THE JOURNAL OF SCHOOL HEALTH 241

SOME CHANGING CONCEPTS IN THE EDUCATION OF PHYSICALLY HANDICAPPED CHILDREN

VIVIAN ELLIS, ED. D.* Associate Supervisor, Education of the Phvsically Handicapped

New York State Education Department

Educational practices, unlike feminine fashions, are not sub- ject to sudden and radical changes. Revisions in a basic philosophy are of gradual development and often it is only by taking a long look backward that we realize that there have been changes. There is strictly speaking no “new look” in the special education of the physically handicapped. This discussion will not cover all of the areas in this important field of education. To some of you many of the points to be considered may seem obvious and of minor importance but they will be problems which have been presented in the schools of New York State during the past school year.

A considerable number of children have disabilities and limi- tations so severe that it is impossible for them to make normal progress in school without special services, instructional tech- niques, equipment or a combination of these adjustments. Justi- fication for special educational programs for the physically handi- capped lies in the fact that these children have special needs and the schools can provide special services to meet these needs.

For the provision of certain types of services and at the same time to keep costs within reasonable bounds, the establishment of special classes is advisable. The value of the services will be greater than the disadvantages of segregation. When there ceases to be a need, the child should be returned as quickly as possible to the regular class. The point should also be brought out that segre- gation without the provision of special services cannot be consid- ered as a justifiable part of an educational program.

We, as educators, are dependent upon you physicians for we realize the necessity of having proper medical diagnosis. For many of these children, it will mean that medical specialists should be consulted and should assist in planning an educational program which will meet the needs of the child. We are also aware of the necessity of maintaining close medical supervision of the children in these classes throughout the school year. If a child is seriously enough handicapped to warrant placement in a special class, he

*Paper presented at the Annual Meetings of the New York State Asso- ciation of School Physicians and the New York State School Nurse Teachers’ Association, Saratoga Springs, New York, July 20, 1948.

-

242 THE JOURNAL O F SCHOOL HEALTH

will be in need of more medical attention than is given to normal children.

Following the discovery of children with serious physical defects, careful planning is necessary so that proper adjustments and services can be provided for each child. I t sometimes happens that not enough individual study is made of these children and, even though they are placed in a special class, their needs are not being met and I regret to say that sometimes children have been placed in these classes through expediency rather than necessity.

One of the problems that needs to be faced and met is that of providing adequate parent education. So often i t is found that a child who, for instance, has a serious visual defect is denied the benefits of placement in a sight conservation class because the parents do not fully recognize the opportunities being offered and consider that this is a stigma rather than a privilege. Closely related to this is the need for the school physician to give guidance to school administrators and to teachers as to the physical condi- tion of the child and the needs and the services which will be neces- sary to help him make an adequate adjustment in school. For instance, principals and teachers sometime object to the children in special classes going into regular classes for part of their work. They often have the feeling that the teacher of the special class is trying to evade responsibilities. They need to be helped in under- standing the value to a physically handicapped child of partici- pating in activities with normal children. To correct a physical defect at the expense of creating a personality problem o r malad- justment is doing an injustice to the child.

Another point that should be made in regard to the coopera- tion of the school physician and the school administrator is that, on the other hand, it must be realized that the school administrator is responsible for the carrying out the program. A physician should guide and make recommendations, but the actual educational plan- ning and supervision must be left to the administrator.

What has been said has been general and could apply to any type of physically handicapped child in any situation. In New York State there are special classes for partially sighted children, for those who are deaf and severely hard of hearing, for those who are physically below par and for the cardiac, orthopedic and cerebral palsy children. Time does not permit a detailed discussion of these various types of classes. There are, however, a few problems which should be brought to your attention.

First, there is a need for the re-evaluation of the educational

THE JOURNAL OF SCHOOL HEALTH 243

provisions being made for physically below par children. In the early development of these special classes, emphasis was placed on the care of “pre-tubercular” children. Conditions such as anemia and malnutrition were thought to be predisposing factors leading to tuberculosis and, in these early classes, a great deal of emphasis was placed on the importance of fresh air, food and rest. Accord- ing to our modern medical findings, medical authorities now ques- tion this concept of a “pre-tubercular” condition. Yet in the 297 health improvement classes in New York State we still find that a majority of children are placed there because they are under- weight, nervous, fatigued or under-nourished. I understand that to diagnose malnutrition accurately requires clinical procedures and careful study. At any rate, the fact that many of these chil- dren were placed in these classes for a period of several years shows that the type of service provided is not meeting their need.

In the early 1900’s when many of these classes were estab- lished, school conditions were quite different. The change in mod- ern educational practices makes us wonder if some of these classes are now wholly justified. For instance, in the modern school, we find a less formal, more flexible program. We also find that there is more emphasis on health service and health education for all children. Within recent years, school lunch programs have been established and are now serving over 50 per cent of the children in New York State. ( In other words, i t is not necessary to segre- gate a child in a special class in order to give him a glass of milk or a cup of soup). Facilities should be available in every school for rest for any child who needs it.

We find, too, a more adequate provision of personnel such it5

the school physician, the school nurse teacher and the dental hygiene teacher as well as the visiting teacher, health teacher, and guidance directors. Another important change in the modern school is the improved condition of school buildings in regard to sanitation, ventilation, heating, lighting, etc.

A convalescent type class may be advisable for certain types of children. These classes should have flexible admission and dis- missal policies. A child may need the service for only a short time following an illness. As I have mentioned before, adequate medical supervision should be given to these classes including careful study before admission or dismissal and frequent check-ups while the child is in attendance.

There are many services which can be provided without hav- ing the child placed in a special class. They would include trans-

244 THE .JOURNAL O F SCHOOL HEALTH

portation, rest periods, lunch and supplementary feeding as well as parent education. I think you would be interested in knowing that in one community in this state where four health improvement classes have been maintained, consideration is being given to an experimental program in which some of these classes will be dis- banded and a more comprehensive type service provided instead. In addition to the usual health services, this community plans to establish a nutrition clinic where laboratory tests and other diag- nostic procedures will be used more accurately to determine the needs of the child. I t is also planned to employ home counsellors who will go into the home and work with the family, giving guid- ance on nutritional problems, sanitary conditions, health habits, mental hygiene, etc. I think this is a plan that merits considera- tion by school authorities in other communities.

Another specific problem concerning physically handicapped children is that of making adequate provision for cardiac children in our schools.

The educational provisions for a cardiac child should depend upon the cardiac classification which, in turn, will be determined by the presence or absence of rheumatic activity and the amount of residual cardiac damage. The cardiac classification and, thus, the educational needs are likely to vary considerably during a year’s time. This makes evident the desirability of providing a flexible program and also emphasizes the need for continuous medical supervision of these children.

Standard classifications such as those established by the New York Heart Association should be used if possible. While physi- cians understand that the term “cardiac” may cover a wide range of disability, the average teacher and school administrator does not have this same understanding and, therefore, does not realize the need for various types of programs. If in designating a child as cardiac you could classify him as I, 11, I11 or IV, the schood per- sonnel would be able to understand this better.

In the active or acute stage, a child should be hospitalized, placed in a sanatorium or receive proper care at home. He would be classified as IV and no education should be provided.

In the sub-acute or convalescent stage, the child should be in a sanatorium, convalescent home or quiet in his own home. He would probably be considered as class 111, hospital and home teaching should be provided.

In the recovered or quiescent stage, children should attend school. For those in class 11, the activities must be slightly limited.

THE JOURNAL O F SCHOOL HEALTH 245

They should either be placed in a special class, or special services and modifications of the regular program will be necessary. A child may be able to return to school at an earlier date if he is placed in a cardiac or health improvement class. Such a placement may help in the hardening up process and would be a transition between home or sanitarium care and the return to a regular class.

Those in class I are also in the recovered or quiescent stage, but will be able to carry on all ordinary activities, if properly supervised. Competitive athletics, however, or games which demand sudden physical o r emotional strain should not be per- mitted. These children should be placed in a regular class

Another phase of special education that should be considered is the care of orthopedic children. Many communities in New York State have classes for orthopedically handicapped pupils in their schools. Children are placed in these classes primarily because they need physiotherapy or because they are non-ambulatory and need assistance in getting around. They may also be placed in this class if special teaching technics are needed such as would be the case with cerebral palsy children.

I would like to tell you a little of the present philosophy in regard to physiotherapy. Within the last few years, the “Daily Demands” program has been developed by some of our leading orthopedists and this program is being introduced into the schools. It is an extension of the former physiotherapy program and trains the pupil in physical skills that are needed in daily living, such as going up and down stairs, getting on and off a bus, crossing the street in the time of a traffic signal, eating, dressing and undress- ing themselves and the manipulation of household fixtures such as faucets, doorknobs, dial telephones, etc. The training of muscles, as desirable as that may be, is not an end in itsef-it is the appli- cation in terms of self-care and daily living that is the ultimate goal for which we are working.

Another recent development in the field of orthopedics is the increased interest among lay people in the field of cerebral palsy. For a number of years, about one-third of the chidren in the ortho- pedic classes of New York State have been children who are handi- capped by cerebral palsy, but recently, 8 centers or classes have been established specifically to care for these children and several more will probably be opened within the near future. These pro- grams are more expensive than other types of educational pro- grams because of the fact that these children need so many types of services, such as physio-therapy, occupational therapy, speech

246 THE JOURNAL OF SCHOOL HEALTH

development and matron service in addition to the services of a teacher who is specifically trained in this field.

In these centers €or cerebral palsy, children are being admitted at nursery or kindergarten age, usually the lower limit is four years. It is realized that with this particular type of disability treatment should be begun at as early an age as possible.

There is one problem that is constantly arising in these centers for cerebral palsy, and that is in regard to the mental ability of these children. In many places, the parents of fecble minded children have “jumped on the cerebral palsy bandwagon” so to speak, and are putting a great deal of pressure on the schools to have their children admitted to these classes. Of course, one must bear in mind the fact that estimating the mental ability of cerebral palsy children is exceedingly difficult. However, we must, on the other hand, use considerable caution so that these classes will not become filled with uneducable and untrainable children. After having been tested by the school psychologist or the mental hygiene clinic, if thcrc is any doubt it may be well to admit these children for a short period on trial, but this trial period need not cover :I

full school ycar. In the Schulman report of the Commission for the Study of

Cerebral Palsy which has recently been published, the statement is made that the number of known cases in New York State is 6,000, and the minimum estimate of the number probably requiring attention is 10,000, Of this number, 1,000 are being cared for by the Department of Mental Hygiene in the various state schools. 625 are attending special classes in the public schools ; 71 are being provided with home teaching, transportation or speech correction through the children’s court; 51 are reported as exempt from school and of these, 18 are reported as being feeble minded.

According to standard estimates, we would expect that one- third of the cerebral palsy children would be very low intelligence, one-third would be mild cases who could adjust themselves in the regular class, and one-third would be mentally normal but scvcrely handicapped physically. If we take the figure of 6,000 linown cases and apply this formula, we find that thcrc would be 2,000 children who should be receiving special education and, as has just been stated, there arc at present only 745 receiving this service. One reason for this discrepancy is that very often these children are not reported to the State Education Department.

Tn addition to special classes, educational provisions such as home teaching, transportation to a regular or special class, and

THE JOURNAL O F SCHOOL HEALTH 247

tuition may be provided by the local boards of education or through the children’s court. If a child is mentally capable of learning but is confined to his home because of a physical disability, school authorities have a definite and moral responsibility for providing suitable education unless the condition is temporary or in the acute state, and the child is too ill to receive instruction. There are cer- tain types of classes for whom court orders for home teaching cannot be approved. Children with visual handicaps and those with hearing handicaps are not eligible except for a few very unusual cases. Mentally deficient children with I.Q.’s under 50 are also ineligible. Home teaching should always be considered as a last resort and should be provided only when it is impossible for the child to attend school.

In closing, let me express the appreciation of the Bureau for Handicapped Children for the cooperation which has been given by school administrators, the physicians and the school nurse teachers. The concern of everyone is to discover the children who need help and to provide them with the proper type of educational, medical and therapeutic service. This means that there must be a coor- dinated program as we are working with children whose needs are often numerous and complex.

Dental Health,-At least 95 per cent of the American people suffer from some form of oral infection. Studies indicate that American children between six and 18 years of age require about 244 million fillings to place their mouths in a healthy condition and that once this bacldog of accumulated need is met dentists would have to insert an additional 33 million fillings per year to fill the annual increment of cavities in that age group.

Cavities develop in children’s teeth at a constant rate, one carious tooth every 16 months, or three-fourths of a tooth per year. Among adults there i s an average need for 4.5 fillings and more than two extractions. About one out of every four adults needs one or more bridges, while one out of every six requires full den- tures. Ur. Lon W. Morrey, Editor, Journal of the American Dental Ass* cialion.