CHAPTER 4

Examining and Evaluating the Disabled Child

To decide what kind of special help, if any, a disabled child may need, first we need to learn as much as we can about the child. Although we may be concerned about her difficulties, we must always try to look at the whole child. Remember that:   A child's abilities are more important than her disabilities. The aim of rehabilitation is to help the child to function better at home and in the community. So when you examine a child, try to relate all your observations to what the child can do, cannot do, and might be able to do. What a child is and does depends partly on other persons. So we must also look at the child's abilities and difficulties in relation to her home, her family, and her village or neighborhood.

To evaluate a child's needs, try to answer these questions:

	What can the child do and not do? How does this compare with other children the same age in your community?
	What problems does the child have? How and when did they begin? Are they getting better, worse, or are they the same?
	In what ways are the child's body, mind, senses, or behavior affected? How does each specific problem affect what she does?
	What secondary problems are developing? (Problems that result after and because of the original problem.)
	What is the home situation like? What are the resources and limitations within the family and community that may increase or hold back the child's possibilities?
	In what way has the child adjusted to her disability, or learned to manage?

To find the answers to these questions, a health or rehabilitation worker needs to do 3 things:

1. Observe the child carefully-including her interaction with the family and with other persons.
2. Take a 'history'. Ask the parents and child (if old enough) for all information they can provide. Obtain medical records if possible.
3. Examine the child to find out how well and in what way different parts of her body and mind work, how developed they are, and how much they affect her strengths, weaknesses or problems.
    

It is usually best to ask questions BEFORE beginning to examine the child-so that we have a better idea what to look for. Therefore, we will discuss history-taking and then examination. But first a word about keeping records.

RECORD KEEPING

For a village rehabilitation worker who helps many children, writing notes or records can be important for following their progress. Also, parents of a disabled child may find that keeping simple records gives them a better sense of how their child is doing.

Sheets 1 and 2 will be useful for most disabled children. Sheets 3, 4, and 6 are for children who may have brain damage or seem slow for their age. Sheet 5 is a simple form for evaluating the progress of children 5 years old or older.

HISTORY TAKING

On Pages 37 and 38 you will find a record sheet for taking a child's history. You can use it as a guide for the kinds of questions it is important to ask. (Of course, some of the questions will apply more to some children than others, so ask only where the information might be helpful.)

When asking questions, we rehabilitation workers must always remember that parents and family are the only real 'experts' on their child. They know what she can and cannot do, what she likes and does not like, in what ways she manages well, and where she has difficulties.

However, sometimes part of the parents' knowledge is hidden. They may not have put all the pieces of knowledge together to form a clear picture of the child's needs and possibilities. The suggestions in this chapter, and the questions on the RECORD SHEETS, may help both rehabilitation workers and parents to form a clearer picture of their child's needs and possibilities.

EXAMINING THE DISABLED CHILD

After finding out what we can by asking questions, our next step is to examine the child. In as friendly a way as possible, we carefully observe or test what parts of the child work well, what parts work poorly, and how this affects the child's ability to do things and respond to the world around him.

In examination of a disabled child, we may check on many things:

The senses: How well does the child see? hear? feel?

Movement: How well does the child move or control her movements?

Form and structure: How well formed, deformed, or damaged are different parts of the body: the joints,the backbone,  and skin?

Mind, brain, and nervous system: How much does the child understand? How well do different parts of the body work together? For example, balance or eye-to-hand coordination.

Developmental level: How well does the child do things, compared to other local children her age?

In addition, a complete physical examination would include checking the health of systems inside the body. Although this part of the examination, if needed, is usually done by health workers, rehabilitation workers need to know that with certain disabilities inner body systems may also be affected. Depending on the disability, these may include:

A detailed examination of all a child's parts and functions could take hours or days. Fortunately, in most children this is not necessary. Instead, start by observing the child in a general way. Based on the questions you have already asked and your general observations, try to find anything that seems unusual or not quite right. Then examine in detail any body parts or functions that might relate to the disability.

Some children require a much more complete examination than others. For example:

Juan lost one hand in an accident 2 years ago, but otherwise seems normal. Probably he will need little or no physical examination other than to see how he uses his arms, stump, and hand. You will also want to check how much he can do with his other hand, with only his stump, and when using both together. The Physical Examination Form (RECORD SHEET 2 on Page 39) is probably the only examination form you need to fill out. However, it would be wise to learn about how Juan's family and others treat him now, and how he feels about himself and his ability to do things. Does he keep his stump hidden when he is with strangers? With family members? What are his hopes and fears? You can write this information on the back of the form.

Ana is 2 years old and still does not sit by herself. She has strange uncontrolled movements. She does not play with toys or respond much to her parents. Ana seems to have many problems.  We will need to check: how well she sees and hears. how strong, weak, or stiff different parts of her body are. in what ways her development is slow (what she can do and not do). how much she understands. signs of brain damage, and how severe. her sense of balance and position. what positioning or support gives her better control and function. It may take weeks or months of repeated examining and testing to figure out all of Ana's difficulties, and how to best help her to function better. It could be a mistake to try to do all the needed examining at one time. To record all the useful information on a child like Ana, you will find RECORD SHEETS 1, 2, 3, 4, and 6 helpful.

Examining techniques: Winning the child's confidence Depending on how you go about it, the physical examination can help you become a child's friend or turn you into his enemy. Here are a few suggestions:

Dress as one of the people, not as a professional. White uniforms often scare a child-especially if at some time he was injected by a nurse or doctor.   Before starting the examination, take an interest in the child as a person. Speak to him in a gentle, friendly way. Help him relax. Touch him in ways that show you are a friend.   Approach the child from the same height, not from above. (Try to have your head at the same level as his.)   Start the examination with the child sitting or lying on mother's lap, on the floor, or wherever he feels most safe and comfortable.

TESTING RANGE OF MOTION OF JOINTS
AND STRENGTH OF MUSCLES

Children who have disabilities that affect how they move often have some muscles that are weak or 'paralyzed'. As a result, they often do not move parts of their bodies as much as is normal.

Loss of strength and active movement may in time lead to a stiffening of joints or shortening of muscles (contractures, see Chapter 8). As a result, the affected part can no longer be moved through its complete, normal range of motion.

In the physical examination of a child with any weakness or paralysis of muscles, or joint pain, or scarring from injuries or burns, it is a good idea to test and record both RANGE OF MOTION and MUSCLE STRENGTH of all Parts of the body that might have contractures or be affected. There are 2 reasons for this:

	Knowing which parts of the body have contractures or are weak, and how much, can help us to understand why a child moves or limps as she does. This helps us to decide what activities, exercises, braces, or other measures may be useful.
	Keeping accurate records of changes in muscle strength and range of motion can help tell us if certain problems are getting better or worse. Regular testing therefore helps us evaluate how well exercises, braces, casts, or other measures are working, and whether the child's condition is improving, and how quickly.

For testing range of motion and muscle strength, it helps to first know what is normal. You can practice testing non-disabled, active persons. They should be of the same ages as the disabled children you will test. Age matters because babies are usually weaker and have much more flexible joints than older children. For example:

A baby's back and hips bend so much he can lie across his straight legs.	A young child bends less but can usually touch his toes with his legs straight.	Around 11 to 14 it is harder to touch toes. His legs grow faster and become longer than his upper body.	Later, upper body growth catches up with legs. He can again touch toes more easily.

In different children (and sometimes in the same child) you may need to check range of motion and strength in the hips, knees, ankles, feet, toes, shoulders, elbows, wrists, hands, fingers, back, shoulder blades, neck, and jaw. Some joints have 6 or more movements to test: bending, straightening, opening, closing, twisting in, and twisting out. See, for example, the different hip movements (range-of -motion exercises) on Page 380 in Chapter 42.

To test both 'range of motion' and 'strength', first check 'range of motion'. Then you will know that when a child cannot straighten a joint, it is not just because of weakness.

Range-of-motion testing: Example:

Knee

1. Ask the child to straighten it as much as she can.

With your hands, support the joint on each side as you straighten it. 2. If she cannot straighten it all the way, gently see how far you can straighten it. without forcing.

3. If at first the joint will not straighten, keep trying with gentle continuous pressure for 2 or 3 minutes.		If it still does not straighten, the range of motion is reduced. This is usually because of a contracture (see Chapter 8).
		If it gradually straightens, spasticity (muscle spasms) may be what makes it difficult (see Page 79). (if it stops before it straightens completely, contractures may also be developing.)

4. If a joint will not straighten completely, try with the child in different positions.		For example, a knee often does not straighten as much with the hips bent as with the hips straight.		For this reason, each time you test range of motion to measure changes, be sure the child is in the same position.
Position affects how much certain joints straighten or bend. This is true in any child, but especially in a child with spasticity (see Pages 101 to 103).

5. In addition to checking how much a joint straightens, check how much it bends.

If joints are kept straight and never bent, they may stiffen or develop contractures that do not let them bend. (This can happen with joint infection, arthritis, and other conditions, or when a joint is kept in a cast for a long time.)

Usually the best positions for checking range of motion are the same as those for doing range-of-motion and stretching exercises. These are shown in Chapter 42.

For methods of measuring and recording range of motion, see Chapter 5.

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Precautions when testing for contractures

Testing range of motion of the ankles, knees, and hips is important for evaluating many disabled children. We have already discussed knees. Here are a few precautions when testing for contractures of ankles and hips.

Ankle

Test the range of motion with the knee as straight as it will go.

With the knee bent, the foot will usually bend up more. But for walking, we need to know how far it bends with the knee straight.

Note: To check ankle range of motion in a child with spasticity: With his body and knee straight, it may be hard to bend the ankle.   So first bend his neck, body, and knees and then slowly bend up the ankle. Then slowly straighten his knee while keeping the ankle bent. Other precautions for testing ankle range of motion are on Page 383.

Hip

To check how far the hip joint straightens, have the child hold his other knee to his chest, like this, so that his lower back is flat against the table. If his thigh will not lower to the table without the back lifting, he has a bent-hip contracture. (See Page 79.)

CAUTION:  The hips will often straighten more at an angle to the body. So be sure to lower the leg in a straight line with the body, or you can miss contractures that need to be corrected before the child can walk.

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Muscle testing

Muscle strength can be anywhere between normal and zero. Test it like this:

It the child can lift the weight of leg all the way, press down on it, to cheek if she can hold up as much weight as is normal for a girl her age. If she can, her strength is NORMAL.   If she can hold some extra weight, but not as much as is normal, she rates GOOD.   If she can just hold up the weight of her leg, but no added weight, she rates FAIR. If she cannot hold up the weight of her leg, have her lie on her side and try to straighten it. If she can, she rates POOR. If she cannot straighten her knee at all, put your hand over the muscles as she tries to straighten it. If you can feel her muscles tighten, rate her TRACE.

Test the strength of all muscles that might be affected. Here are some of the muscle tests that are most useful for figuring out the difficulties and needs of different children.

Ankle and Foot

If the child can walk, see if she can stand and walk on her heels and her toes.

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Knee

Hips

BENDING

STRAIGHTENING

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Stomach and Back

To find out how strong the stomach muscles are, see if the child can do 'sit ups' (or at least raise his head and chest).		To test the back muscles, see if he can bend backward like this.
Sitting up with knees bent uses (and tests) mainly the stomach muscles. Feel stomach muscles tighten.	Sitting up with knees straight uses the hip-bending muscles and stomach muscles.	Feel the muscles tighten on either side of the backbone. Notice if they look and feel the same or if one side seems stronger.

You can check a child's trunk control and strength of stomach, back, and side muscles like this. Have him hold his body upright over his hips, then lean forward and back, and side to side, and twist his body.

If a child's stomach and back muscles are weak, he may need braces with a body Support- or a wheelchair.

IMPORTANT: Be sure to check for curvature of the spine- especially in children with muscle imbalance or weakness of the trunk.

Shoulders, Arms, and Hands

When a child's legs are severely paralyzed but she has FAIR or better trunk strength, she may be able to walk with crutches if her shoulders, arms, and hands are strong enough.

Therefore, an important test is this. Can she lift her butt off the seat like this?

If she can, she has a good chance for walking with crutches.

If she cannot lift herself, check the strength in her shoulders and arms:

ARMS	SHOULDERS

If the shoulder pushes down strongly but her elbow-straightening muscles are weak, she may be able to use a crutch with an elbow support.

Or, if her elbow range of motion is normal, she may learn to 'lock' her elbow back like this. However, this can lead to elbow problems.

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You may want to make a chart something like this and hang it in your examining area, as a reminder.

In muscle testing, it is especially important to note the difference between FAIR and POOR. This is because FAIR is often strong enough to be fairly useful (for standing, walking, or lifting arm to eat). POOR is usually too weak to be of much use.

EVALUATING STRENGTH OR WEAKNESS OF MUSCLES CAUTION: To avoid misleading results, check range of motion BEFORE testing muscle strength.

Sometimes with exercise POOR muscles can be strengthened to FAIR; this can greatly increase their usefulness. It is much less common for a TRACE muscle to increase to a useful strength (FAIR), no matter how much it is exercised. (However, if muscle weakness is due to lack of use, as in severe arthritis, rather than to paralysis, a POOR muscle can sometimes be strengthened with exercise to GOOD or even NORMAL. Also, in very early stages of recovery from polio or other causes of weakness, POOR or TRACE strength sometimes returns to FAIR or better.)

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Other things to check in a physical examination

Difference in leg length. When one leg is weaker, it usually grows slower, and becomes shorter than the other leg. An extra thick sole on the sandal might help the child stand straighter, limp less, and avoid curving of the spine. A short leg may also be a sign of a dislocated hip. So it helps to check for, and to measure, difference in leg length. (For tests, see Page 155 and 156.)

Curve of the spine

Especially when one leg is shorter or there are signs of muscle imbalance in the stomach or back, be sure to check for abnormal curve of the spine (back bone). The 3 main types of spinal curve (which may occur separately or in combination) are:

Some spinal curves will straighten when a child changes her position, lies down, or bends over. Other spinal curves will not straighten, and these are usually more serious. For more information about examining spinal curve and deformities of the back, see Chapter 20.

EXAMINING THE NERVOUS SYSTEM

Sometimes physical disability results from problems in the muscles, bones, or joints themselves. But often it comes from a problem in, or damage to, the nervous system.

Depending on what part of the nervous system is affected, the disability will have different patterns.

For example, polio affects only certain action nerves at points in the spinal cord (or brain stem). It therefore affects movement. It never affects sensory nerves, so sight, hearing, and feeling stay normal. (See Chapter 7.)

A spinal-cord injury, however, can damage or cut both the sensory and action nerves, so that both movement and feeling are lost. (See Chapter 23.)

Unlike polio and spinal-cord injury, which come from damage to nerves in the spine, cerebral palsy comes from damage to the brain itself. Because any part or parts of the brain may be damaged, any or all parts of the body may be affected: movement, sense of balance, seeing, hearing, speech, and mental ability. (See Chapter 9.)

Therefore, how completely you examine the workings of the nervous system will depend partly on what disability the child appears to have. If it is fairly clear the disability comes from polio, little examination of the nervous system is needed. But sometimes polio and cerebral palsy can be confused. If you have any suspicion that the disability might be caused by brain damage, you will want to do a fairly complete exam of nervous system function. Damage to the brain or nervous system can cause problems in any of these areas:

seeing (See Chapter 30.)	hearing (See Chapter 31.)	unusual or strange behaviors; signs of self- damage (See Page 364.)
eye movement or position  (See Pages 40 and 301.)	use of mouth and tongue, and speech (See Pages 313 to 315.)	muscle tone (patterns of unusual floppiness, tightness, spasms, or movements). (See Chapter 9.)
fits or seizures (epilepsy) (See Chapter 29.)	mental ability; level of development (See Pages 278 and 288.)	reflexes; muscle jerks (See Pages 40 and 88.)
balance, coordination, and sense of position (See Pages 90 and 105.)	feeling (pain and touch) (See Pages 39 and 216.)	urine and bowel control (See Chapter 25.)

Methods for testing some of these things are included on the next few pages and on the RECORD SHEETS 2, 3, and 4. Other tests that you will need less often, we include with specific disabilities. Refer to the page numbers listed above.

EVALUATION OF A CHILD WHOSE DEVELOPMENT IS SLOW

For the child who cannot do as much as other children do at the same age, a special developmental evaluation may be helpful. Additional information about the child's mother during pregnancy, or any difficulties during or after birth may explain possible causes. Measurement of the distance around the head may show possible causes of problems or other important factors. Repeated head-size measurements (once a month at first) may tell us even more.

For example, a child who has had meningitis (brain infection) at age 1, and whose head almost stops growing from that age on, will probably remain quite retarded. We should not expect a lot. However, if the child's head continues to grow normally, the child may have better possibilities for learning and doing more (although we cannot be sure).

A child who is born with a 'sack on the back' (spina bifida, see Page 167) may have a head that is bigger than average. If the head continues to grow rapidly, this is a danger sign (see Page 41 and 169). Unless the child has surgery, she may become severely retarded or die. If, however, the monthly measurements show that the head has stopped growing too fast, the problem may have corrected itself. She may not need surgery.

RECORD SHEET 4, on page 41, covers additional questions relating to child development, and includes a chart for recording and evaluating head size.

To help the child who is developmentally delayed, you will first want to evaluate her level of physical and mental development. Chapter 34, Pages 287 to 300, explains ways to do this.

You can use the Child Development Chart on Pages 292 and 293 to find a child's developmental level, to plan her step-by-step activities, and to evaluate and record her progress. We have marked this 2-page chart, RECORD SHEET 6.

RECORD SHEETS

On the next 5 pages are the sample RECORD SHEETS that we discussed on Page 22. You are welcome to copy and use them. However, they are not perfect. They were developed for use by the village rehabilitation team in Mexico, and we are still trying to improve them. Before you make copies, we suggest that you adapt them to meet the needs of your area.

In addition to the 4 RECORD SHEETS here, you may also want copies of RECORD SHEET 5 "Evaluation of Progress," Page 50, and RECORD SHEET 6, "Child Development Chart," Pages 292 and 293.

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