Develop. Med. Child Neurol. 1972, 14, 703-704

EDITORIAL

ARE WE HANDICAPPING THE HANDICAPPED ?

ANYONE who started out in utter poverty finds it extremely difficult to choose the point a t which to cry halt as offers of increasing wealth pour in. We all started out, not too long ago, unable to make any treatment recommendations for the motor-disabled child. There were none. Now, new techniques are continually being offered, each with greater enthusiasm than its predecessor. A trend has been firmly established to ‘aid’ the disabled child by ‘treatments’ at home and in the hospital. Even if we are non-believers in the popular treatment modes of the day, we are inclined to go ahead and prescribe the technique in vogue, or the one with which the therapist who is to do the treatment has the most experience. This is what I do, and what 1 believe many physicians do; justifying these treat- ment recommendations with the conviction that: (I) something must be done actively since the parents cannot sit back and do nothing; (2) there is no proof that the treatment is ‘ineffective’; (3) if we have no ‘treatment’ to offer, the parents will shop around until they find someone who has; and (4) that it is less time-consuming to refer the patient for therapy than to counsel the parents.

1 think it is time to cry halt. 1 think we have an obligation to motor- handicapped infants and children to question the entire philosophy of treatment prescriptions.

Let us not forget the economics involved ; the professional time wasted, the loss of parent time that might have been given to their other non- handicapped children, and the time wasted by the handicapped child himself, which may have been put to better use to develop his mind instead of his muscles.

Are we further ‘handicapping’ our motor-handicapped infants and children by subjecting them to the many doctrinaire treatment techniques commonly in use? There is no hard evidence to indicate that treatment programmes which attempt to modify sensory input, to inhibit primitive reflexes, or to modify or inhibit abnormal movement patterns are ever successfully incorporated into the maturing nervous system with resulting improvement in motor function. It is even doubtful if there is carry-over from one day to another. Nonetheless, we persist in prescribing such treatment techniques from the start.

I recall two experiences. The first was when watching a severe athetoid adult approaching a closed door. As he started to reach out for the door-knob, I wondered how he could possibly succeed in opening the door. He did, and with dramatic effectiveness. He quickly turned his head to the right, his right arm then extended and became stiff with fewer flailing movements, and the door knob was reached with ease and relative dexterity. This man had learned (probably by trial and error) to make use

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1972, 14

of his persistent tonic neck reflex to achieve a functional result. Would most of our present-day ‘habilitators’ have recognized the potential of a primitive reflex in aiding postural adjustment for improved motor control?

The second experience was with a 12-year-old boy with clumsi- ness secondary to a minor motor dysfunction who was being teased and ridiculed by his peers because of his inability to compete athletically. His father, an excellent golfer, decided to take his son to the golf course on weekends, in the hope that with good instruction the boy would become proficient in this sport. Unfortunately, these outings almost always ended in polemics between the pair of them. As the father explained it to me, ‘you know how unpredictable my son is. I show him the exact way to approach the golf-ball, the correct stance and the perfect swing. He then tries to imitate what he saw and misses the ball completely. Then, when I am no longer interested in what he does, he stands completely wrong, holds the club clumsily and swings unbelievably wrong, but hits the ball 150 yards straight down the fairway.’ The father became angry because he believed his son was trying to ridicule his teachings, and because what was intended to be a pleasant outing always ended painfully. Unfortunately, what this father did not realize was that to use a style of swinging based on postural adjustments most suited to a normal neuromotor system was inappropriate for the boy who had another pattern of neuromotor innervation, an abnormal one. The father was actually adding to his son’s handicap by asking that his own style be imitated. The boy had to find the style that suited himself best in order to obtain the best functional result.

We are probably unaware of many primitive reflexes and postural control mechanisms that influence motor activity. Even if we were completely knowledgeable about motor mechanisms it would still be necessary to carefully micro-analyse the movement of each motor- handicapped child to be able to prescribe specific stance, postures and movements that would give the best functional result. Until this becomes possible, let us allow youngsters to ‘find their own way’, rather than prescribe controversial treatments. This is best accomplished by motivating the child to try a task and to practice it so he reaches the optimum efficiency his nervous system will allow. As an example, I told this father that if he wanted to have his child improve in baseball he could not expect him to want to play with his peers, since that was an ego-deflating experience for the boy. Instead, the father was advised to take his son into the back yard and throw the ball to him so he could learn to bat and catch, and no instructions on how to do it should be offered.

A child who is motivated to try a new task in a non-competitive setting and without formal instructions is likely to find a way to succeed, although the performance style may be unconventional, even ungainly. It may be necessary at present to forego the appearance of graceful posture and movement in favour of functional result rewarding for the child. And let us hope that in the foreseeable future we will be able to improve both at the same time.

LAWRENCE T. TAFT 704