Pediatric Annals

WHO SHALL BEGIN? WHAT DIFFERENCE DOES IT MAKE? EARLY CHILDHOOD INTERVENTION

Madeline E Dalton

Abstract

1. Bernstein, B. Developmental Programs lor Delayed Learners. New York: Bureau for Children with Retarded Mental Development, 1972.

2. Bloom, B. S. Stability and Change in Human Characteristics. New York: John Wiley and Sons, 1964.

3. Granowitz, S. Pupil Resume Report. New York: Bureau for Children with Retarded Mental Development, 1973.

4. Hellmuth, J., ed. The Special Child in Century 21. Seattle: Special Child Publications, 1964.

5. Hunt, J. McV., Intelligence and Experience. New York: The Ronald Press Company, 1961.

6. Hunter, M. H., Schuckman, H., Friedfander, G. The Retarded Child from Birth to Five. New York: The John Day Company, 1972.

7. Jordan, T. E. The Mentally Retarded. Columbus: Charles E. Murili Books, Inc., 1961.

8. Michal-Smith, H. The Mentally Retarded Patient. Philadelphia: J. B. Lippincott Company, 1956.

9. Reger, R., Schroeder, W., Uschold, K. Spec/a/ Education Children with Learning Problems. New York: Oxford University Press, 1968.

10. Stevens, H. A. and Heber, R. Mental Refardal/ort, A Review of Research. Chicago: The University of Chicago Press. 1964.

11. Stevens, B., ed. The Training ot the Devel· opmentally Young. New York: The John Day Company, 1971.…

F or hundreds of years, mentally retarded children have been variously discarded, ignored, mistreated, and more recently treated and studied, but the primary effort to improve their care and treatment has come not from professionals but from indomitable parents, aroused citizens, and responsible legislators.

FEW ANSWERS TO CAUSATIVE FACTORS

Contrary to what might be expected, the medical profession has few answers concerning the causative fac^ tors of mental retardation or how to prevent or cure them, whetRcf they are related to prenatal, natal, or postnatal conditions. According to the President's message to the 86th Congress (1963), mental retardation "can result from mongolism, birth injury or infection or any host of conditions that cause a faulty or arrested development of intelligence to such an extent that the ability to learn and to adapt to the demands of society is impaired."

For most persons so affected, the impairment is not reversible. Medical science has found no cures. However, early detection followed by suitable care and training can, in some cases, arrest the condition or in others significantly improve the level of functioning and potential for adjustment.

FACTORS AFFECTING THE UNBORN CHILD

The most significant factors affecting the unborn child that may be associated with mental retardation are those related to maternal health and well-being-infection, nutrition, chronic illness, drug ingestion, radiation, trauma, anoxia, toxemia of pregnancy, blood incompatibility, rubella syndrome, and prematurity. Prematurity itself is associated with 15 to 20 per cent of all cases of mental retardation. Curious relationships of maternal age to several types of congenital abnormalities such as Down's syndrome are observed. However, both younger and older mothers run greater risks of birth defects under varying circumstances that require further study.

Available data indicate that children born with major and minor anomalies identifiable within the first year of life represent, respectively, 4 to 13 per cent of total births. Of these, approximately 50 per cent of the former and a significant per cent of the latter are mentally retarded.

Conditions which place the baby at high risk at birth are congenital anomalies of the brain, convulsions, metabolic disorders, and respiratory disorders. Difficult, precipitous, or prolonged labor or blood incompatibility all add to the risk of birth injury and mental retardation.

Although the outcome of abnormal neurologic symptoms at birth cannot be predicted with certainty/ it is, of course, necessary that the best care and treatment be given and that regular pediatrie examinations include effective checks for signs of possible brain damage. continued

After birth, the causes of mental retardation are so varied and numerous that it would be difficult to adequately categorize them. Medical practice and social action could significantly reduce or ameliorate the effects of mental retardation, but neither the medical profession nor society has yet given priority to this effort.

IMPORTANCE OF EARLY DETECTION AND TREATMENT

Emphasis in research and demonstration programs over the last decade on the critical years of early childhood as preparatory periods for later learning has highlighted the importance of early identification and treatment of special problem areas. Pediatricians and educators have been urged to initiate help as early as possible in the life of the child. Lack of positive action to attack early childhood deviations can result in a compounding of difficulties and overwhelming odds against later rehabilitation.

Early detection of neurologic defects, endocrine disturbances, and metabolic disorders has permitted the pediatrician to institute appropriate treatment more quickly, before the disease process produces irreversible intellectual damage. Dietary intervention in cases such as phenylketonuria and galactosemia and prescription of seizure control medication and glandular substances where indicated can aid in controlling the development of associated intellectual deficiencies.

Other physical conditions present at birth should alert the pediatrician to the high risk of retardation and thus require close follow-up in the postnatal period. Prematurity, prolonged and difficult labor, anoxia, and jaundice are among the alerting signals that demand frequent and extensive examination and observation. Early medical intervention for conditions such as hydrocephalus may arrest the process of brain damage and reduce the possibility of permanent damage and retardation.

For mentally retarded children, as for all children, early learning constitutes the basis for later skills. Conditions that hinder or facilitate opportunities for learning affect the child's present and future behavior. For the retarded child, especially, it is crucial to identify his or her handicaps at an early age in order to provide immediate, positive intervention and avoid the false starts, needless frustrations, and lost time that may further retard his or her progress.

As early as 1962, the President's Panel on Mental Retardation recommended the establishment of preschool centers for socialization and stimulation of retarded children and for counseling of parents relative to effective home training of the retarded. Federal legislation was passed to provide for the establishment of special programs aimed at developing new approaches to helping preschool handicapped children.

More than a decade later we are still searching for these preschool centers. They are few and far between. Perhaps the explanation lies in the fact that, in many children, retardation is not identified or diagnosed until the delays or gaps in development are so pronounced that the children are set apart from their peer group by their inability to cope with the demands of that young society.

Of the 60,000 to 100,000 mentally retarded children born each year, most are asymptomatic at birth. However, evidence suggests that approximately 20 per cent of the profoundly and moderately retarded children are identifiable by physical anomalies that could be discovered and interpreted by the examining pediatrician. Even in the absence of these physical anomalies, pediatricians may have grave suspicion at the time of birth that mental retardation is a possibility. Prematurity, anoxia, low Apgar ratings, asphyxia, and various types of birth difficulties may all contribute to a reasonable suspicion of future difficulties.

INITIAL APPROACH OFTEN CRUCIAL

Since the physician is often the first professional person to suspect the presence of mental retardation in the preschool child, his or her initial approach to the diagnosis and its implications is often crucial in initiating treatment. Failure to explore the possibilities suggested by suspicions may deprive the child of possibilities for early medical and educational intervention.

In making that first diagnosis, the physician must deal with many difficult questions early in the life of the high-risk child. Should he or she discuss the suspicions with the parents? Which parent? When? Should he or she be authoritative or nondirective? Is he or she prepared to answer the inevitable questions the parents must ask? Can he or she handle their anguish and denial honestly and compassionately? Is he or she familiar with appropriate resources for concrete help? Can he or she involve these parents in a more extensive counseling process as more definitive diagnostic tests and judgments are developed?

Even though anxious parents are frequently subconsciously aware of developmental lags or other suspicious signs of mental retardation, they turn to their physician not for judgment but for reassurance. When they cannot cope with the impact of his or her appraisal, they all too often reject the doctor or become angry that he or she cannot supply all the answers or solutions.

The doctor, too, finds it difficult to "pronounce a judgment" with such grave implications, for he or she may not be able to identify a cause, provide a therapy, or forecast the possible consequences or implications. Diagnostic tools are limited and definitive answers are seldom possible. The pediatrician's judgments must be supported by the findings of other professional colleagues.

FIRST DIAGNOSIS IS THE BEGINNING OF REALITY

However difficult it is, and tenuous as it may seem, that first diagnosis is the beginning of reality. Knowledge and certainty are preferable to anxiety and doubt, and constructive planning can begin. Parents and professionals must unite in their efforts as early as possible to develop a comprehensive plan for the mentally handicapped child. The knowledge and skills of many disciplines must be joined in a coordinated program to ameliorate the handicaps, to remediate the defects, and to develop the assets of the retarded child. The professional team must include all the disciplines that can contribute to the well-being of both child and family.

Since some forms of mental retardation respond to early medical intervention, a complete evaluation must begin with a careful medical history, physical examination, and laboratory procedures, which might include blood count, urinalysis, test for phenylpyruvic acid, electroencephalogram, and skull x-rays. Other procedures might include tuberculin skin test, buccal smear, chromosomal analysis, or even spinal puncture, pneumoencephalogram, or ventriculogram, if indicated.

To assess the child's mental capacities and personality factors- so crucial in constructive educational planningthe psychologist must use all appropriate psychological tests and other evaluative tools at his or her disposal.

The social worker must not only provide support and counseling for the family, but must serve as the link between the child and family and all the community services and agencies available to them.

A most significant member of the professional team, especially for the very young child, is the public health nurse. He or she should be available to encourage the best possible care and management of the child at home and to assist the parents in carrying out the team recommendations.

At an early age, hopefully beginning in the preschool years, other professionals should add their skills and competencies to the developmental and habilitation team. These should include speech and hearing clinicians, nutritionists, physical therapists, laboratory technicians, medical specialists, and educators. Together they must pool their findings to provide the comprehensive support and realistic counseling that will enable the child and the parents to function at their optimum potential.

FINDING CHINKS IN THE ARMOR OF DISABILITY

Working individually or collectively, neither the pediatrician, psychologist, social worker, therapist, educator, nor their combined professional effort can cure the incurable. They cannot reverse the laws or acsidents of nature, but they can together find the chinks in the armor of disability and provide a constructive program that will enable every child to capitalize on his or her assets and limit his or her handicaps.

Each member of the team, in a total coordinated effort, can provide constructive support that works in a geometric rather than arithmetic progression to help each child function at his or her most optimistic level of performance. Improvement in general health leads to improvement in mental health. Improvement in physical coordination leads to improvement in self-concept, cognitive awareness, and readiness for learning. This in turn encourages more optimistic expectancies and more hope and support from parents and teachers. Parent counseling, special therapies, and special education give hope to the bewildered and confused parent and individualized programming and assistance to the child with special problems.

In many ways, special education has acted as a pioneer in the whole field of education. Psychologists and educators have, for many years, recognized the need to bring the handicapped child into an educational setting at a very early stage in life. The studies of Dr. Samuel Kirk in the 1950's with preschool retarded children sparked a whole series of theories and studies to measure the effects of early educational intervention. Yet, it is general education that has capitalized on the results of such studies. Head Start and Sesame Street and many other federally-supported programs are government efforts on behalf of the disadvantaged child, and only incidentally are the handicapped included.

CRITICAL ROLE OF EARLY EXPERIENCES

Many handicapped children, even today, are not admitted to school until age seven or older, even though they are well beyond the chronological age eligibility for early childhood programs. The experiences and opportunities of these early years cannot be recaptured.

The critical role of early experiences in the total development of the young child is highlighted by the studies of Bloom,2 which indicate that 50 per cent of a child's development takes place between conception and age four. An additional 30 per cent of development toward maturity at age 17 occurs between the ages of four to eight. It would seem imperative then to make every effort to fully utilize these early childhood years for maximum support and enrichment for every child.

If we agree that early education is a mandate for all children, especially for the deprived child, how then can we neglect the handicapped child, who by the nature of his or her condition is deprived of the normal and natural experiences of childhood and who by the nature of apprehensive parents is zealously guarded and protected from an unfriendly and rejecting environment and society, which should provide the stimulus for normal growth and development? When parents suspect delayed development, they usually are reluctant to expose their child to the demands of a preschool program for fear of rejection or of the child being unable to cope with the demands of the more advanced peer group.

A major problem in the management of the mentally retarded child is finding out how to govern the encounters of this child with the environment. Which intervention techniques are best employed with which children, when, and under what conditions, in order to foster both an optimally rapid rate of development and satisfactory life experiences?

According to the observations of Piaget and his collaborators on the development of intelligence and logical thinking, appropriate encounters with the environment at appropriate levels of development are critical in determining the eventual functioning level of each child. While the genes may set limits for intellectual potential, as for height and weight, interaction with the environment must determine whether or not that full potential can be achieved.

To the extent that a child's perception of his or her environment is distorted or limited by a handicapping condition such as blindness, deafness, physical disability, or mental retardation, so, too, are his or her interaction with and reactions to that environment. The role of the physician and clinical team, then, must be to repair or ameliorate any condition which distorts the child's perceptions, while the role of the educator must be to prepare and structure the child's encounters with the environment to reproduce or simulate normal interaction sequences.

EARLY INTERVENTION FOR HIGH-RISK CHILDREN

Operating on the premise that such early intervention through an orderly and appropriate series of environmental encounters can make a difference in stimulating maximum efficiency for every handicapped child, the Bureau for Children with Retarded Mental Development (BCRMD) of the New York City Board of Education in 1970 enlisted the support of Maimonides Child Development Clinic in Brooklyn, N. Y., to establish an early childhood educational program for high-risk children whose serious developmental lags indicate mental retardation at the preschool and early childhood years. The program is unique in that for the first time, under public school auspices, the whole child is treated and habilitated within the framework of an educational focus.

As part of the Regional Program for Mental Health/Mental Retardation Services, the Maimonides Child Development Clinic redefined its geographic catchment area to include all mentally retarded children who live or "attend school" in the designated area. Without infringing on the traditional role of the Bureau of Child Guidance, Maimonides Child Development Clinic pledged to provide a multiservice support team including pediatrie, psychological, psychiatric, and other diagnostic medical, health, and social services on a continuing basis and as part of a continuum of special education in the vulnerable years of early childhood.

AN EXPERIMENT IN EARLY EDUCATION

An enthusiastic principal and an enlightened district superintendent provided appropriate space and administration and supervisory support for the BCRMD supervisor, whose major focus and publication credits were in the area of early childhood special education. Three bright, second-floor classrooms, strategically located for easy access, supervision, and ready integration in the life of the school, were assigned to the project.

Three teachers were selected on the basis of their background and experience in special education for the mentally retarded, early childhood education, educational diagnosis and analysis skills, empathy with parents, and ability to work as members of an interdisciplinary team. These teachers were assigned to two classes.

The third teacher, a master teacher, served as resource specialist- providing assistance, developing materials, demonstrating techniques, providing and planning individualization of instruction, and organizing and planning the parent education and home training program.

In addition to her responsibilities within the school unit, the resource teacher also serves as a liaison between the referring agencies, the school, and the families of the children in the program. She attends case study conferences at the clinics and agencies, where she is briefed on the child's special problems and needs, which she translates into individualized educational plans. She works closely with the pediatrician, psychologist, and members of any other discipline serving the child. Any change in child behavior, positive or negative, is reported to the clinic. When it seems advisable, an appointment is set up immediately with the parent.

The first children placed in the early childhood program came through referrals from Maimonides Child Development Center and from community agencies serving the mentally retarded. Maimonides Child Development Center accepted responsibility for continuing evaluation and service to these children and their families. The BCRMD accepted the challenge of developing a curriculum, using the principles of early childhood education and special education, to meet the unique needs of these children, whose first encounters with living and growing had been traumatic.

The experimental group. The first children accepted for the program were identified, through preplacement psychological evaluations, as six trainable and seven educable retardates with I.Q.'s ranging from 33 to 59. In addition to the diagnosis of mental retardation, two of the children had physical limitations from cerebral palsy. Both required assistance in walking up and down stairs, in moving about the classroom, and in all physical activities. Two other children had vision problems, another had a heart murmur, one had asthma with related breathing difficulties, and one suffered from a thyroid disorder and diseased adenoids that caused a constant, uncontrollable nasal discharge.

General goals and objectives were outlined, but careful observation of each child soon established the need for setting individual goals within the framework of the general goals. Individual profiles of assets and objectives were developed for each child. Daily observations, informal testing/ and regular entries in social, emotional, physical, and academic development were made.

Social development. For eight children, this school program provided the first social experience in group living and association with children other than siblings. Three children had experienced unhappy, frustrating periods in kindergarten, and the remaining two had attended short-time play groups.

Emotional development. Emotional disturbances were common. Behavior in the classroom reflected parental attitudes of overprotection and rejection. Several children had home problems that would have been burdensome even to the normal child -divorced parents, extreme physical abuse, even, in one case, the responsibility for sharing in the care of a younger brother and infant sister. For air of these children, the classroom offered a new kind of honest acceptance with invitations to experiment and achieve, to explore and choose, and to develop a sense of independence and personal worth.

The security, comfort, and consistency of the school day soon enabled the children to relinquish infantile needs in favor of the satisfactions of cooperation and participation.

Physical development. For most of the group, retardation in motor development and coordination was very evident. Since self-concept is so closely identified with ability to control and manage the body and its parts, special attention was given to encouraging and teaching movement exploration. A physical education resource specialist taught body awareness, spacial relations, and perceptual motor coordination through games using simple equipment - tires, hoops, rocking boards, stepping frames, balance beams, parachutes, and seesaws as well as the usual balls, bean bags, tricycles, and jungle-gyms. Marching, running, hopping, jumping, and dancing were skills to be taught, not taken for granted.

Fine muscle coordination was developed through using pegboards, stringing beads, cutting and pasting, painting and coloring, using wooden blocks and jigsaw puzzles, and through a variety of arts and crafts projects.

Self-help. The skills of daily living were taught in practical and devised situations throughout the day, and teachers were reminded to do nothing for a child that he or she could do for him- or herself. This took great patience and restraint, but carried its own reward as teachers charted each small step toward personal independence.

Academic development. Academic skills, such as language and concept development, auditory discrimination, listening skills, verbal communication, number concepts, and counting were part of the curriculum. A parttime speech improvement teacher provided individual therapy for children with special problems and general speech development and stimulation for all children in small or large groups.

Music. Of all the areas taught, music was the most universal leveler. All children responded eagerly. They learned to beat and clap rhythms, to move and sway with the music, and to play simple instruments, and all tried hard to sing their favorite songs. Here, in the joy and freedom of response, inhibitions and differences in ability were lost in the chorus of song.

HOME MANAGEMENT AND TRAINING

Interviews with parents revealed that many could not cope with the management and training of their children at home. They requested help and guidance.

Parent workshops and home visits became part of the public school commitment. In addition, Maimonides conducted a series of mothers' guidance seminars to inform,, help, and guide parents about the nature of mental retardation, management and handling of children, community resources available for various aspects of parent and child problems, and realistic aspirations and expectations.

At workshops conducted by the school, parents learned how to work with their children. They exchanged ideas and techniques they had devised to cope with common problems. They became partners in setting realistic goals and in carrying out educational prescriptions or therapies recommended by teachers or other members of the interdisciplinary team.

The social worker, psychologist, psychiatrist, and pediatrician sometimes joined the workshops to interpret, inform, and guide parents, but most of all to reassure them that all avenues of assistance were being constantly explored and that each child was being observed and evaluated on a continuing basis.

The cooperation of parents in continuing the school and team programs at home is a crucial factor in the child's improvement. As each child becomes more trusting and secure, he or she grows increasingly available for more formal training. Progress, in turn, is greatly facilitated as parents begin to relinquish excessive anxiety and overcontrol.

As parents become more trusting and secure, their concerns about safety and cleanliness give way to parental satisfaction and pride in their child's improvements. Realistic interest then begins to replace overprotection.

Perhaps the major contribution of the multidisciplinary team to the child's well-being was, indeed, the help provided for the parents in clearing up misconceptions that added to their problems and in teaching parents how to stimulate and focus the child's learning as early as possible.

Parents tend to assume that a child will draw sufficient stimuli from the environment and use, assimilate, and integrate them automatically in the growth process. Through their workshops and seminars they learned that the retarded child needs direction from the beginning because of his or her limited ability to learn on his or her own initiative.

Parents became aware of the signs of natural maturation. When these were replaced by nonresponsiveness, nonawareness of the environment, and failure to meet simple milestones of growth at expected ages, parents became partners in using special training techniques to attempt to change the course of future development. Facilitating techniques individualized by the interdisciplinary team for each child and for the dynamics of his or her family added new dimensions to the therapeutic efforts and led to more realistic goals and better understanding of the child and his or her capabilities.

REWARDS OF EARLY INTERVENTION AND INTERDISCIPLINARY EFFORTS

The first year was indeed a year of happy experiences and wondrous learning for children, parents, and teachers alike. It was rewarding and gratifying, but more than that it lighted a flame and proved a conviction that early intervention and total habilitation through medical, clinical, and educational team effort could change a life and our perception of and reaction to it. A child comfortable in his or her relationships with parents and peers and physically able to cope with his or her environment is more adequately prepared and psychologically ready to meet the challenges of future training and learning.

Encouraged by the first year's success, the teachers, supported by the interdisciplinary team, continued to refine their skills in observation, management, curriculum development, and individual programming.

By the end of the second school year, 11 children were ready to move with their age peers beyond the early childhood classification into preprimary or primary special classes. However, for four children who showed unusual progress, retesting was recommended. These trainable-level children with I.Q/s of 40, 33, and 38 showed retest scores of 56, 55, and 65, respectively, while one educable child with a pupil placement LQ. of 58 received a retest score of 85. Both children with cerebral palsy were considered eligible for promotion to a special doubly handicapped class.

New children have joined the original group along the way. These continued in the program, and others have replaced the graduates. Again at the end of the third year, progress and improvement is evident for every child. Children who had not been heard to speak are speaking, singing, and reading words from charts. All the children have developed self-help and social skills which belie the fearful, dependent, immature, high-risk youngsters who joined the program on referral from clinics and services for the mentally retarded. For some children, change and progress is indeed dramatic.

DRAMATIC CHANGES

Stephen C,- d.o.b. 11/66. Stephen was premature (7 months), weighed 4 lbs. 2 oz., and required exchange transfusion and incubation. There was marked motor, speech, and language delay in development.

Referred by the Maimonides Child Development Center, Stephen was recommended for placement in the early childhood program for high-risk children in September 1972. He was most difficult to manage because he was extremely hyperactive, struck children, and was undisciplined. His only vocalization consisted of unintelligible jargon and frequent screams or shrills. Careful observation and regular entries on his profile sheet enabled the teachers to suspect a pattern of behavior indicative of hearing loss. The Child Development Clinic was informed of these observations, and Stephen was referred to the communication disorder service of a nearby hospital. Audiologic testing revealed a moderately severe bilateral hearing loss. The diagnostic impression was of expressive language impairment in addition to the hearing loss. Stephen was fitted with a hearing aid. His mother was referred to the social service unit of the Maimonides Child Development Clinic for special parent counseling. Now that she has a better understanding of Stephen's problems, she finds him much easier to manage.

With a new perception of his small world through correction of his hearing loss and with more acceptance and better understanding by his family, Stephen is now making remarkable progress in school. He has been referred for evaluation for more appropriate class placement. In view of the more definitive diagnostic findings, he has been placed in a class designed to meet his particular handicaps to learning- a special class for language and hearing impaired children.

Mark E. - d.o.b. 2/68. Mark's mother reported normal pregnancy, birth, and early development, except for poor vision and strabismus. Speech developed at age three, but with very severe articulation problems. Mark's speech was unintelligible. He was always hyperactive. Mark's mother, who was disorganized and unstable, has had the assistance of a Maimonides social worker since Mark's infancy. She was concerned about his speech problem because she didn't want him to be in a "special" class. However, since he was distractable, disruptive, and unresponsive, he was unable to function in the kindergarten group. He was therefore referred to the Board of Education's Bureau of Child Guidance for evaluation. Found to have an I. Q. score of 66, he was then recommended for the early childhood program.

After a complete physical and health examination, Mark was referred for an eye operation. The strabismus was corrected, and Mark was fitted for glasses. Parent counseling was begun, speech therapy was provided, and individualized curriculum experiences were designed. Careful observation by the speech therapist revealed that Mark had a paralysis of the tongue. Special treatment with follow-up by the teachers and Mark's mother has proved most successful. Mark has made remarkable progress. He has begun to read. Retesting indicates a normal I.Q. of 104.

To ensure appropriate placement with continuing attention to his special speech problems, Mark will be evaluated by the Board of Education Evaluation and Placement Unit and recommended for selected school placement, where continuing therapy will be provided.

Florence M. - d.o.b. 8/66. Florence's mother reported normal pregnancy, but the child weighed only 4 lbs. 6 oz. at birth and was incubated for five weeks. The neonatal period was complicated by failure to thrive, probably due to milk allergy. There is also a history of three febrile convulsions and episodes of generalized body stiffness.

A comprehensive study conducted at Maimonides Hospital in 1971 concluded with a neurologic impression of macrocephaly and mild atonic diplegia. Florence achieved an I.Q. score of 66 on the Stanford-Binet individual intelligence test. However, the Bender gestalt reproductions showed little resemblance to the models, supporting evidence of severe perceptual motor deficit. Florence'was recommended for placement in the early childhood program.

Parent counseling was started, and individualized educational experiences were planned with special focus on developing movement exploration and perceptual motor coordination and training.

All educational and interdisciplinary team recommendations were carried out as indicated. A recommendation for additional medical follow-up resulted in admission to the hospital in April 1973 for further observations, which revealed diabetes. Retesting indicated an I.Q. score of 76. Recommendations of the Evaluation and Placement Unit indicate that Florence will be recommended for placement in a class for brain-injured children, where special methods and materials will aid her in understanding and dealing with her own problems while receiving the support and guidance of the Evaluation and Placement support team.

Virginia C. - d.o.b. 4/66. Virginia's mother reported that pregnancy and birth were difficult. Virginia is hydrocephalic. At two months of age she was operated on and a shunt was inserted. It was to have been revised at three years of age, but Virginia's parents resisted since she seemed to be developing normally.

Virginia was admitted to kindergarten, but could not function with the group. She was extremely shy and withdrawn, and her achievements were poor. On referral to the Bureau of Child Guidance she obtained a score of 63 on an individual psychological evaluation. Parents were shocked by the diagnosis and needed much help in accepting placement in the early childhood program.

Soon after her placement, teachers became aware of an awkwardness of movement. Virginia did not respond to the perceptual motor training that became a part of her daily program. The Maimonides staff was alerted. Virginia's records were transferred to her "school register" catchment area. She was observed at the Maimonides Child Development Center. Parents were counseled, and the needed operation was performed. The old shunt, which was not functioning, was replaced in February 1972.

Virginia appears to be doing well since the operation. She has begun to read and has made such fine progress that it is the opinion of school personnel that she is now functioning within the normal range. She will be retested soon to determine appropriate school placement.

These cases, of course, are more dramatic than the cases of five youngsters with Down's syndrome and other mentally retarded pupils who, though showing marked progress, continue to function in the retarded range. For the cases with dramatic reclassification, we can easily relate to the new life of hope and expectation opened up for them. Yet, for the latter, too, teachers and parents alike have recognized a new kind of participation and zest for living in the children. They have learned to interact with their environment and to maintain a certain control over it. They have a new awareness of self and of each other. They have learned to reach out to life rather than to hide from it. One parent expressed his satisfaction and gratitude for his son's progress when he said, "My son used to function like a tin lizzy, but now he moves on all cylinders like a Cadillac."

NO MAGIC POTIONS FOR RETARDATION

Too often in the past, a diagnosis of mental retardation was without hope. Pediatricians themselves did not see the potential hidden behind the handicap. Without knowledge of the cause or cure, they were reluctant to face the issue. It seemed more compassionate to dispel the parents' immediate anxiety and let time and increasing evidence bring awareness and acceptance of the deficit. But time holds no magic potions for the retarded, and unrealistic hope can delay positive action and professional help.

An effective diagnosis is the first essential step, but a definitive diagnosis is not as critical as early identification of the condition ancf efficient management. A child who is mentally retarded cannot afford the added handicap of a bad start. As early as possible, health and medical problems must be appropriately dealt with. The child must be referred to an educational setting adapted to his or her special needs and limited abilities so that he or she may be encouraged to move at his or her own pace into each new challenge for living and learning.

POSITIVE EFFECTS OF A STRUCTURED, ORDERED ENVIRONMENT

By structuring and ordering the environment, under controlled conditions of a preschool or early childhood program, it is possible to systematically alter the presentation of stimuli in order to facilitate perceptual and sensory responsiveness. Through continuing evaluation over a period of time, it is then possible to study the basic parameters of daily development and to reassess particular functions and identify important clues to patterns of growth, rate of development, and conditions which facilitate learning.

For the child who is suspected of mental retardation, we must nurture all his or her potentials in all aspects of development - physical, social, and emotional as well as intellectual. We cannot limit our hopes for his or her future or measure his or her worth in one dimension alone or we devalue the quality of the whole person. Each child is unique and has varied endowments, and we must see each as a constantly changing human being.

As skilled professionals we have an opportunity to influence that change in a positive way by alleviating pain, minimizing defects, and providing opportunities for joy, satisfaction, learning, and adventure that will give meaning to a child's life today and shape and form to the kind of person he or she will become in the future.

For each child, the future is tentative. There is no typical course or outcome. It is impossible to predict with certainty, but it is important to realize that what we do today will seriously influence tomorrow and hopefully will provide a better future for the child whose potential was dimmed or delayed by a difficult beginning.

More than most children, the mentally retarded will be what we make of them by beginning at the beginning. By facing the problem of mental retardation when and where it is first suspected we can mobilize all professional disciplines and enlist parental positive action to seek care and treatment that will make a difference.

EARLY INTERVENTION MAKES A DIFFERENCE

From our short experience with early intervention by a full interdisciplinary team, combining the total efforts of medicine, surgery, therapy, parent counseling, social assistance, and education, we have been privileged to see that our efforts do indeed make a difference- for the child, for the parents, for the future of our society.

As we share our findings and our skills, we discover that what is resistant to one discipline may be responsive to another. The clues that were insignificant by themselves, under one set of circumstances, become beacons under more intensive scrutiny and continued observation.

Let us begin, then, at the first suspicion of mental retardation. That first clue may be the spark to set the wheels in motion, and the difference may be a discarded, unpolished jewel or a fulfilled human being functioning at full potential. The difference may be that "tin lizzy" or the "Cadillac functioning on all cylinders."

BIBLIOGRAPHY

1. Bernstein, B. Developmental Programs lor Delayed Learners. New York: Bureau for Children with Retarded Mental Development, 1972.

2. Bloom, B. S. Stability and Change in Human Characteristics. New York: John Wiley and Sons, 1964.

3. Granowitz, S. Pupil Resume Report. New York: Bureau for Children with Retarded Mental Development, 1973.

4. Hellmuth, J., ed. The Special Child in Century 21. Seattle: Special Child Publications, 1964.

5. Hunt, J. McV., Intelligence and Experience. New York: The Ronald Press Company, 1961.

6. Hunter, M. H., Schuckman, H., Friedfander, G. The Retarded Child from Birth to Five. New York: The John Day Company, 1972.

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8. Michal-Smith, H. The Mentally Retarded Patient. Philadelphia: J. B. Lippincott Company, 1956.

9. Reger, R., Schroeder, W., Uschold, K. Spec/a/ Education Children with Learning Problems. New York: Oxford University Press, 1968.

10. Stevens, H. A. and Heber, R. Mental Refardal/ort, A Review of Research. Chicago: The University of Chicago Press. 1964.

11. Stevens, B., ed. The Training ot the Devel· opmentally Young. New York: The John Day Company, 1971.

10.3928/0090-4481-19731001-09

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