An occupational therapist’s approach to the vocational problems of the cerebral palsied

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AN OCCUPATIONAL THERAPISTfS APPHOACH TO THE VOCATIONAL PROBLEMS OF THE CEREBRAL PALSIED

A Thesis Presented to the Faculty of the Occupational Therapy Department The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Arts

hy Estherine Avery Connell August 1950

UMI Number: EP62274

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T h i s thesis, w r i t t e n by

...... Mrs* KatherinB Avery Connell under the guidance of

h.9X....F a c u lty C om m ittee,

and approved by a ll its members, has been presented to and accepted by the C o u n c il on G ra duate S tudy and Research in p a r tia l f u l f i l l ­ ment of the requirements f o r the degree of

Raster of Arts

Date.

August 28, 195D

Faculty Committee

Chairman

■Xa

"~\S

ACKNOWLEDGMENTS The author wishes to express sincere appreciation to the staff members of the Orthopaedic Hospital Cerebral Palsy Unit, the Los Angeles County Crippled Childrenfs Society, and the Bureau of Vocational Rehabilitation, whose cooperation made possible the gathering of clinical data for this study, and to Miss Margaret Rood, Miss Charlotte Ander­ son, and ^iss Bekke Engelke of the Occupational Therapy and Physical Therapy Departments, The University of Southern California, under whose guidance and direction this thesis was written*.

TABLE OP C O M M I T S CHAPTER I*

PACE

XHTROBHGTIOH . . . . . . . . . . . . . . . . . . The problem

• • ...........

. • » • * • • • •

2

Statement of the problem •

2

Importance of the study

• » » • • • » « • •

2

Definitions of terms used

• • • • • « , « . ,

3

Cerebral palsy •

3

Rehabilitation

4

Occupational therapy . • « • « • • • • • • •

5

Occupational therapist

6

Methods of procedure

7

Sources of material

8

Limitations of the study . . . . . . . . . . .

9

Organisation of remainder of the thesis II.

X

• • ,

REVIEW OF THE LITERATURE . . . . . . . . . . . .

10 12

Literature on rehabilitation and job placement of the physically handicapped

* . . * • • •

12

Literature on vocational problems of the cerebral palsied Limitations of previous studies III.

15 . . . . . . .

25

FACTS ABOUT CEREBRAL PALSY . . . . . . . . . . .

27

Causes Incidence

29 • • • • • • • • • • • • • « . . • *

33

Iv

CHAPTER

PAGE Classification and characteris tics

IV.

• • • • • •

35

VOCATIONAL t r a i n i n g a n d j ob placement of t h e CEREBRAL PALSIED

41

Extent of the problem * « • « • • * • * • • • •

41

Statistics The need

•

41

..............

42

Obstacles to employment • • • • • . * • • * • • Physical handicaps

43

* • « • * • * • • • # • *

Emotional and psychological factors • . . Attitude of employers

43

* •

..........

46

Facilities for rehabilitation • • * • • • • • • Historical background • • • • • • * • « Private agencies

49

•••

49

.............

51

Government agencies • V.

44

55

CALIFORNIA'S PROGRAM FOR THE CEREBRAL PALSIED . . Services and facilities provided by the state

*

58 58

Diagnosis and treatment • • • • • • • • • • •

58

Special education and training

. . . . . . .

62

Vocational rehabilitation » . . . . . . . . .

63

Non-official agencies and organizations * #

. .

66

California Society for Crippled Children

• •

67

The United Cerebral Palsy Association of Los Angeles County Other voluntary organizations

70 71

V

CHAPTER VI.

PAGE TEE QUESTIONNAIRE ATI) I ;fTEH FRET ATI Oil OP RETURNS

75

Data compiled from answers to questionnaire . .

74

Number of cerebral palsied who received vocational training » • * » • • •

75

Humber placed on jobs after vocational training

• • # * • * * • « • • » • • • • •

76

Types of employment in which the cerebral palsied were placed » * » • * « • * » * . •

76

Specific disabilities of those who became employed

• • * • * » • * •

• • » » . • • •

79

The consideration of various factors in re­ lation to the employment of the cerebral palsied in certain vocational fields Suggestions and plans for the future

VII.

. • •

* * * * *

81 85

Suggestions and other information offered . *

85

Plans for the future

87

• » • • « • • * • * « •

CASE STUDIES OF INDIVIDUALS TESTED

.............

Group of employed cerebral palsied Individuals Case I

Case III

* . * . . . . * * • * . * • . * * .

Case IV . . . . . . . . . . Case V

88

• * • • • • • * • • * . » • • * • » .

Case II • * * • • * * * * • * * * * « * * .

. . . . . . . . .

88

88 *

89 90 91 92

vi CHAPTER

PAG 13

Croup of young adult cerebral palsied without

VIII.

work experience •

93

Case A

94

........... • . . « * • • • • • * »

Case B

96

Case C

97

Case D

98

Case E

99

TECHNIQUE AND EE STILTS OF THE TEST . . . . . . . Nature and purpose of the test

. . . .

nature of the test

. . .«

101 101

. . . .

102

Purpose of the test • « . . « . . • • • * «

102

Technique and adraInis tra 11 on

104

Technique

104

Administration

...

104

Groups tested

105

Employed cerebral palsied Individuala . . .

105

Young cerebral palsied adults without work experience

•

. 106

Scoring and interpretation of results « • . . Methods of scoring Tabulation of scores

• . . . . . . . . . . . . . . . . .

. . . . .

Individual profile charts XX.

IDS 106 108 108

THE ROLE OF OCCUPATIONAL THERAPY WITH REGARD TO THE VOCATIONAL PROBLEMS OF THE CEREBRAL PALSIED 116

vii CHAPTER

PACE Training In activities of daily living Feeding training

« • • •

* * • • « * * * • • * • » «

Dressing training Personal hygiene

117 121

...............

122

Communication • • # • * • * • • • • * • * • «

122

Utilities

124

Locomotion and travel

125

Crafts and pre-vocational activities

• • « « ♦

Cooperation with other agencies of the cossaunity X.

117

SUMMARY AKD COUCLUSI0BS » • • • • • « . • • * • • Summary Conclusions « • • • • « • «

125 127 129 129

• • « •

Recommendations for further study • • • * » • •

130 136

BIBLIOGRAPHY •

139

APPENDIX

149

LIST OF TABLES TABLE I*

PAGE Humber of Cerebral Palsied Trained and nlaced 1948-1949

XI.

. . . . . . . . . . . . . . . . . .

Humber of Cerebral Palsied Placed in Jobs* 1948-1949* Classified by Type of Employment

III.

151

.

Classification of Employed Cerebral Palsied by Type of Disability * • • . • • • • * • * * • *

IV.

77

80

Relative Importance of Various Faetors Concerned with Employability of the Cerebral Palsied in Certain Fields

V.

81

Individual Time Scores on Each Activity of the Dally Living Activities Test for the Cerebral Palsied

•

161

LIST OF FIGURES FIGURE

PAGE

1*

questionnaire

• • • •

* • » • • • • » • • * • • »

Zm

The Relative Importance of Certain Factors In

149

Estimating the Employability of the Cerebral Palsied in Various Fields

• • • • • • • • • • «

3.

Daily Living Activities Test • « . « * . . .

4*

Profile Chart (Case A) Dally Living Activities Test for the Cerebral Palsied

5*

* • • • * • * . , •

110

* • » • • * • « «

..............

111

•

113

Profile Chart (Gase D) Dally Living Activities Test for the Cerebral Palsied

8*

156

Profile Chart (Case G) Daily Living Activities Test for the Cerebral Palsied

7.

*.*

Profile Chart (Case B) Daily Living Activities Test for the Cerebral Palsied

6*

82

114

Profile Chart (Case E) Daily Living Activities Test for the Cerebral Palsied

» • • » • • • • •

115

CHAPTER I IN TR0DT7CTI OH A1though the cerebral palsied have been with us since time began, It has been only in comparatively recent years that any concentrated effort has been brought to bear on an attempt to help them*

The public Is becoming increasingly

aware of the problems created by the condition which Is popularly, though erroneously, known as "spastic paralysis*ff Although many have yet to learn that spastic paralysis Is only one of & group of conditions Included under the classi­ fication of "cerebral palsy," the public Is generally aware that these people can be helped by special treatment and training*

As a consequence, more and more facilities are

being provided to offer the help so badly needed by those handicapped by this condition* The emphasis at present seems to be on case finding, education, and treatment of the cerebral palsied childj auth­ orities agree that early diagnosis and treatment are of primary importance if the maximum benefits are to be obtained from the treatment program*

Special techniques have been

developed to teach the cerebral palsied child to walk, to talk, to feed and dress himself, to read, and to write* Educators are making every effort to see that the cerebral palsied child has the same educational opportunities that

2 th© wnornm.lw child has*

Special schools and classes have

been set up to deal with the educational problems peculiar to this type, of disability*

Clinics have been established

to which a cerebral palsied child may go, at public expense, for any type of specialised treatment he may need*

One can

not but wonder, as he contemplates the tremendous expenditure of time, effort, and-money that goes into such treatment pro­ grams, latiat the future may hold for these children* I*

THE PROBLEM

Statement of the problem*

It was the purpose of this

study (1) to review the facilities now existing in the United States, and particularly in California, for the vocational training and placement of the cerebral palsied; (2) to study, from an occupational therapist1© viewpoint, the abilities, potentialities, and limitations of a selected number of cerebral palsied cases, with regard to vocational aspirations and vocational success; (3) to determine the place of occupa­ tional therapy In helping the cerebral palsied to meet their voc&tional prohlems• Importance of the study*

The final goal of all treat­

ment programs, of education, and of vocational training, is to ©quip the handicapped Individual to achieve Independence and to make a satisfactory adjustment to his handicap*

What

3 is the advantage, then, of providing elaborate services for teaching and training the cerebral palsied, if they must later learn that there is no place for them in our modern, competitive scheme of things?

ho one can deny that the recent

arousal of interest in the problems of the cerebral palsied lias resulted in the establishment of facilities which have long been needed, and in improved methods of treatment and education, the results of which are most gratifying*

If the

final goal of social and economic independence Is to be reached, techniques and facilities must also be improved to help the cerebral palsied achieve the greatest vocational success possible*

Hie occupational therapist, as a member

of the team working with the cerebral palsied, should be aware of the vocational problems as well as the medical prob­ lems * Occupational therapy and vocational rehabilitation, although striving for the same goals, have heretofore worked more or less independently of each other*

If their efforts

could be more closely correlated, utilizing the specialties of each, die common, objective of economic and social independ­ ence would he more likely to he achieved* II.

DEFINITIONS OF TEH!JS USED

Cerebral palsy* Cerebral palsy may be defined in general as an Impairment of muscular control, due to disease

1 or* injury to tho ’ brain*

It was described by Phelps

as a

condition, resulting from damage to tho brain, which interrupts the outgoing portion of the nerre circuit and prevents coord­ inated responses.

The tern was more fully defined by ,Tensen

and hackle in the words: Cerebral palsy may be defined as an Impairment of motor function by injury to certain portions of the brain which govern muscular control. The manifesta­ tions of cerebral palsy vary greatly In degree and extent* although over half the cases show some involve­ ment of all extremities and of the speech mechanism. Different areas of the brain may be damaged* causing different types of cerebral palsy. Spasticity* athetosis, rigidity, ataxia, and tre7mn;^"are"'Tne ones commonly recognized, With the largest number of cases falling Into the first two groups Rehab il 1ta11 on .

Strictly speaking, the word 11rehab­

ilitation* is not applicable to one who has been handicapped since birth, because It implies restoration to a former status. The word is defined here, however, because the cerebral pal­ sied are eligible for the vocational rehabilitation services which are provided by the states with the assistance of th© federal government.

The definition adopted by The Council

on Rehabilitation is perhaps as concise as any to b© found, 1 Winthrop Morgan Phelps and T. Arthur Turner, The Farthest Corner (Elyria, Ohio: The National Society for Crippled children and Adults, Inc., n.d.), p. 3. 2 Carol K. Jensen and Roma ine P. ’Tackle, Twenty Questions on the Cerebral Palsied Child in OalIfornla (Sacramen to• CaTl^omia State Department of Education , 1^48) , p. 1.

and the one generally accented: Vocational rehab 115 ta tion. is the restoration of the handicapped to the fullest physic si , mental, social, vocational, and economic usefulness of Y»*hich they are capable

Hie term !rrehab III tation* has acquired

new connotations In accent years, as a result of civilian and military experience, wrote Dr* Kessler 4 who went on to say: It lias cone to be regarded as a creative process in which the remaining physical and mental capacities of the physically handicapped are utilised and developed to their highest efficiency. It is an organized and systematic method by which tho physical, mental, and vocational powers of the individual are Improved to the point where he can compete with equal opportunity with the so-called nonhandIcapped*5 The word ^rehabilitation1* as used in this paper, then, carries the broader meaning without the implication of re­ storation to a former status. Occupational therapy.

As occupational therapy has

come Into Its own as a profession, many definitions have appeared, some brief and some lengthy*

Willard and Spaok-

3 'Symposium, May 25, 1944, The National Council on Rehabilitation., hew York, as cited by The Committee on the Severely Handicapped, Rehab illtatlon Facilities for the Severely Handicapped (SKicago: ’SSeT Ha'ilonal’ "Socle ty For Crippled Children and Adults, Inc*, 1947), p. 2.

4. Henry H* Kessler, Rehabilltation of the Physically Handicapped (New York; Columbia TinIvors ity PressT r -----T o* lllj f f . " ... .1*

*

H. . . ! — . ,

5 Loc. cit.

»

6 6

man

briefly defined occupational therapy as any activity,

mental or physical, which is medically prescribed and pro­ fessionally guided to aid a patient In recovery from disease or ■injury.

Elaborating upon this definition, they went on

to say, ^Therapy means treatment, and occupational therapy is treatment by .means of participation in occupations or activities devised to attack specific problems resulting 7 from disease or injury,” Occupational therapist. Any therapeutic activity must be supervised by on© trained not only to understand both the human and medical problems involved, but also to 8 give directions for details of performance, The person so qualified is described in the Manual of Occupational Therapy as follows: The occupational therapist is professionally trained to carry out the physician’s prescription through the selection and adaptation of activities which meet the patient*s physical and psychologic needs. The activi­ ties used as treatment must be sufficiently interesting to the patient to motivate him to active participation. The therapist also provides the physician with in­ formation regarding the patient’s symptoms, reactions and. progress while under observation*^ 6 Helen 3. Willard and Clare 5, Spackman, editore, Principles of Occupational Therapy (Philadelphia: J, B,

IT p iin c o t’l ^m pany, 115T7r; p T W T 7 hoc, cit, 8 xbid., p , 11,

9 Manual of Occupational Therapy (Chicago: American Me dical As s o d a tToh, re p'rin ted J u l y " 943 5, p , 5 *

7 Part of the occupational therapist1s job Is to keep a record of the treatment administered to each patient,

III.

METHODS OF PROCEDURE

For general background material, as well as factual data, a survey was mad© of available literature related to the problem.

Personal interviews were held with a number of

occupational therapists, physical therapists, vocational re­ habilitation officers, psychologists, and other professional people working with the cerebral palsied.

To gain additional

information, questionnaires were sent to a number of Insti­ tutions, organizations, and agencies interested in the re­ habilitation of the handicapped.

The returns from these

were then tabulated and an Interpretation of the results was presented. Case studies were made of a group of five cerebral palsied Individuals who had achieved some degree of vocation­ al success, and of another group composed of five young cerebral palsied adults who were not employed at the time, but who would soon be ready for vocational training and subaequent placement. In an effort to measure the ability of the cerebral palsied Individual to perform certain activities necessary for independence In daily living, a performance test called Dally Living Activities Test for the Cerebral Palsied was

B

devised and administered to the individuals comprising the two groups described above.

On th© basis of comparison*

using the employed people as a control group* an evaluation of the results of the test was graphically presented.

At an

appropriate place In this study* the test is described in detail, together with 'the methods and techniques of admini­ stration * IV.

SOURCES OF MATERIAL

The numerous books, pamphlets, and journals to which the investigator referred were procured from diverse sources* Much of the material was found in the libraries on the campus of The University of Southern California, including Doheny Library, the Medical Library, and the library of the Occupa­ tional Therapy Department*

The Journal of Rehabilitation*

to itilch reference was made, is the official organ of the National Rehabilitation Association*

The Crippled Child is

a magazine published bimonthly by The National Society for Crippled Children and Adults, Inc*, to whom the experimenter is indebted for other valuable material used in the study* Ho small-part of the factual material used was procured from tlrie Departments of Education and Public Health, of the State of California* Much useful Information was gained from interviews with personnel of the California State Bureau of Vocational

9 Rehabilitation, and of the Crippled Children’s Society of Los Angolas County*

Several physical therapists and occupational

therapists, experienced in the field -of cerebral palsy, were

also interviewed* The questionnaires were sent to various rehabilitation centers, curative workshops, sheltered workshops, and to each of the state bureaus of vocational rehabilitation in. the United States and its territories* V*

LIMITATIONS OF THE STUDY

The social and economic welfare of all handicapped people Is a national problem, deserving of consideration by professional and lay people alike4

The problems of the

cerebral palsied,, although more or less unique, are indica­ tive of those of many handicapped people*

In limiting this

study to the vocational problems of the cerebral palsied, the investigator did not mean to imply a lack of appreciation of the problems facing other handicapped persons*

On the

contrary, it was hoped that the findings here submitted might shed a little light on the situation as a vAiole* and contribute, in some small way, to the efforts being made to find a solution* An attempt was made to- present an over-all picture of the rehabilitation facilities in the United States, particu­ larly in California, and to describe the degree of success

10 which has been achieved in the vocational adjustment of the cerebral palsied.

Of necessity, however, personal interviews

and observations, as well as clinical studies, were limited to California. The scope of this problem-

lm

bo

great that, to attack

it thoroughly from all angles and perspectives, would require volumes.

The general approach, therefore. Is from the view­

point of Hi© occupational therapist, for which the investi­ gator Is best equipped by training and experience.

Ho attempt

was made, in this study, to approach all the possible facets of the vocational problem, nor to discuss all the possible contributions which the well-trained occupational therapist Is equipped to offer. VI.

ORGANIZATION OF REMAINDER OF THE THESIS

Chapter II will be devoted to a review of the recent literature pertinent to this problem, while in Chapter III the general facts about cerebral palsy will be discussed.

Vocational training and job placement services for the cerebral palsied will be dealt with In Chapter XV, and Californlafs program for the cerebral palsied will be dis­ cussed In Chapter V.

In Chapter VI an Interpretation of

returns from the questionnaire will be presented.

The ease

studies of several cerebral palsied individuals will be offered In Chapter VII, and Chapter VIII will contain In-

11 formation about the performance test given to the same people. Including a discussion of the techniques of administration, and an Interpretation of the results.

In Chapter IX, the role

of occupational therapy will he discussed in relation to the problem of the cerebral palsied*

The summary and conclusions

will he 'presented In 'Chapter X, together with recommendations for further study,

A bibliography and an appendix will make

up the last pages of the thesis*

CHAPTER X! REVIEW OF THE LITERATURE

As far as the Investigator was able to ascertain, nothing has as jet been published which Is specifically con­ cerned with the problems and responsibilities of the occupa­ tional therapist in regard to the vocational problems of the cerebral palsied.

Several books and articles were found,

however, which were considered of sufficient Interest in relation to the study to be included in this chapter. Literature on r©hah1111a11on and Job placement of the

physically handicapped.

“The Rehabilitation of the Disabled

from Bed to Job,** the subtitle of a recent book by Rusk and 1 Taylor, is perhaps more descriptive of the contents than is the title Itself*

Bernard M. Baruch, author of the Foreword,

had this to say of the hook: Long Identified with the rehabilitation of military personnel, veterans and civilians, the authors of this book have told the story of the remarkable advances mad© in rehabilitation in the military services and Veterans Admin1s trati on. The challenge which they present on making such opportunities available to the far greater number of disabled civilians Is one that we cannot ignore. The investment In rehabilitation is an Investment In the greatest and most valuable of our possessions, the conservation of human resources T'~X" Howard A. Rusk and Eugene J. Taylor, New Hope for the Handicapped (Hew York: Harper F Brothers Publishers, I B ? 9 l T W ppT “ Trr,r

2 Ibid., Foreword•

13 Brief reference was made to the unique problems of the cere­ bral palsied*

To occupational therapists, the opinion of the

authors that "retraininn in the basic physical skills of daily living is primary • » • for daily activity skills are 3 the basis for all subsequent rehabilitation processes," is of particular significance* 4 Bridges1 book was written specifically for the layman T^iose duties include the responsibility for the effective use of man power*

The factual information which he presented,

however, should be useful not only to the person who hires, selects, places and supervises men, bxit also to the pro­ fessional person whose interest centers around the rehabili­ tation of handicapped people,

Tho purpose of the book,

published as the result of a study started in 1944 by the Zurich Insurance Companies, was "to make a thorough investi­ gation of tho theory and practice of rehabilitation and to prepare a report of practical usefulness for the firm’s

5 policyholders*n

The study Includes a discussion of the

handicaps and obstacles to employment of the physically dis­ abled, and a brief review of the rehabilitation services which are available*

Included In the text are recommendations

& Ibid., p. 95. 4 Clark D* Bridges, Job Placement of the Physically Handicapped (Tew York; 'IcGraw-Vjill Book Company, inc., 1§46), $>£§ pp . 5 Ibid., p. v.

14 Tor modern methods of reporting physical examinations, of job analysis particularly designed for employee placement, and of matching the physical capacities of workers to jobs.

A

considerable portion of the text is devoted to non-technical descriptions of specific disabilities, designed to give the layman a basic understanding of anatomy and physiology, and the physical conditions that affect work capacity. Louise Heuschutz approached the problem from yet another angle, in her book Jobs for the Physically Handi­ capped

Written primarily as a guide and inspiration for

the handicapped themselves, the text was designed to meet the need for more information on the subject of vocations for the physically handicapped job-seeker.

After a brief

discussion of the principal types of handicaps, the remainder of the text is devoted to descriptions of numerous occupa­ tions which offer opportunities for self-support through individual effort to those handicapped persons who are unable to find regular employment in commerce or industry. Perhaps the best description of Yost and Gilbrethxs

7

book, Normal Lives for the Disabled,

may be found in the

introduction written by Lillian M. Gilbreth, and reproduced 6 Louise Heusehutz, Jobs for the Physically Handi­ capped (New Yorks Bernard Ackerman Incorporated, 1944), 240 PP* 7 Edna vost and Lillian Gilbreth, Normal Lives for the Disabled (New York: The r^acmillan Company, 1§~4'4), £¥6 pp.

15 in part as follows? This hook is intended for men and women who have become disabled and want to know what the future holds. The writerrs aim is to understand and state their problems clearly and sympathetically, and then help them work out the best possible solution. No matter how the handicap has occurred, in war or in civilian life, there is the same need to face it, to study it, and ultimately to use it. A recent book by Kessler9 includes contributions from many authors, each with special experience in the field of rehabilitation*

Interesting and authoritative material on

physical and vocational rehabilitation is contained In this work, which Includes a chapter by Wilma L. West, Executive Secretary of the American Occupational Therapy Association. Another chapter, dealing with rehabilitation of the cerebral palsied, was contributed by WInthrop M. Phelps, one of the foremost authorities on the treatment and training of the cerebral palsied. Literature on vocational problems of the cerebral palsied. Writing of the educational and vocational aspects of the cerebral palsy problem, Dr. Earl R • Carlson, who Is himself cerebral palsied, expressed the opinion that "every intelligent cerebral palsied person should have the right to § Ibid T, Introduction. 9 Henry H. Kessler, The Principles and Practices of Rehabilitation (Philadelphia; Lea L Febiger, l950),44& pp.

16 an education* Irrespective of the extent of the physical 10 disability,** For those too seriously handicapped to compete In a normal school environment* he advocated the estab­ lishment of special schools,' which should also be equipped to offer physical therapy, occupational therapy, speech therapy, and other necessary remedial activities.

In th© opinion of

the author, 19the movements of the cerebral palsied are less chaotic when he forgets himself in studies and other activities 11 that help him to attain a feeling of personal worth,** Re­ garding the vocational aspects, Carlson said that the cerebral palsied whose nervous system has a low threshold of Irritabi­ lity, cannot be expected to become as efficient as the normal Individual,

Such a person can not find happiness until he

has learned the limitations which his hyperactive nervous system imposes on him, and has been taught to cope with his shortcomings.

Several examples were cited of cerebral palsied

individuals who had been able to circumvent their disabilities by adjusting their ambitions to their physical capacities* Carlson concluded his article with these significant wordsi Why is so Much being done for infantile paralysis? .Because there are Individuals with poliomyelitis who have made a success. But there are very few individuals with cerebral palsy who have had a chance to be c o t © io ua'r1 R , Carlson, "Educational and Vocational Aspects of the Problem of the Cerebral Palsied," Journal of Rehabili­ tation, 12:2:24-25, 31* June, 1946* 11 Loc, cit*

17 successful. I feel that if we begin with the vocational end it will allow some of the so individuals to prove their

worth*12 In his book, Born That Wav, Carlson attributed much of the cerebral palsied person's difficulty in making a sat­ isfactory adjustment to the lack of understanding on the part 13 of the general public* Recognising the need for funds to establish institutions and special schools for the cerebral palsied, he felt that there was a still greater need for philanthropic gifts which could be used to offer employment to handicapped people who have no opportunity to earn their living.

nOnce the sens© of personal worth has been estab­

lished by the successful performance of remunerative duties,” he said, tfth© spastic can usually stand on his own feet 14 economically.” 15 Beaver and Brown emphasized the necessity for facing the problem realistically.

In their opinion, the majority of

cerebral palsied boys and girls should never attempt college, because the college expenses would be a serious drain on their 12 h o c cit. 15 Earl R. Carlson, Born That Taj (TTew Yorks Tohn Bay Company, 1941), p. 168. 14 IB id., p. 172. 15 George G. Deaver and Mary Eleanor Brown, ^Making Man Powers Vocational Rehabilitation of Those Handicapped by Cerebral Palsy,” Archives of Physical Medicine, 23:12:719727, December, 194& .

18 families, and after graduation they can rarely be expected to achieve professional success without considerable outside help*

Although they may possess superior intelligence, they

often find that their specialized training is of little value in finding employment, because of their odd facial express­ ions, speech difficulties, and the inability to write legibly or even to fold a sheet of paper*

In the opinion of the

authors, It would be much more practical to endeavor to evaluate the limitations and the abilities of each Individual, and then select a trade which the person can learn.

They

stressed the necessity for objectives In treating and teach­ ing the cerebral palsied child, and outlined the factors essential for vocational rehabilitation as follows % 1) Must be able to walk and to travel; 2) Must be able to take car© of himself as far as handling wearing apparel, eating, and bathroom necessities are concerned; 3} Must have some use of his fingers, since all trades require finger movements. In another article, written especially for parents of 16 cerebral palsied children, Reaver said that the greatest need is for parents to have a more adequate appreciation of the problem and wtfae application of modern knowledge and common sense.”

Although the services of physicians and

therapists are necessary in formulating exercises to develop ...... IS" George 8* Deaver, ”Latfs Prepare Them for Dally Living,” Spastic Review, 10s3:4~6, March, 1949.

19 the desired patterns of movement, he maintained that progress can he attained only if the parents or the individual carry out instructions for continuing the exercises at home* The writer considered physical restoration to he of primary im­ portance, since education In Itself has no commercial value* *Unless a person is able to walk and travel, use his hands, and have adequate speech,” he wrote, **he is unable to use 17 the knowledge he has acquired *n The vocational problems of the cerebral palsied were attacked even more directly in another recently published 18 article by Denver* His realistic approach is indicated by these words? There is no evidence at present which indicates that the number of children born with cerebral palsy will be reduced* Prom a humanitarian standpoint and that of sound economics we cannot have these handicapped persons in our midst living as invalids, requiring care and support* and totally unproductive He stressed again the four basic physical requirements for daily living, which seem to be self-evident*

Yet the

fact remains that practically all of our cerebral palsied children are being transported to and from special schools in busses*

Although they may be graduated with good educa-

r f T o c r eit* 18 George O* Beaver, "Life Adjustment for the Cerebral Palsied,” The Hervous Child* 8:2:222-225, April, 1949, 19 Loc* clt.

tions and m a n y wi t h adequate vocations, n e v e rtheless

some of

them are horachound because they have not been taught to meet the physical demands of daily living*

"Someone forgot,"

said Beaver, "that physical rehabilitation precedes vocation20 al training." He recommended the following' procedures incounselling the cerebral palsied in their selections of suitable vocationss I.

Evaluate the physical capacity of the person in

his ability to perform the activities essential to daily living and working. II.

Based.on this evaluation, the Individualfs mental

capacity, education, and vocation may then be discussed. Beaver suggested home hound vocations for those whose disabilities are so severe that they are unable to travel or to tend to their daily needs.

Sheltered workshop vocations.

In which the worker is paid according to his production, may be provided for those who are able to care for their daily needs but are unable to work with sufficient speed to compete with the normal worker.

Some of the cerebral palsied improve

to the extent that they nay leave the sheltered workshop to find outside employment.

Although many handicapped people e

can meet the requirements of daily living, they may still be limited in the choice of vocations because of the nature of

their disabilities.

It is therefore essential* when select­

ing a special vocation for the handicapped, to evaluate the physical d e m n d s of the Job as well as the physical abilities

of the worker.

All vocations may be open to a fourth group

of the handicapped, including those cerebral palsied indivi­ duals with such a wild residual paralysis that their physical 21 abilities are not limited. In an address given before the Annual Convention of the National Society for Crippled Children and Adults, on 22 November 9, 1949, E . H. Van Del den,

Director of Industrial

Relations, Libby—Owens-Ford Class Company, presented the viewpoint of the placement worker in Industry, regarding the

employment of the cerebral palsied.

Referring to the problem

of job placement, he said, 11We use three common personnel tools— job analysis, effective screening and selective place23

merit*11

The physical examination is used, not to eliminate

applicants, but rather to "make an appraisal for placing 24

workers In jobs which they can do safely and efficiently.1* While placing the burden of responsibility for the satisfact­

ory placement of the cerebral palsied worker on the shoulders 21 L o c ~ c l t ♦ 22 E. H. Van Do Idea, "Employment of the Cerebral Pal­ sied,M The Crippled Child, 27:5:12-13, 26, February, 1950.

of the employment counsellor and the placement worker* lie gave due credit to those who prepare- the cerebral palsied indivi­ dual for his role in our economic life* 25 II. E* Odor off*- chief of the Research and Statistics Section in the Of.flee of Vocational Rehabilitation* federal Security Agency, Washington., B* C

reported that in 1944

persons with poliomyelitis were rehabilitated into employment by State Rehabilitation. Agencies in the ratio of ten oases of poliomyelitis to one ease of cerebral palsy*

This statement

achieves significance only when one considers the fact that cerebral palsy and poliomyelitis are thought to constitute similar percentages of the total of all disabling conditions* 'The expansion of facilities and improved techniques of treat­ ment may be expected to result in an increased number of cerebral palsied cases to be referred to Vocational Rehabili­ tation Agencies for vocational guidance, training, and even­ tual placement.

As a result of earlier, Intensive training,

a decrease may be expected in the number of cerebral palsied ”who cone to the Vocational Rehabilitation Agencies with neuro-rauscular behavior patterns inadequate for vocational

26 training.w

There will be a need, then, for the Vocational

"Ss> Si.' fe. Odoroff, *Vocational Rehabilitation for the Cerebral Palsied,* Journal of Rehabilitation, 11:4:5-9, December, 1945* 26 h o c » c it .

Rehabilitation Agencies to coordinate their programs with the treatment centers In order that speoi.fi a muscular re-education programs may be better oriented towards vocational training. Types of jcbs in which cerebral palsied persons were placed by State Vocational Rehabilitation Agencies were listed systema tic ally , based on data received from the state agen­ cies,

The total number of cerebral palsied cases rehabilitat­

ed during the fiscal year, 1944, was reported to be 238. 07 A more recent study was mad© by Mr* Cdoroff covering the fiscal years 1944 through 1948, from data made available to him by the Office of Vocational Rehabilitation*

Re report­

ed that 219,039 disabled Individuals were rehabilitated and placed In employment by State Vocational Rehabilitation Agencies during the five years, and that, of this number, 2,689, or about 1*2 per cent of the total group, had diagnos­ es reported as cerebral palsy*

During the same period, 14,141

eases with diagnoses reported as poliomyelitis, were closed aa rehabilitated and placed in employment by the same agencies* This number represented some 6*5 per cent of the total number of disabled persons classed as rehabilitated* No attempt will 'be made here to reproduce In full the results of /»r• Odoroffrs study, but some of the most pertinent data will be presented*

It is interesting to note that of

27' M* E1* Odoroff, ”Vocational Rehabilitation for the Cerebral Palsied,” The Nervous Child, 3*2:214-221, April, 1949*

24

the 2,689 cerebral palsy cases which were* rehabilitated,

1,389 were males and 800 were females*

211 were married, and

the group as a whole had a total of 273 dependents*

host of

the number were reported to be rather severely involved* After an analysis of the age and education factors, the author mad® this statement, ”The selective factors at work apparently tend to refer to State Rehabilitation Agencies younger, better 28 prepared individuals*” Approximately sixty per cent of the individuals were referred from education, health, or welfare sources, and of the remaining half, self referrals and the public employment agencies accounted for about thirty-five per cent of the referrals* Of the 2,689 placements made, eleven per cent were professional, managerial or semi-professional positions! thirty-five per cent were clerical or sales jobs; twelve per cent were jobs In the service occupations! five per cent were in agriculture! fourteen per cent were placed in the skilled tradesj thirteen per cent in semi-skilled jobs; eight per cent in unskilled jobs; and two per cent were unpaid family workers*

The average weekly wage for the 2,565 fully employed

persons was fSO.OO, which compared favorably with the average weekly wage of $34*00 for all disabled rehabilltanis for the same period*

The most significant fact, in the opinion of

28 L o c * c i t *

the author* was not the amount of the weekly wage* hut that eighty-four per cent of the group were unemployed at the time

of referral, thirty-five per cent had never been employed and thirty-two per cent, up to that time, had unsubstantial em­ ployment *

’’The effect cannot he measured merely in earnings,n

said Mr* Odoroff*

"The satisfaction received from achieving

29 some degree of independence must also he considered•" As a result of his study, Odoroff found that, although the field of employment may he narrowed for a particular in­

dividual, the vocational possibilities for the cerebral palsied group, as a whole, are limited only by good vocational counselling and job knowledge*

He mentioned the importance

of matching the jobs with the physical capacities of the in­

dividuals*

“As more and more analyses and descriptions of

the physical demands of jobs are made,n he wrote, "the number 50 of jobs available to the disabled will be increased*" Limitations of previous studies * Although it is obvious that occupational therapy has a vital part to play in proparin.g the cerebral palsied for employment, apparently no studies have previously bean mad© by occupational therapists along this line*

26

It must he remembered, In studying the statistics compiled from the data of the Office of Vocational Rehabilita­ tion, that those figures represent only the numbers of cerebral palsied who have been trained and placed by the state vocational rehabilitation agencies*

Wo information was found

regarding the number of cerebral palsied who have been trained and placed by other official or nonofficial agencies, or who have found employment through their own individual efforts*

CHAPTEH III

FACTS ABOUT CFREBHAL PALSY The condition now known as ncerebral palsy” was first described by 'Dr. Dill lain John Little, in 1862, and was con­

sequently given the name "Little’s Disease.”

Later studies

made it clear that the drooling, grimacing, feeble-minded child who walks with a "scissors gait,” as described by Dr. Little, represents only a small proportion of those who are

handicapped by cerebral palsy.

Unfortunately, the popular

misconception that feeble-mindedness is a characteristic of 1 cerebral palsy exists even to this day. This connotation of mental deficiency Is thought to be one of the reasons for the slow development of Interest In cerebral palsy*

Another reason was that all cases were

formerly grouped together under the term "spastic paralysis” and treatment, based on undifferentiated diagnoses, was often ineffectual or actually detrimental. It is now generally recognized that there are five possible types of cerebral palsy, spasticity, athetosis, ataxia, tremor, and rigidity.

Combinations of two or more

types .may exist In the same person, depending of course on 1 Viola E. Cardwell, The Cerebral Palsied Child and his Care In the Home (lew YorkV Associa11onT'Yor”'the^TTd^oF Crippled cKildren ,"1947) , p . 1 *

28 the location and extent of the lesion, which also determine the decree of handicap*

Both arms may he affected, both lens,

an arm and a leg,- all four extremities, or only one extremity* The muscles of the back and neck are sometimes involved, re­ sulting in grotesque head movements, or difficulty in maintain­ ing head balance*

Visual and auditory defects are often

present, and most of the cerebral palsied have speech defects* 2 Phelps estimated that two of the seven eases born each year per ©very 100,000 population, are feeble-minded and will probably require custodial care for the rest of their lives. Correct diagnosis and differentiation of types, though not always easy, is of the utmost importance in planning treatment.

The treatment which produces the best results In

an athetoid, for instance, may be definitely contraindicated for a spastic or an. ataxic*

"The general future for reclama­

tion of cerebral palsy,” said Phelps, "is much brighter as our knowledge of differentiation of the various types develo ops.” rv

As is to be expected, in a condition of such a complex nature, no one factor can be named as the causative, agent, 2" Winterop Morgan Phelps, "Recent Significant Trends in the Care of Cerebral Palsy,” Southern Bedleal Journal, 39:2:132-158, February, 1946.

3 , "The Management of Cerebral Palsies,” Journal of American Medical Association, 117:19:1621-1625, Noveraber”l3, 1941.

29 Contrary to former beliefs, only a small per cent of tlie cases are now thought to be due to poor obstetrics* Causes * For a thorough understanding of the various etiological factors thought to be responsible for this con­ dition, a comprehensive knowledge of neurology, physiology, and anatomy is essential*

Since it is not the purpose of

this study to present a detailed analysis of the medical aspects involved, only those facts considered essential to a general understanding of the problem are discussed.

For 4

further information, a recent article by Dr. Meyer Peristein is recommended.

Specific causes of cerebral palsy include anoxia, asphyxia, hemorrhage, infection, trauma and developmental malformation.

They may be divided into three general classi­

fications, according to the time of occurrence,! pre-natal, natal, and post-natal* The pre-natal causes, occurring during the period between conception and the beginning of labor, include

hereditary and congenital developmental defects, as well as 5 infectious and metabolic factors. An abnormal development T'MeyerA. • Peris te in, "Medical Aspects of Cerebral Palsy? Incidence, Etiology, Pathogenesis,** The nervous Child, 8:2:128-151, April, 1949. 5 M. A* Peristain, The Problem of Cerebral Palsy Today (Hew Yorkt Association fo r ^ e T m ? Crippled Children, 1947} , p* 5.

50 of the fetal brain -may be due to a defect of the germ plasm, in which case more than one child in the same family might possibly be affected.

Congenital developmental defects,

though not necessarily hereditary, may be due to pre-natal 6

influences.

Anoxia may occur as the result of some inter­

ference with the placental circulation, or a pre-natal hemorrhage may damage the brain tissue.

The mother may

develop certain infectious or metabolic diseases during her pregnancy, such as toxemia or lerman measles, which may 7 affect the childfs brain. Certain nutritional and vitamin deficiencies of the mother may also result in damage to the fetal brain.

Erythroblastosis foetails, due to incompatible

Hh h§§K>d factors between the fetus and the mother, is one of •**V

the important causes of cerebral palsy. According to Pari­ es w stein eight to ten per cent of all cases of cerebral palsy are due to this factor. Natal causes of cerebral palsy are those which occur between the onset of labor and the time of delivery.

The

delicate brain tissues may be injured, and the blood vessels ruptured, by undue pressure of obstetrical forceps, or by 0

£oc'.~T~cit»

7 hoc» clt♦

8 Meyer A. ferlstein, "Medical Aspects of Cerebral Palsy: Incidence, Etiology, Pathogenesis,” The Nervous Child, 8:2*128-151, April, 1949. ’

51 trauma which occurs as the head passes through the birth canal, especially

If the labor is prolonged*

is very sensitive

to low oxygen intake, it may easily be

damaged by a lack

ofthis vital element*

If,

Since the brain

for any reason,

the oxygen.-supply is cut off during the birth process, anoxia may cause permanent brain damage * Among the causes of delayed breathing are breech delivery, blockage of the respiratory passages by mucus, collapse of the lungs, circulatory dis­ turbances, or the use of pain-relieving drugs during labor, 9

which may inhibit the child’s respiration* Cerebral hem-* * 10 orrhage, according to Perlat^in, Is next In Importance to anoxia or asphyxia as a natal cause of cerebral palsy*

Al­

though obstetrical trauma may obviously result In brain hemorrhage, such bleeding may be caused by other predisposing factors*

Anoxia affects the blood vessels as well as the

brain tissues* making the vessels more fragile and suscep­ tible to rupture*

other factors responsible for cerebral

hemorrhage are prematurity, congenital syphilis, a bleeding tendency due to lack of vitamin II, and sudden change In pressure which often occurs as a result of a pi’ocipitous '§ IT* 'A*"'~*Per1st©in, The Problem of Cerebral Palsy Today (Mew York: Aosociation for^the'’a'IS’of CrippTecT Ch'ilarert,' 1^47) , p. 5. 10 Loc* cit.

32 11

birth or even from a caesarean section.

There are many

other possibilities which might be considered in a discussion of natal causes, but those mentioned above, anoxia, asphyxia, and cerebral hemorrhage appear to be the most common. The post-natal causes of cerebral palsy may operate at any time during the life of an individual, and include the effects of trauma, such as head wounds or skull fractures. Besides the direct effects of such trauma, there may also be secondary effects resulting from hemorrhage.

Infections,

such as meningitis or encephalitis, and neoplasms or brain tumors are also responsible for a certain number of cerebral palsy cases*

Lead poisoning, arsenic poisoning, or a prolong­

ed Insulin reaction may result In brain damage.

Certain

vascular conditions sometimes lead to cerebral hemorrhages or thromboses, which in turn cause 71strokes,” often resulting In the clinical picture of spastic hemiplegia.

Anoxia, which

may result from strangulation, drowning, or carbon monoxide poisoning, Is another post-natal cause of cerebral palsy, and tends to involve the basal nuclei more often than the cortical areas.

Although the post-natal factors are the least common

causes of cerebral palsy, It is probable that the prolonged span of life will result In an increased number of these con-

iriocTcit.

12

ditions in the adult population. Present available data seem to Indioate that there are certain factors which predispose to the occurrence of cerebral palsy.

It occurs nore frequently anonr firstborn children

and those with heavy birthweights, and is more common among premature than full-term babies,

bore boys are affected than

girls, and the occurrence seems to be higher among children of the white race than among Negroes.

Except for these fact­

ors, there seem to be no economic, social or geographic 13 predilections for cerebral palsy* Incidence. Estimates based on extensive surveys made — n ----by Phelps indicate that we may expect to find about 126 cerebral palsied children under the age of twenty-one for ©very 100,000 of the population.

It has been calculated,

from such surveys, that for each 100,000 people In the United States, seven children are b o m each year with cerebral palsy. 15 Peris t©in reported that the findings of a recent survey made by the New York State Department of Health on the preva­ il Yeyer A* Perlstein, "Medical Aspects of Cerebral

Palsy: Incidence, Etiology, Pathogenesis,n The Nervous Child, 8:2:123-151, April, 1949. 13 Ioc . cl t. 14 Winthrop Morgan Phelps and T. Arthur Turner, The Farthest Corner (Elyria, Ohio: National Society for Crippled Children ana Acful ts, Inc., n.d.), pp. 6-9 • 15 Perlsteln, loc. cit*

oi lence of cerebral palsy In Schenectady County correspond fair­ ly well with Phelpsf estimates» He called attention to the fact, however, that the prevalence of the- condition will vary with the birth rate of the community, and that it is estimated 16 to occur about once in two hundred birth a* 17 Phelps estimated that of the seven cases born each year per every 100,000 of the population, one cerebral palsied child dies before the aye of six, and two are feeble-minded, requiring permanent custodial care for the rest of their lives. Of the remaining four, one Is so severely handicapped that he will probably remain hxn&ebound, and although he may benefit to some degree from treatment, training, and education, it is extremely doubtful that he can ever make any kind of a voca­ tional adjustment,

Two of the four considered treatable, are

moderately handicapped and should be capable of sufficient physical rehabilitation to find places for themselves in the social and economic world.

Since one of the original seven is

so mildly involved that a prolonged program of treatment will be unnecessary, he will create no great problem. Considering the problem, then, from the standpoint of vocational rehabilitation alone, our chief concern Is for the ~16~ L og ', 1cit * 17 WInthrop M, Phelps, "Recent Significant Trends In the Care of Cerebral Palsy,” Southern Medical Journal, 39:2: 132-138, February, 1946*

two moderately handicapped cerebral x>alsied Individuals of norma?,, intelligence tora each year per every 100,000 of the peculation.

It is estimated that in the On 1ted States alone 18 there are 56,000 of these people under twenty years of aye.

Based on a life expectancy of forty years, the total number of cerebral palsy cases in the United States, including the mentally defectives, the hornet)ound, the severely handicanoed, 19 and the mildly handicapped is approximately 356,000. "Unless some miracle of science can drastically reduce the incidence of cerebral palsy, we may assume that the figures quoted will remain relatively stable.

On this basis, we arc able to

estimate with a fair degree of accuracy the number of handi­ capped at each age level, and to formulate plans for their tre a tne at and tra in ing • Discussing the cerebral palsy program. Dr. Margaret Jones summarized our main problems in these words: . . . placement facilities for the low mentality group, both placement and treatment facilities for the severely handicapped individuals of normal mentality, and shelter­ ed workshops and more aid in vocational guidance for the moderately handicapped of average intelligence.^0 Classification and characteristics*

Authorities

iS Loc~cit. 19 Loc. cit. 20 Margaret Jones, "Cerebral Palsy Programs as Seen at the Southern California Cerebral Palsy Clinic,” American Journal of Mental Deficiency, 53:3:466-469, January, I§4§.

56

differ in their methods of classifying the existing types of cerebral palsy.

The neuropathologist may employ one method,

the pediatrician another, and the orthopedist still another. The most familiar classification, undoubtedly, is that of 21 Dr. ^helps who described five general groups, spasticity, athetosis, ataxia, tremors, and rigidity.

Tn this discussion,

brief consideration is given to each of these groups, and some attention Is given to the various "special disabilities" which often accompany the muscular Involvements* Spasticity is a condition resulting from a lesion of the motor areas of the cerebral cortex, the internal capsule, or the extrapyramidal system.

Because of the proximity of

the intelligence areas and the motor areas of the cerebral cortex, intelligence is more apt to he impaired in this group than, in the others.

The most outstanding characteristic of

the spastic is the stretch reflex; when a spastic muscle is put on stretch, it contracts and prevents its antagonist from 22

performing the intended movement.

Clinical symptoms which

characterize the spastic group include hyperactive deep re­ flexes, clonus, resistance to manipulation, and lack of abdominal reflexes.

Hie spastic usually exhibits a shut-in

type of personality, with fear as the predominating factor. 21 Wlnthrop ?,!organ Phelps, "Let’s Define Cerebral Palsy," reprint from The Crippled Child, June, 1948. 22 Loc• c it.

37

He is fearful of new situations, of strange people, and because of his tense muscles, he is constantly afraid of falling*

The

spastic is slow to show anger, and his anger is usually of S3 short duration* Flaccidity, a condition often included under the general classification of spasticity, is the result of damage to the pre-motor areas of the cerebral cortex, or to a pyramidal tract* Damage to the basal ganglia, whose function Is inhibi­ tory in nature Is generally thought to be the cause of athe­

tosis, a condition in which involuntary movements are super­ imposed on voluntary movements *

It is characterised by

writhing, twisting movements, which tend to disappear in sleep or when the a the told is completely relaxed.

As Egel

24

so aptly described this condition, an athetoid lacks the ability to control the direction of his motions and therefore Is unable to complete attempted voluntary movements.

Certain

clinical signs characteristic of the athetoid are hyperextension of the fingers, a spontaneous Bab inski, and the fact that the deep reflexes may be hyperactive at times, and normal at other times*

The personality of the a the to Jcl is

usually the opposite of that of the spastic, and lie is found §S_ Paula F. Egel, Technique of Treatment for the Cerebral Palsy Child (St * Louis t 'the C* V* rosbyCompany, i M i T p . i i r ------

24 Ibid., p. 21.

33

to be quite fearless in any situation.

Tie likes to be with

other people, and does not worry about what they may think of him.

The athetoid is quick to show anger, and is inclined to 25 hold his anger for s. comparatively long time. Dr. Perlstein said of the spastica and athetolds * These two categories include perhaps BO per cent of all types of motor disabilities. The remaining 20 per cent of the cases include those labelled by the terms "ataxic,* "rigidity," "tremors," and others which are characterized by definite clinical neurologic traits and disabilities*^® The type known as ataxia is characterised by lack of automatic balance and by disturbance of directional control, due to a lesion of the cerebellum.

The ataxic walks with

his feet wide-spread, which gives him a "staggering" gait, and is apt to fall frequently. effort to right himself.

If pushed, he will make no

Other results of this condition

are hypotonia, or diminished muscle tone, and a coarse terminal tremor which appears during voluntary activity. 27 Gardner said that when an ataxic Is asked to put his finger to his nose, he may be able to do so, but Is not able to stop his finger at his nose and may jab himself In the face. Damage to the basal ganglia, often the result of en-------SS" IB IT.. P. 28. 26 M. A. Perlstein, The Problem of Cerebral Palsy Today (Hew York: Association for the Aid of CrTppled Children, 1947), p . 5. 27 Krnest Gardner, Fundaiaentals of Heurology (Phila­ delphia: W. P . Saunders Company, 1 & 4 & ), p. "UlSI .

59

cephalitis, may produce involuntary motion which is reciprocal in nature, and which is referred to as a tremor.

A tremor may

he classified as an intention tremor, which occurs during an attempt to perform voluntary movement, or as a non-intention tremor, which remains more or less constant* Rigidity, which may be due to a combined lesion of the globus pallidus and Area 6 of the cerebral cortex, is de­ scribed by Phelps as tta sustained, non-voluntary condition of contractility and loss of e l a s t i c i t y . T h e anti-gravity muscles are apt to be affected to a greater degree than others, producing a picture of exaggerated postural tone. The lack of elasticity in the muscles, and the absence of the stretch reflex distinguish rigidity from spasticity* A true picture of cerebral palsy must include consid­ eration of the associated disorders of hearing, speech, vision, and mental processes, which may be present in some degree.

Regarding the incidence of speech disorders among

the cerebral palsied, Dr* Palmer wrote; Almost every child with an extensive dysfunction of the extremities also has a dyscoordination of the muscular patterns of breathing* laryngeal valvinr, chewing, suck­ ing, and swallowing,2$ £6 Win thro p Morgan Phelps, ffDescription and Differ­ entiation of Types of Cerebral Palsy,” The Nervous Child, 8:2:107-127, April, 1949. 29 Martin F. Palmer, ”Speech Disorders in Cerebral Palsy,” The Nervous Child, 8:2:193-202, April, 1949*

40 It oan readily be seen that such an involvement not only affects the speech of a child, but also presents a serious feeding problem.

Hearing losses often occur, especially in

the athetold group, to complicate the situation.

Spasticity

or weakness of the muscles of the ©ye may cause a strabismus or other visual handicap. of the eyes.

The ataxic often has a nystagmus

A lesion or malformation of the cerebral cortex,

or interruption of certain pathways, may restilt in aphasia, agnosia, apraxia, astoreognosis, or some other involvement of the mental processes. Because no two cases of cerebral palsy ever present exactly the same picture, it Is of the utmost Importance that all members of the team working with the cerebral palsied consider each person as an Individual case, with physical, mental, and ©motional characteristics demanding a thoughtful and we11-planned therapeutic approach.

CHAPTER IV VOCATIONAL THAI NINO A!TD JOB PLACI I NT

OF THE CEREBRAL PALSIED For a person handicapped by cerebral palsy, the possi­ bility of a satisfactory vocational adjustment depends on many things*

The Importance of early diagnosis and treat­

ment can not be over-emphasised, but even when these have been adequate there are quite often other obstacles to success.

Many Individuals and organizations In the United

States are working together to help the cerebral palsied overcome those obstacles*

It la essential that anyone work­

ing with the handicapped be aware of the factors which oper­ ate against their employment, as well as to be familiar with the services and facilities which function for their welfare* Some conception of the extent of the problem may be gained by a brief review of statistics, based on the survey 1 made by Phelps and Turner* I* Statistics *

EXTENT OF THE PROBLEM In the United States alone, approximately

9,800 children are born with cerebral palsy each year.

Of

this number, 1,400 loy7nent. To overcome such obstacles to em­ ployment, much remains to be done in the way of public educa­ tion and en 1 Igh te runen t • In a recent report on the problem of the severely handicapped, submitted by the State Departments of Public Health and Education, the limitations of the service of the Bureau of Vocational Rehabilitation were outlined as follows: (1) Since the number of applicants for the service Is greater than the bureau can serve with Its present staff and facilities, 1 t Is the present policy to give priority to cases which give the best promise of quick productive returns to society. This tends to limit the service for persons suffering from severe physical handicaps of long standing or from handicaps which are distinctly progress­ ive In spite of treatment. (2) Since the efforts of the bureau are primarily directed toward Job placement for Its clients, the like­ lihood of placement is an Important factor In determining the suitability of applicants. This limits the services rendered to multiple handicap cases of long standing who also present Intellectual, social, and emotional disabilities.^ As a result of the survey made by the State Depart­ ments of Public Health arid Education, which included an eval­ uation of the adequacy of present programs for the severely handicapped and cerebral palsied In the State of California, certain recommendatlons were made for improving the facilities available to this particular group.

A need was indicated for

68 a rehabilitation center or centers which would provide for the care, treatment, education and training of physically handicapped persons of normal intelligence who are so severe­ ly disabled that they cannot receive adequate car© in the home or under the existing program#

Such a center would

offer to both inpatient and outpatient cases the following services % A • Treatment Y T ’MedXcal--general and specialized 2* Physical therapy 3# Occupational therapy and training in self-help 4# Speech therapy B. Education I* Academic training equivalent to public school programs 2. Speech correction 3* Vocational training and guidance C * Sheltered and Curative Workshops I. Sheltered-'-^or'7 permanent cli'sabill ties 2# Curative— for those who will be placed eventually in industry D* General 'Related' services not specifically covered above and including social and emotional adjustment, recrea­ tion, etc *3-5 II*

N 0 If-OFF ICIA L AGENCIES AND ORGANIZATIONS

Many voluntary organizations in California, as else­ where, are concerned with the welfare of physically handicap­ ped children and adults* 1 6 Ibid., p. 11.

Such organizations often render

67 valuable services not possible in the budget of an official or government agency, and In numerous ways help to promote 16 the work of the official agencies. California Society for Crippled Children.

Such* an

organization as that described above Is the California Society for Crippled Children, whose slogan is "California Cares#” With over thirty local units, the Society Is dedicated to the welfare of physically handicapped individuals In the State of California, and stands ready to cooperate with any agency, either public or private, In meeting the needs of the handi­ capped*

The California Society Is, of course, an Integral

part of the National Society for Crippled Children and Adults, whose activities aro described at another place In this study. The Cerebral Palsy Division of the state society has been particularly active in the organization of parent groups throughout the state, and hopes that eventually there will be an organized group of parents In each county where there Is a Society for Crippled Children*

The Division not only

serves in a n advisory capacity to the State Departments on many problems which affect the State Cerebral Palsy program, but has also given advice to groups in other states who look 17 to California for guidance. !€> Jackie, o p . clt., p* 18. 17 “The Cerebral Palsy Division,” California Cares, 4:5;5, September,1948.

•The local units of the California Society for Crippled Children study the needs of the physically handicapped in their particular communities * and search for viays and means to meet those needs*

An example of a successful enterprise

may be found in the El Portal School for cerebral palsied children, in Burlingame, California, which Is housed In the carriage house of an old mansion*

The enterprise was begun

as the result of a survey made by the Crippled Children1® Society of San ilateo County, in 1944, which revealed that there were more than fifty severely handicapped cerebral palsied children In the county who were without an adequate educational program.

The county school department supplies

the teachers at the school, the State Pepartment of Public Health furnishes the physical and occupational therapists, and the county Crippled Childrenfs Society assumes all other 18 obligations * The Sheltered Workshop of the Crippled Children’s Society of Los Angeles County represents the answer of anoth­ er local society to a particular need of the physically handicapped in the community.

The workshop is operated to

help meet the needs of many of the young adult group, par­ ticularly the cerebral palsied, who are unable to compete in IS Mrs.George Spann, nA Carriage House Becomes a School: The Story of El Portal,” The Crippled Child, 26:6: 12-13, 30, April, 1949*

a normal employment situation*

This particular sheltered

workshop is unique only in that they hare endeavored to make it available to the more severely hand5capped, and in that "certain other services of the Society are available to the personnel in the shop, such as, case work services and reere19 ational facilities*” They have adopted the policy of not refusing work to anyone, regardless of the severity of his handicap, providing they think they have a job for him and if transportation is available.

In order to carry on such a

program, the shop is subsidized by Easter Seal funds; for the first fiscal year of operation, when the shop averaged about forty-five workers, this subsidy amounted to approximately 20

1-26,000*00* Registered occupational therapists are employed as supervisors in the workshop*

It has been found that the

professional training of an occupational therapist more near­ ly provides the skills necessary for supervisors than does any other type of professional training.

Hie procedure for

the Sheltered Workshop applicants includes a complete social service work-up of each case, and requires a prescription and statement from each applicant's physician.

Transportation to

19 11The Sheltered Workshop as a Project of a Crippled Children's Society,” (unpublished paper, Crippled Children's Society of Lea Angeles County, n*d.), p. 3. 20 Ibid., p. 9.

70 the workshop is a problem in many oases, and must be provided for some individuals.

Q,ulte often a handicapped person can

be trained to use public transportation, and an occupational

21 therapist can provide this training. In a workshop of this nature, where the principal activity is the manufacture and sale of products, the workers are usually paid on an hourly basis; the wage rates must, of course, be cleared with the wage and hour authorities.

Some

of the workers in the shop are so severely handicapped that )

they arc unable to produce much in the way of labor, but it is felt that some benefit Is realized from the group associa22 tlon and motivation of the workshop situation* The United Cerebral Palsy Association of Los Angeles County.

The United Cerebral Palsy Association of T,os Angeles

County is set up along the same lines as the national organ­ isation, and has the same purposes*

The first annual fund-

raising campaigns of both the national and local organisations were launched In May of this year*

A goal of $160,750.00 was

set by the local unit for the year 1950, to be disbursed as follows: 68,500*00 to go to the national organisation as Its share; $4,100.00 to cover local campaign costs; #15,000.00 for a survey of cerebral palsy In the County; $25,000.00 to ------- ST"T 5 T 3 T ,

pp

. 5-7.

22 Ibid., p. 10.

71 establish a nursery school for cerebral palsied children; 130,000.00 for vocational training and job placement for cerebral palsied over sixteen years of age; and {,10,150.00 for public Information service.

It Is the professed aim of

the local organization to coordinate and provide services not being met by other agencies in the area. With the funds allocated for. vocational training and job placement, the local organization Intends to help plan and finance a model program for cerebral palsied over sixteen years of age, where a well-tra Ined staff of teachers and technical experts will be able to develop the potentialities of the Individual, and help him to a more productive and 23 satisfying existence. Other voluntary organizations. Among the many other organizations in California who offer special assistance In meeting the needs of handicapped people are the Shrlners, Rotary, Wiwsnis, Lions, Foroptlmlsts, Business and Profess­ ional Women, Optimist Clubs, the American He cl Cross, church organizations, and the California Congress of Parents and 24

Teachers, Inc.

The California Congress of Parents and

Teachers was particularly active in backing the movement of 23 bBasic Facts He: T7.C.F.A., Inc. and TI.C.F.A. of Los Angeles,” (unpublished paper, The United Cerebral Palsy Association of Los Angeles County, n.d.), p. 4.

24 Ivfackle, op. clt., p. 13.

72 1945 which resulted In the legislation through which the pro­ gram for cerebral palsied children was established.

This

organization has also been active In finding ways to meet the need for trained personnel to work with handicapped child25 ren * It was the purpose of the investigator to present, In this chapter, an over-all picture of the work that Is being done in California for the welfare of the physically handi­ capped and the cerebral palsied In particular*

A more de­

tailed study of the services rendered by the various agencies would not be appropriate to the purposes of the study*

Jensen and MackI©, o p . cit.» p. 24

CHAPTER VI THE Q.OEST IONI AIRE AID INTERPRETATION OF RETURNS A questionnaire, reproduced In Figure 1 on page 149

of the Appendix, was designed for the purpose of Investigat­ ing certain factors relevant to the vocational problems of the cerebral palsied, as followss 1* The approximate number of cerebral palsied persons who received vocational training in the United States during the years 1948 and 1949. 2. The number of those who found employment after vocat iona1 tra in ing • 3* Types of employment in which they were placed. 4. Disabilities of those who found employment. 5* The degree of Importance which various factors bear In relation to the employability of the cerebral palsied, In certain vocational fields. Suggestions and further Information concerning the vocation­ al problems of the cerebral palsied were invited, and space was provided for information regarding future plans of the agencies to whom the questionnaire was sent. Questionnaires were mailed to seventy-nine organiza­ tions and agencies, and replies were received from fifty-four. In other words, sixty-eight per cent of the recipients re­ sponded, although not all of them were able to supply the

74 Information requested*

The agencies to whom the questionnaires

were sent may he classified as follows: 52 state vocational rehabilitation agencies 5 sheltered'workshops 8 rehabilitation centers 9 curative workshops 6 miscellaneous agencies * Of the agencies who replied, ten reported that they had no special classification for cerebral palsy, and were therefore unable to supply some of the information requested.

Pew of

the curative workshops provide vocational training or job placement services* I.

DATA COMPILED PH CM ANSWERS TO QUESTIONNAIRE

It must be remembered, in considering the numerical data presented here, that the figures are by no means con­ clusive and can b© regarded only as an indication of present trends*

Many of the agencies reported that their statistics

were based on a fiscal year* beginning July 1st and ending June 30th, whereas other figures were apparently based on the annual period between the first of January and the thirty-first of December*

Although information was requested

for the years 1948 and 1949, several of the re turns Indicated that the data supplied was for only one year*

There also

seemed to be a little confusion regarding the matter of

75

”closures” with some of the state vocational rehabilitation agencies*

A number of them Included only ”closed” cases in

their data regarding the number of people who had received vocational training, while others Included those in training at the present time*

There is, therefore, a certain amount

of variance in the figures presented. Number of cerebral palsied who received vocational trainIng.

In response to the request for Information regard­

ing the number of cerebral palsied who received vocational training during the past two years, twenty-four of the re­ porting agencies supplied statistics.

Ten of the others

reported that, although they do Include the cerebral palsied In their services, they have no special classification for them, and wore therefore unable to supply the Information requested.

Others reported that they do not offer vocational

training or job placement, and still others indicated that they have not had occasion to render such services to cerebral palsied individuals.

Certain data compiled from the returns

are presented in Table I, on page 151 of the Appendix, According to the information received, approximately 626 cerebral palsied people received vocational training during the past two years*

It is interesting to note that

this figure includes thirty-nine such cases In California, representing only a seven months’ period.

76

Humber placed on jobs after vocational training*

Out

of line 626 who received vocational training, 316 were report­ ed to have subsequently found employment*

Seventy-eight

additional cases were reported as rehabilitated without spec­ ial training*

Inasmuch as this information was volunteered,

it is quite possible that there were other such cases, which might have been reported had a request for such data been included in the questionnaire. At any rate, the statistics seem to indicate that only about fifty per cent of those who received vocational training during the past two years were successful in finding employment after their training*

This

would tend to bear out the opinion expressed by many of the rehabilitation officers that the cerebral palsied are very difficult to place* Types of employment in which the cerebral palsied were placed *

Of the 316 cerebral palsied Individuals reported to

have been placed following vocational training, the types of employment were listed for all but three*

Several of the

agencies reported the types of employment for cerebral palsied people who had been Hrehabilitated” without vocational train­ ing; this number amounted to thirty-four.

There were, then,

a total of 347 cases to be considered In relation to the types of employment in which they were placed, as Indicated by Table II*

0 ct P H 01

o ct pJ 0 4

u o & ©

m ct H* o

Vi

(9 H» H H* $ ?■
aot year, If figures not available for 1040)? *48

*49

2 « H ow many of these subsequently found employment? *48

f49

Types of employment in which they were placed: Ho.self- Involve- No.employed Involveemployed merit by others xnent a. Agriculture . . b * Horticulture • _____ c • Industry • • . _____ d. Clerical work • _____ e . Photography • .______ f. Professions ♦ •______ g. Building trades _ _ h. Belling . . . . _____ 1. Other employment _____

_ _ _ _____ _____ _____ _____ _____ _____ ___

_____ _ _ _____ ____ _ _____ _ _ ' _____

_____ ____ _____ _____ _____ _____

(Use other side cf paper, If necessary, for description of Involvement*) Please check the following items according to the degree of Importance which, in your opinion, they bear in deter­ mining the employability of the cerebral palsied indiv­ idual, in relation to the vocations listed above, Examples Using the alphabetical key above, if you consider Intell­ igence to be of prime Importance In clerical work, put ndw In the space opposite intelligence11 In the first column below; if you think intelligence is of some import­ ance In the building trades, put TfgM in the second column and If you consider It to be cf least importance In agri­ culture, put naw In the third column. Follow this procedM

4.

FICURE

1

Q.ITESTI0UUA IRE

150 ure for each of the traits Hated below* Prim© Some Least Importance Importance Importance Intelligence * * * * * * _____________________________ _ Personality . * * . * • ______ ______ ______ Emotional stability • • ______ ______ ______ Personal appearance • * Manual dexterity * * * *__ ______ ______ ____ Speech * * • • • * * • * _ _ _ ______ Good vision * • « * • • _________ ______ ______ Good hearing * * * * * * __ ______ ______ ______ Writing ability * * * * ______ ______ Heading ability . * . * ______ ______ ______ Ability to walk * * * * _ _ _ _ _______ _ _ _ ______ Independence la self-care __________ ______ Independence In use of ______ ____ _ public transportation _ _ _ 5.

Suggestions, and/or additional information*

6.

Plans for the future*

ifame of agency By

FIGURE

1 (continued)

QUESTIONNAIRE

_ _ _

HUTJBEH CF CEREBRAL PALSIED TRAINED AND PLACED 1948-1949

Report Ing a.Teney

Alabama Rehabilitation Service Arizona, Vocational Rehab­ ilitation Division California, Bureau of. Vocational Rehabilitation

Trained for jobs

Placed after vocational training

55

27

7

3

39

Placed with­ out voca­ tional training

39 (7 nos * period)

Colorado State Board for Vocational Education, Rehabilitation Division

6

6

Connecticut Division of Rehab 11 ita tion

3

3

District of Columbia Rehabilitation Service

15

5

Florida Vocational Rehabilitation

23

7

Idaho Vocational Rehabilitation

13

4

Indiana Vocational Rehabilitation Division

23

23 (closures)

Iowa Vocational Rehabilita­ tion

10

10

Maryland Division of Vocational Rehabilitation

4

4

Minnesota Division of Vocational Rehabilitation

69

14

Missouri, Vocational Rehab­ ilitation

30

14

13

31

13

152 TABLE I (continued) NUMBER OF CEREBRAL PALSIED TRAINED AND PLACED 1948-1949

Reporting agency

Hew Hampshire, Vocational Rehabilitation

Trained Placed after Placed with­ vocational out voca­ for traInlag job s feIonal tra in ing 5

2

Hew York, Division of Vocational Rehabilitation

20

20

North Dakota, Division of Vocational Rehabilitation

B

8

Ohio Bureau of Vocational Rehabili tation

46

25

Oregon, Division of Vocational Rehabilitation

47

22

Pennsylvania, Bureau of Rehab11ita tion

21

12

South Dakota, Division of Vocational Rehabilitation

12

4

State of Washington, State Board for Vocational Education

16

State of West Virginia, Division of Vocational Rehab illtati on

16 (1 year)

1

1

Wisconsin State Board of Vocational and Adult Education, Rehabilitation Division 112

31

Bridgeport Rehabilitation Center

21

0

Goodwill Industries of Detroit

11

11

21

153 TABLE I (continued)

NUMBER OF CEREBRAL PALSIED TRAINED AND PLACED 1948-1949

Reporting agency

Milwaukee Goodwill Industries

Trained Placed after Placed with­ for vocational out voca­ jobs training tional training 11

Sheltered Workshop, Crippled Children's Society, Los Angeles

(56)

Totals

626

5

316

78

^Hot included "in Yotal/because' training was limited to a sheltered situation*

154 TABLE IV RELATIVE IMPORTANCE OF VARIOUS FACTORS CONCERNED V7ITH EMPLOYABILITY OF IRE CEREBRAL PALSIED IN CERTAIN FIELDS Vocation

Degree* a

b

c

d

e

f

Factors'" B h. i

3

k

1

m

Agriculture

P S L

Horticulture

P S L

3 6 3

Industry

P S L

Clerical work

P S L

12 7 0

8 4 1

8 12 6 10 0 0

8 6 0

6 14 9 6 0 0

7 17 11 8 5 8 0 0 1

2 7 8

9 4 1

5 8 1

Photography

P S L

7 6 0

3 8 1

3 7 1

4 8 1

4 5 1

2 13 5 5 4 0

3 6 4

0 6 6

4 6 3

2 6 5

6 3 2

3 6 3

Professions

P S L

22 12 20 14 2 7 2 6 0 0 0 0

5 9 1

9 10 17 8 7 2 1 2 2

4 5 4

9 5 3

6 6 4

Building trades

P S L

3 10 2

5 9 0

2 7 3

1 2 7

3 13 6 1 6 1

7 3 0

6 8 2

Selling

P S L

7 22 12 18 1 22 3 13 9 1 4 5 5 0 10 5 1 1 0 1 14 1 3 1

7 7 3

8 4 3

9 10 14 4 1 4 3 1 1

Other employment

P S L

0 6 2

0 2 1

1 1 2

3 2 2

3 1 7 3 7 16

5 0 7 5 1 15

1 2 0 0 14 7 5 2 6 4 8 10 16 11 1

3 6 5

6 7 0

0 6 8

1 8 3

2 4 7

0 3 8

0 9 5

6 7 2

4 2 6 2 16 0 9 10 11 10 5 11 2 3 1 4 0 4

9 6 3

7 8 0

0 6 9

1 9 3

9 11 12 7 6 3 3 0 1

5 1 10 0 8 16 1 5 8

0 5 6

1 2 2

3 6 4

2 2 1

1 3 9

1 12 5 8 6 0

2 13 4 8 9 1

1 3 1

0 1 4

3 3 6

1 1 1

0 2 3

1 2 1

*P - Prime importance; S - Some Importance; L - Least importance.

8 2 3 2 2 11 6 2 2

2 0 2

1 3 8

1 1 1

155 TABLE XV (continued) RELATIVE IMPORTANCE OF VARIOUS FACTORS CONCERNED WITH EMPLOYABILITY OF THE CEREBRAL PALSIED IN CERTAIN FIELDS *Fac tors 2

Intelligence a b • Personality c mm Emotional stability d mm Personal appearance e mm Manual dexterity f - Speech S — Vision

h i j k 1

m —

Hearing Writing Reading Walking Self-care Use of public transportation

156 DAILY LIVING ACTIVITIES ILL:' Name (or Ca3e No.) ____ Sex

Date of birth

Marital status _____ Lives tlone

with family^

Diagnosis _______ Disability Education

X.Q.

(Test used)

Prevocstional and/or vocational training Type of employment _____________

Dateemployed

Hours per week on Job __________ Transportation used Amount earned _________ Special Interests, hobbies, etc.

GRADE N 0

(normal) - Mo apparent involvement. (good) - Able to perform activity with speed and accuracy, in spite of involvement. F (fair) - Able to perform activity, but with slow­ ness and Inaccuracy of movement. P (poor) - Partial performance. 0 - Enable to perform the activity. (Time each activity carefully, and record in space designated.) Date test given

Administered by ________ (Therapist *s name) TIME

ACTIVITIES A.

GRADE

EATING AMD DRINKING

1. Spread butter on slice of bread S. Cut meat (or bread) with knife and fork PI GHEE

3

DAILY LIVING ACTIVITIES TEST

r\\-T*-FIDliTno

157

ACTIVITIES

TIME

(TRADE

CONTENTS

A* (continued) 3« Use fork (grasp, raise to thou tb , remove food, re turn fork to plate, and release) 4. Drink from cup (grasp, raise to mouth, return to table , rele ase ) 5. Drink from glass (grasp, raise to mouth, return to tahle, release) 6* I*our Water from pitoner Into glass 7* Carry tray of food arid dishes ten feet 6* Use salt siiak'er 9V Use spoon (grasp, raise to mouth, remove food wlth lips, return spoon to plate, release) 10. Drink 1iquid through a atraw (th ree swallows) 11. Wipe mouth with-napkin 3.

DRESSING AND UNDRESSING

1* Put on shoes, lace and tie, or fasten 2* Put ori shirt (dress) and button 3* Tie necktie 4'* fcemove socks, or stockings 5. Operate zipper 8* Put on trousers (slip) Untie, unlace, or unfasten shoes, and remove *~I7kkntTeand.."remove 'rieeEtliT 9* Unbutton and remove shirt (or dress) 10. Pub on socks 11• Remove trousers (or slip) FIGURE

3 (continued)

DAILY LI VX"-hi^ ACTIVITIES TEST

--- ----------■ ---- —

IDS jri.

XV

.j_ j. it-j

i 1.

B*

(continued)

12 * IS* 14 . 15 * 1$ .

T''ast en be 11 Ha nr up cl dtiling Put on coat, "dr sweater he move coat or sweater (unbuttoned) Uni*as t en h Git

C•

APPLIANCES

'jr.rt.Uw

1. Put on braces 2* Take off braces ’ S# Lock and unlock braces D.

PERSONAL HYGIENE

1* Wash face and hands dlean fingernails Shave (put aa make-up) 4* Shampoo liair (go through mo ti on s ) 5* Brush teeth (go through motions) Comb hair Trim nails (clip or file one nail) h* Hake two pin-curls (girls) 9* Use handkerchief lo* Use toilet paper (tear piece off roll, and flush down toilet) 11 * Get on and off toilet E • COHHUHICATIOU 1. Write name and address on typewriter 2. Hrlie name aho address with pencil 3. Fold letter, place in envelope, and seal FI 0UEE

3 (con 11 nue d )

DAILY LIFTED ACTIVITIES TEST

E «.

(continued)

4, Write name and address with fountain pen 5* Gprm envelope, remove and unfold letter 6* Pick up telephone receiver, dial, and replace lustramen t "7« Yean aloud a passage oT pi"ose ot i-c-e try 0, Turn radio on, dTaT, and turn. off R.

UTILITIES

1* use needle and thread (sew on button) £* 7'ake change from coin purse or pocket 3» iJse scissors to cut along: a straight lino 4* Remove hill from wallet, and replace 5* Wind clock (three turns} 6* Strike a match (folder type) T* Open and close window S. Plug In electric cord §* Open' and close drawer 10 « Turn water faucet on and off 111 Turn light switch on and o ff

-— _.— - —— — —— -— --- —

0 , LOCOTCTIOII AMD TRAVEL 1* Tall: up and down flight of standard steps (with) or (without) rail 2. “insert key In lock, turn and remove FIGURE

3 {con 11nued)

DAILY LIVXKG ACTIVITIES TEST

>»

(VjOiiU^ikUGG f

S. ha Ik up and down an ■ incline i* Talk forward 10 yards on smooth ourface 5* Gross street (40 feet) B . V/alk Torward 10 yards bn rough surface 7. Get out of an automobile &. Get into au. automobile 0, Open doors of automatic elevator, enter, and operate i"0» Open door, using door knob, v all' through, and close door 11 • Pick up five-pound package from floor and carry 15 feet IS* Cot clown on floor and up again 13* Get on bus (practice) 14* Get off of bus (practice) 15* Get in and out of a chair 16* Step up an b-inch curb I?* Step down an G-lnch. curb

FI G'CJHS 3 (c on 11 rmed) DAILY LIVING ACTIVITIES VEST

161 TABLE

V

INDIVIDUAL TIME SCORES ON EACH ACTIVITY OF THE DAILY LIVING ACTIVITIES TEST FOE THE CEREBRAL PALSIED

I A . Eating and Drinking 1 2 3 4 5 6 7 8 9 10 11 B* Dressing and Undressing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

GROUP WJ'TROUT WORK EXPIiKI EMCE

EMPLOYED GROUP

ACTIVITIES

19 9 5 4 8 10 7 5 7 6 4

16 86 mmmm

35 5 12 8 38 3 5 12 9 10 5 8

II III IV V (Time In seconds)

35 4 4 4 4 10 7 3 7 4 7

A

c u E B (Time in seconds )

44 19 6 5 9 0 12 13 6 7 3

97 67 32 25 17 0 0 15 7 6 7

8 7 5 5 11 5 7 4 6 11 4

59 42 8 9 7 16 0 11 9 5 7

47 26 10 6 9 8 20 11 10 18 9

43 21 7 4 5 8 36 6 9 14 23

55 10 4 4 3 6 8 11 4 9 4

18 13 4 4 5 8 11 3 10 14 3

217 109 63 24 24 83 43 28 20 47 46 14 18 18 15 4

0 0 0 140 98 0 86 0 P 0 0 48

59 34

1125 262

127 74

8 18 14

30 52 216 265

17 11 33 21

13 18 12 4 8 8 5 4

68 90 103 109 93 123 127 75

50 152 29 33 20 23 9 S

320 43 0 22 29 94 55 0 27 89 45 19 43 23 12 5

58 55 92 6 10 24 13 131 18 35 12 10 16 17 8 11

154 69 68 12 6 52 28 78 30 32 28 24 14 10 9 9

0 P 15

162 TABLE

V (c cmt Inued)

INDIVIDUAL TINE SC ONES ON EACH ACTIVITY OF THE DAILY LIVING ACTIVITIES TEST FOE THE CEREBRAL PALSIED

AC

I C * Appli­ ances 1 2 3

, — ——

B* Person­ al Hygiene 1 2 5 4 5 6 7 8 9 10 11

35 52 58 22 22 33 33 0 15 8 2

E* CoBiannication 97 1 2 159 3 33 0 4 34 5 6 15 7 19 8 11 F. utili­ ties 1 2 3

GROUP WITHOUT WORE EXPFP TFNC'

EMPLOYED GROUP

7**"mnp ^

210 20 19

IV V II III (Time In seconds)

— —

——

112 25

498 104

D C D (Time In seconds)

—

104 67

—

E

251 55

—

50 65 40 68 25 47 58 12 7 4

55 35 79

—

—

A

123 103 0 87 0 45 0 32 95 18 42 28 0 15 — 8 13 7 4

37 123

107 133 ■»«a 75 41 117 42 58 47 82 82 94 0 0 36 15 24 54 23 6

38 42 32 26 IS 20 10

8 18 5

179 107 182 71 23 13 21 —•» 17 21 2

146 60 43 45 29 29 20

9 13 5

0 124 55 0 23 24 39 16

70 144 0 7S 62 IB 16

19 22 23 10 16 10 8

163 65 93 105 53 25 10 37

65 58 55 74 58 26 19 12

0 95 60 0 65 47 0 8

144 30 38 35 29 14 13 6

62 43 59 65 41 35 49 6

0 38 34

0 69 40

46 9 12

95 116 22

231 43 32

202 39 30

282 26 32

160 24 21

163 TABLE

V (continued)

IEDI VI DUAL 1 1 HE SC QBE S ON EACH ACTIVITY OF THE DAILY LI VINO ACT IV IT IBS TEST "'OK THE OF BE BEAL PALSIED

I F.

fcontfd ) 4 5 6 7 8 9 10 11

0. Locomo­ tion and travel 1 2 o 4 5 6 7 8 9 10 11 12 13 14 15 16 17

'vr.)mrrx: GROUP KIT r ;i * . " ■ 'TORT EXPEL r-.it/iri

E '1PL0YED cmorjp

a A v Ab .~ -r L