives which is good. Have you perhaps considered consulting literature that focuses on strategies that may potentially assist schools in dealing with situations similar to yours and maybe also research strategies that may be of assistance to physiotherapy and/or medical students should they encounter these kind of situations within a clinical setting? I think that would be of great help and may potentially enable you to adopt those strategies and implement them within the clinical setting. Your writing piece if definitely a job well done !