Parenting Children with Mental Handicap
This parent guide is designed to help you help your child with mental handicap in his or her development and to keep him or her in functional and developmental health. It should be remembered that this guide does not constitute a cure for mental handicap - a disorder which varies extremely from child to child. Many of the problems described will not be encountered by most parents. The intention in including them all is that information is readily at hand whenever required. This guide covers the most important period in the life of a child. Development is maximal in the first six years of life. The guide should not be interpreted too literally, for each child differs from the other in his or her rate and level of development. This manual is meant to be a guide which if used in conjunction with the help of a disability specialist, will yield good results in maximizing the potential of your child.
Parenting Children with Mental Handicap A TRAINING MANUAL Madhumita Puri Society for Child Development New Delhi Early Sensory Training Feeding Warmth Developing Movement Skills Second-Level Development And Training Third-Level Development And Training Early Sensory Training Feeding Warmth Developing Movement Skills Second Level Development And Training Third-Level Development And Training Communication, Speech And Language Development Normal Language Development Language Development In Children With Mental Handicap Teaching Communication Skills Teaching Speech And Language More Tips To Remember Management Of Problem Behavior How Do Problem Behaviors Develop Methods For Modifying Problem Behavior Understanding The Child With Down's Syndrome Developing Cognitive Skills Pre-School Education INTRODUCTION This parent guide is designed to help you help your child with mental handicap in his or her development and to keep him or her in functional and developmental health. It should be remembered that this guide does not constitute a cure for mental handicap - a disorder which varies extremely from child to child. Many of the problems described will not be encountered by most parents. The intention in including them all is that information is readily at hand whenever required. This guide covers the most important period in the life of a child. Development is maximal in the first six years of life. The guide should not be interpreted too literally, for each child differs from the other in his or her rate and level of development. This manual is meant to be a guide which if used in conjunction with the help of a disability specialist, will yield good results in maximizing the potential of your child. 1. GENERAL HEALTH AND CARE EARLY SENSORY TRAINING The child with mental handicap is generally poorly developed, particularly in its nervous and blood circulation systems. The baby may be limp and unresponsive; its muscles may appear soft and powerless; and he or she may rarely cry or seem to demand anything. It is for this last reason particularly that the child should not be left alone in its cot for long periods of time. For most of the first year, a baby left alone to lie motionless on its back, starting at a featureless ceiling on the rare occasions when it is awake, provides no exercise for the body or mind. In the case of the child with mental handicap, with its poor nervous system and muscle tone, a lot of the potential the child had at birth will be irrevocably lost. The first months of life and the first five years are absolutely vital to any child's development and much can be done to maximize the child's potential if intervention is provided as soon as detection occurs. Handling the Baby As much as any other baby, a baby with a handicap needs love and affectionate handling to develop a stable and peaceful mind. The baby must not be neglected simply because he/she does not respond to your stimulation at once. The Brain and Mental Handicap In most cases, the brain of the child with a mental handicap is not damaged in the real sense of the term. However, though the brain cells are generally intact, the pathways (also known as nerves) which carry message from one site to the other are weak and slow. Intense stimulation helps these pathways grow stronger and faster. In medical science in the 1990s, very little is known about the full capacity of the brain. Nonetheless contrary to popular belief, it is the organ most easily reached through the five senses. What is the function of the brain? The brain is the 'telephone junction' from where messages are transmitted from one part of the body to another. It is the first organ to start developing and the last to stop. By six months, it has already doubled in size and volume since birth and has reached half its adult weight - the fastest development it will ever have in a lifetime. FEEDING The baby's swallowing reflex may not be well developed, so feeding tends to be difficult. Keep the baby fairly upright when feeding to prevent infections. Do not lay the child down until you are certain that it has brought up all its wind. Bottle Feeding Bottle feeding can be very slow because the baby forms a seal with its lip and tongue round the teat, so that air cannot return into the bottle. The flow stops and it may take you up to an hour to feed an ounce of milk to the child. To prevent this happening, twist the teat and work it from side to side in baby's mouth until bubbles come up into the bottle. Baby can then feed again until it forms the seal again. If youtervals the baby can take a whole feed before dropping off to ig up because the milk has cooled. If feeding trouble persists, try a shaped feeding bottle with an air valve at the opposite end. Spoon Feeding After the first 4 months, start adding small quantities of custard or something similar to the baby's diet. Form a very thin cream, which will start to flow from the bottle if you enlarge the hole in the teat by forming an X notch. As soon as the baby can take a fairly thick mixture from its bottle, attempts should be made to introduce spoon feeding. This can be very tiresome as the child's swallowing reflex is still poor, and the child may try to push out each mouthful. It might seem as if the food is being rejected. But if the food is kept thin and placed well back on the tongue, success will soon be yours. In Indian families, the concept of performing the 'annaprasan' - offering cereal to the baby for the first time - has its merits and demerits. Perhaps the tradition began in the days of yore to ensure that the infant was breast -fed for as long as possible. The merit in that is cognizable but for our handicapped one, it could well turn out to be a demerit. Due to emotional problems faced by the mother and poor ability to feed by baby leads to undernourishment. For those of you, who wish to follow the traditional custom, do introduce top-fed skimmed milk only after 4 months. It would be better if this milk is allowed to boil for a while to achieve the consistency of thin cream (almost like a think kheer). This should be fed by a spoon. Semi-solids When baby is ready for semi-solids, steam and strain vegetables through a sieve to make a light soup. You may have to try several combinations of vegetables before you find the one that baby prefers. Variety should be aimed for; as such children can be extremely stubborn and resist the slightest change in routine at a later stage if they are not given such variety and choice quite early. Some babies like to suck the yolk of a soft-boiled egg from a 'finger' of bread and butter. Otherwise, soft rusks can be soaked in milk and served by spoon. Some milk should be given from the bottle, or attempts should be made to get the child to drink from a special baby-cup after the semi-solids as the baby may otherwise refuse them. Add foods which contain iron, such as spinach. (Important -Spinach should not be given more often than once a fortnight). Chewing Babies should always be introduced to solids before the end of the first year, as their tongues tend to thrust food up against their palates where it sticks. When this happens, babies over one year tend to panic and feel that they are choking. A few small lumps should gradually be introduced, increasing them in size and solidity over a period of five. If baby is given only liquids for too long, the experience of chewing is denied and might take a very long time to develop later on. Good control of the tongue etc. in feeding will help later with speech development. Vomiting Any persistent tendency to throw up semi-solids immediately and violently after being fed (known as Projectile Vomiting) should be referred to your doctor because, in some cases, partial or complete intestinal blockage may be present. While this is not common, it is better to be sure. WARMTH Most children with mental handicap may have an inefficient temperature control and may not respond well to changes in weather, so that their own temperature may vary in conditions of extreme heat and cold. Keep baby well wrapped in winter and cool in summer. At night babies tend to push off their covers, so it is important to ensure that baby remains covered during the night when the temperature falls. Guidelines for Adequate Clothing A question which often plagues many a parent is - How many woolens are appropriate for the child. The general rule of thumb during the winter months is: Layer the child, with the first layer being a cotton vest (never put woolens or any synthetic material against the skin - they prevent the skin from breathing and may cause skin infections), the second layer could be a sleeveless woolen undershirt, the third a full-sleeved cotton dress or shirt, the fourth a light woolen followed by another light sweater. Such a pattern is generally sufficient for the north Indian winter. The principle behind this method is that the various layers form pockets of warm air - thus the woollies and the air provide double insulation against the cold. Yet another point to be remembered is to keep the feet covered. In summer, the pattern to be followed involves wearing loose, airy cotton clothing. In case soft cotton is not available, it is a good idea to stick to cotton T-shirts (No Synthetics Please!) Problems mostly arise at the time when the seasons are changing. If the baby is kept too warm, he or she may begin to perspire, causing the clothes to become damp - thereby leading to chest infections. DEVELOPING MOVEMENT SKILLS Exercise for Developing Muscles If the baby does not move on its own accord, arms and legs can be passively exercised. The exercise will be needed to be given with some care at first, as baby's joints are not firm. They are very flexible and special care should be taken with the hip and shoulder joints, which can easily be dislocated at this stage. With baby on its back, take baby's hand or foot in your open hand and gently toss it up and down until baby begins to tighten its muscles to check the movement. Alternatively, place the baby on its tummy, draw the arms forward and then lift them parallel with the head. The baby will then try to lift its head. Neck and Back These exercises will prepare the child for crawling, sitting and standing. Exercise 1 Place baby face down on a firm surface (table covered with a bath towel is best) for a short period each day. In the early days the child tends to lie limply with its head to one side, but after a month it can move its head a little. This position encourages the child to lift its head and chest. The child usually cries and struggles in this position, but this should not deter parents. Spending at least five minutes in this position, the child's rage and discomfort will stimulate it into movements which are ultimately beneficial. Exercise 2 Lay the child on its back on your knees. Take the child by the upper arms and shoulders and raise gently until the weight of the head can just be felt. At first the head will hang limply back. Lifting must be very slow and limited, as the baby's head does not have the usual support offered by its mother's hand. Some tension will begin to show in the neck muscles after a few days of this brief exercise. Eventually the child will take some of the weight on them and, if raised until the child's head is barely touching the support, the child will begin to lift its head, only a fraction of an inch at first. As soon as the child does this, lay the child back for a rest and repeat the exercise twice more . As the neck muscles gradually strengthen during the first six months, the child can gradually be raised higher. When he or she succeeds in making a visible effort to lift its head, pull the child slowly towards a sitting position on your knee. You will find that there is a certain critical point at which the child's head is just on the verge of falling forward. Hold the child exactly in this position and it will be able to pull its head forward on its own. These exercises should be kept up until such time as the child can steadily keep its head up on its own for at least a minute or two. As time goes on you will notice that the point from which the child can pull its head up will shift further and further back. The child should be held at this balance point. As the neck gets progressively more exercise by this method, the child will be able to raise its head when lifted and will be ready for the next set of exercises. SECOND-LEVEL DEVELOPMENT AND TRAINING This level covers the period from the fourth to the sixth month. Do not interpret this too strictly as individuals vary greatly in their rate of development. The main objectives of this stage are to encourage the child to use its eyes and hands and take an interest in its surroundings. The exercises outlined earlier should be continued. Body Exercises Exercise 1 Lay the child on its back and gently roll it first onto one side, then the other. Then hold the baby on it's side, with one hand on the small of the back. Lift one leg over the other towards the side you want him to roll to. Hold the foot firmly with the other hand, so that the child's hip is fixed and can be used as a pivot for the trunk, stomach and shoulder muscles to roll over. Repeat the exercise several times daily, on each side in turn, until the child can roll over completely from back to front. Exercise 2 Hold the child's feet in one hand. Steadily swing the child's leg from touching the ground on one side to touching the ground on the other. This rotation of the hips helps to strengthen the stomach muscles. Foot Exercises Lay the child on its back. Push gently with both hands against the soles of the child's feet. If you ease your hands gently backwards and forwards about half an inch, you will feel a point of balance between the muscles of the child'' legs, around which it tends to move its legs spontaneously. This ''cycling' movement, will develop into an exercise which should be used right up to the time the child can stand up on its own without support. It will help co-ordination when the child begins to stand and walk. Leg Exercises Exercise 1 Lay the child on its back. Raise both legs slowly until they are in the child's line of sight. Touch the child's nose with each foot in turn. The child may not attempt to move its hands at this stage, but will probably open its mouth in response. Exercise 2 Lay the child on its back. Turn the feet facing them sole to sole and clap them together gently, preferably while singing to the child. Then hold the feet together, the toes will probably come together and move against one another. If the child can see this, then sensation will arouse curiosity and severe to tell the child that its feet are part of its person. Eye Exercises Exercise 1 Look the child straight in the eyes at about fifteen inches range. Gradually move your face closer until your nose touches the child's and then slowly withdraw. Repeat this exercise regularly as it concentrates the child's attention and helps it to learn to focus its eyes. If the baby clutches at your hands or face, hold its hands gently and retreat slowly to the baby's arm length. This will give the child appreciation of distances. Exercise 2 Repeat Exercise 1 using a small toy and touch the child's face and encourage it to take the toy in its hand. Reluctant babies who keep their hands closed beyond the first months can often be induced to open them by stroking or rubbing the back of the hand in the direction of the shoulder with your thumb. Hand Exercises Some children begin to grasp at objects spontaneously, others do not seem to realize they have separate fingers. Exercise 1 Take the child's hands in turn and run a pencil or similar object across the back of the fingers. Do this fairly firmly. After a while, even babies who have never moved their fingers before, begin to separate them and move them and gradually begin to show an interest in them. Exercise 2 Take one of the child's hands and draw it to your face. Run the hand over your features and touch it with your hair. The child may either grasp or feel your features with spread fingers. Exercise 3 As soon as the child can close its hands, even feebly, it will clutch at hair which is allowed to touch its face, as even babies with limited vision are attracted by strong contrasts and pattern. A nodding of hair, moved up and down so that the child sees a pattern of contrasting light and dark hair, will attract its attention. Exercise 4 As soon as the child the child can hold a small object, a rattle should be provided. The baby should be shown how to move its arms to make a sound. Leave rattles near the child at night. Some babies who show little activity in the day have been heard to play quite energetically in the dark. THIRD-LEVEL DEVELOPMENT AND TRAINING This level covers the period from six months to one year. This should not be interpreted too strictly, as mentioned earlier, individuals vary greatly in their rate of development. The objectives of this stage are to teach the child to use its hands, build up a sound basis for later speech and language, and to prepare the child for walking. LOCOMOTION Pre-crawling Exercises Many children will stand and walk before or around two years of age, though there is enormous variation. As some have more difficulty than others, it is well to look at these and in particular to see the points at which they tend to get stuck. First, in most babies with developmental delays, especially Down's babies, the hip joints may not be as securely held by their rather slack ligaments. The legs tend to spread and the child lies flat between his thigh with his hop girdle and bottom on the ground. As it is not possible to crawl properly in this position, some children adopt the method of rolling in order to get around. This should not be encouraged for too long as it does not lead towards a normal way of movement. Others open their legs wide with the feet turned out and proceed by a sort of 'frog 'kick', others sit down and pull themselves along with their feet while pushing with their hands.This 'bottom shuffling' is acceptable as long as it does not become obstinately fixed and hinder further development. Most children play in the sitting position, with their legs apart and the toy between their knees, but Down's babies tend to spread their legs wider and turn their knees outwards and over until they touch the ground. Many, indeed, especially when very young, can turn their hip joints almost completely around the swing their legs from front to rear to arrive at the crawling position. This is not the best way of doing things. Instead, when the child is seated, fold his legs to one side and rest his weight on one buttock and both hands. He will probably resist this at first and perserverance is needed to make him do it for a short time on each occasion. As his arms grow stronger, get another person to hold his hips and play with him on the side on which he is supporting himself to get him to gradually use one arm for support and the other to hold objects. From this point you will find that a gentle up and over lift to his bottom will turn him into the crawling position, with both hands in front and his seat raised. It is also the preliminary position for crouching and rising to a standing position, at which we are aiming. Another exercise for this time is lifting the child's seat while he is lying on his tummy with arms forward, so that his legs, instead of spreading, are drawn up under him in the crawling position. Do not lift him very high as his arms are still rather weak, Place a folded bath towel under his chest and out forward in case he 'nose-dives' onto the ground. Better still, do the exercise on a settee or mattress. Then move to support his weight in the loop of a roller-towel, with the towel spread under him from under his arms to his waist. It needs a strong arm to raise the child like this so that he is partly supporting himself on his hands and knees and you may find it easier to stand astride him holding the other loop of othe towel in both hands. Let him kick and push and move slowly forward with hi hands. Regular 'gos' at this will let him feel what it is like to be in the crawling position and if you practise bouncing him gently, let him place the weight on his arms and push up, it will also help. If two people are available, one can lay a flat board against his feet for him to push against. You will see which foot he is pushing with and should tilt the board towards the foot that is drawn forward alternately. If no one is around to help, hold the child in the towel near the wall, so that he can push on that. Some children may be slower than usual to crawl on hands and knees and tend to do a flat crawl along the floor for a long time. To help them, kneel behind them, strapping their legs close together between your own knees, support yourself on one hand and support the child's chest with the other hand. Then get a helper to place a toy that you know the child likes a few feet out of reach; this will help your child to keep his legs together. Raise his bottom and hold him up high enough to see where he is going. It is not always easy for an adult to creep forward on a carpeted floor, so it may help sometimes to put a slip mat or sheet of plastic under yourself and the child so that you can slide forward more easily. It is helpful during such exercises to take off the nappy. If the other parent or the helper can sit in front of the child and offer the attractive object to the child's preferred hand, and switch it quickly to the other hand immediately the child goes to grasp it, it will also encourage the correct alternate movement of the arms for a walk with a proper gait. Crawling Give the child practise at crawling upstairs. Mount a few stairs yourself and lean down to offer the child your hand. Encourage the child to climb up to you. This is a difficult task, owing to the child's usually small size, short legs and immature balancing skills. Sitting Balance Some children also need to be propped up on their feet against an arm-chair or settee with one hand under their bottom and encouraged to play while on their feet. The hand may be gently removed after a time to see if the child can remain on his feet for some time before flopping down on his bottom. Walking and Pre-walking Exercise Once a child can walk, he generally wants to do so only if there is some objective of his own. If you want him to walk with you for any distance you have to first see that there is always some definite reward at the end of the walk. Show him something interesting there or play with him for a while before bringing him back. Expect only short walks at first. Children with mental handicap may have short legs and may have rather lax muscles and weak ankles, and they soon tire of walking when they are small. Always take a push-chair with you until he is about four years old for any journey of more than about half a kilometre. Let him push it. He will like to do this and will thankfully clamber in when he is tired. He may push a doll in the chair as he gets older and can be weaned from the chair as he becomes gradually able to walk further unaided. From about two, with improved locomotor skills, most of our children are very curious and love exploring the house and investigating everything. Keep heavy and dangerous objects out of reach, particularly lighting cables, and do not leave breakable or valuable objects on low shelves. The child's habit of pulling out drawers can be dangerous if the contents are heavy, and stops should be fitted if they are not already there to prevent the drawer from falling on the child. Apart from this, it is best not to have large table cloths which offer enough grip for the child to pull everything off the table. Pulling out pots and pans is harmless enough, though a nuisance, and is best endured until the child is old enough to be told not to take them without permission. Walking To help the child to learn to balance, do not walk behind him, holding his arms above his head, as you would with a normal child. Crouch before the child, hold his hands out well below shoulder level with your own arms bent. This is a tiring activity for parents, but does help the child to keep his balance, by teaching him to keep his arms and, hence , centre of gravity, low. If the child does learn to walk this way he may stick to the 'baby toddle',with arms to the side or front, at shoulder level, instead of acquiring the more mature gait with hands held and swung at waist level. Moreover, hands held at shoulder level are more limited in the activities they can carry out than those held at the waist. Shoes As many children reach the age of two they need to be fitted with shoes, and in many cases where the ankles are weak, the doctor's help can be sought in getting orthopaedic boots such as the Baluja flat feet shoes, which are soft and light but support the ankle well. Children who have difficulty in staying on their feet can benefit greatly here. These boots, however, are ideal as they are professionally designed for the purpose and most doctors will help you to get them from an orthopaedic department at a reduced cost. Similar versions are also available commercially. As soon as your child has shoes, make a point of naming them until your child will point when you say, Where are your shoes ?, Show me your shoes' or later, using a gesture, 'Bring Mummy your shoes'. This helps language development. Balancing Try getting the four to five-year-olds who can walk and trot steadily and jump down well from a step, to fold their arms when they jump, as they tend to collapse into a crouch when they land, whereas with arms folded, they tend to land on their feet with only slight knee bending and spring up to the upright position again. Some of our children, however, cannot do this well until they are seven or eight, and you should always be there to catch them if they land awkwardly or bump their heads on the wall at the foot of the stairs. Expanding Skills Provide practise in climbing and scrambling, crawling and walking upstairs, (start by sitting on one step up and helping the child up to you). Let the child scramble and walk up and down sloping banks or uneven fields. Hold the child standing up on an unstable surface on a large, partly inflated ball, air-pillow, etc. and get him dance from one foot to the other. Then let him walk, if he falls off, always catch him with a smile. Three- years odds can be encouraged to scramble, jump and bounce on their beds. Then they can be held up to practise balancing on the seat of a rocking horse or large rocker and to rock it with their feet. With less secure infants, support the child standing on both your knees and hold him while you swing your legs or move them rhythmically up and down. Smile and sing to the child. With two or three-year-olds practise crawling across a very low bridge board between two stools, low chairs or flat cushions. Let the child walk barefoot whenever possible, especially on rough grassy ground. Offer an object just out of reach - gradually give practise in reaching out without overbalancing. Encourage children to kick a ball a few inches from a standing position. Practise sitting side-saddle with hands on the ground, sitting with legs dangling. Practise sitting on a cushion and on a chair as well. Balancing with Greater Skill Some children whose motor skills are sufficiently well developed can be taught to stand on one leg, holding onto furniture at first, copying either the mother or father, and gradually moving away until they hold by their fingertips only and then balance independently for five or six seconds. If your child can do this, practise regularly until he has mastered the skill as it is later useful to be able to hop and to play hopscotch at school. Getting him to walk along a boardwalk set up on screwed blocks about an inch above the ground can also be helpful. A good game using a toy tea-set is to train the child to balance on one leg and pick up a row of saucers with his feet and transfer them to the appropriate hand. Many can do this very effectively once they have learned to stand on one leg and though it may seem a party trick, the practise of picking up a row of saucers in this way is excellent for their balancing skills. During the early school years, try to get your child to balance himself first on one leg then on the other holding onto a chair back. As he grows older, encourage him to balance using fingertips only on t he chair, and finally to stand on one leg for a few seconds at a time. Games such as hopping, skipping and jumping can gradually follow as your child progresses and he or she may learn these skills at any age between about seven and sixteen, depending on his degree of handicap. Remember, however, that you can always try these things earlier as some children who are much slower than average intellectually, can become quite nimble on their feet with plenty of practice. They are apt to be flat-footed as a rule and even though supporting boots mentioned elsewhere do help their ankles, walking barefoot and climbing up a short length of ladder with rounded rungs will help exercise the muscles under the foot and can help the feet from becoming too flat. Swimming Swimming is an excellent exercise for all children, though children with mental handicap, especially need to learn in a pool with warmed water (80 to 880F degrees is ideal) if the are not to catch cold. Always dry them off rapidly and let them spend only short spells in the water at first, though their responses to cold should improve twith age, this should always be watched. At first take your child only down the steps with you and encourage him to splash his legs by kicking the water for about ten minutes at a time, or for as long as he enjoys the game. Gradually introduce him to the water with blow-up floats around his arms and let him paddle in the shallow end with you. Children are usually able to follow instructions and copy examples well enough to eventually start proper swimming lessons with a qualified instructor. Some children however need additional help from a physiotherapist, especially if their hips are widely turned or, if when standing, their legs are rotated outwards or inwards and their feet stay stubbornly at right angles to the side so that they cannot stand on their own. If the child is easily frightened and plainly fears the water, drop the idea for a while and try again each year until the child does gain confidence, as many do at eight to ten years, even if they are rather slow learners. Coordinated Exercises for the Eyes and Hands This involves the child performing a single coordination task 1. Dance brightly coloured ribbons in front of the child to encourage him to reach out and grasp them. 2. Get large wooden bricks and set them up for the child to knock down. 3. Show the child how to bang with its hand on a toy drum or a steel plate. 4. A xylophone is very useful after about ten months. Holding the child's hand, show him how to bang the instrument and how to make a 'glissando' by sliding the stick across the keys. 5. Get an abacus with coloured balls which fit over the pegs. At first, guide the child's preferred hand to lift the balls a little way off their pegs and let them drop to make a click. The sound is a reward to the child and after a while the child will do this on his own. Next, take the balls off and guide the child's preferred hand to place the balls onto the pegs and let them drop to make a click. Again, the sound is a reward to the child. 6. Place wooden rings over the child's head, arms and feet. Encourage the child to take them off. 7. Teach the child to hit wooden balls on the floor with a stick. Cluster them round just within arm's length and let the child make a sweeping movement. Demonstrate this yourself at first. 8. Offer blocks one by one to the child and invite him by gesture to hand them back. To encourage the child to change hands, offer the brick to the non-preferred hand.The child will probably transfer from that hand to the preferred one in order to hand the block back. 9. Offer the child a number of small containers which hold things that rattle. Encourage the child to explore the interior with its fingers. Put small jelly sweets or raisins (not too many) inside, to encourage the child to pick up small objects with fingers and thumb. The container should be of a size such that the child cannot scoop the contents out with a closed fist. 10. Let the child play with containers and water so that he may practise filling and pouring. 11. Show the child how to build a tower of bricks. Make a 'train' by setting the bricks end to end. Give the child a fat non-toxic crayon. By guiding the child's hands, show him how to make marks on the paper. Do not try to teach him to draw any-things. At this stage he cannot do it. What he needs is to play with colour and produce something. You can call it anything it resembles (if anything). Let him use one colour at a time (non-toxic water colours or foodcolouring spread on a plastic tile). Being to name colours, through he will not be sure of them for some time. 12. Other useful play materials for the four-year-old are wood nails and a small wooden hammer. A toy in which pegs can be hammered by a wooden mallet is useful. Children generally love dressing up and games of imagination should be encouraged. They can be encouraged to play out little plays with you, with them as an important character as soon as they can speak to some extent. 13. Try introducing scissors and show how to cut paper and old toy boxes. Again, this needs supervision to avoid cuts, but do get proper scissors. Cheap plastic scissors are generally frustrating as they will not cut paper but round-ended scissors are available are the best. 14. Teach the child to pull off socks and booties. 15. Offer the child dolls wrapped up in tissue or grease-proof paper. Encourage the child to unwrap them. 16. Give the child a small hairbrush and comb. Hold the child's hand and comb first your hair and then the child's. 17. Dressing and undressing practise is useful at this stage. Show the child how to untie simple bows in silk and shoe laces by pulling, and putting arms in sleeves. Partly take off vests, i.e. one arm out and after a few practise sessions leave the child to complete the job. 18. Large simple jig-saws are most useful in extending and exercising the child's vocabulary. They also encourage precise grasping, and handling and releasing the pieces in the right place. The ability to match cut-out shapes with the correct hole is a very good spatial exercise. If the child is slow to find the correct place, run the child's fingers first round the cut-out piece, then round the inside edge of the corresponding hole. Using the Hands Give the child a wide variety of objects to handle so that he may practise grasping and adapting his hand to different shapes. Encourage the child to feel the textures and surfaces of the objects. Offer the child tough brown paper so that he may experience pulling, crumpling and tearing. Offer the child things to throw down from its high-chair and when the child follows the object with his eyes say, 'Down'. Exercise for Changing Hands This exercise can be started at six months, but do not expect instant results. It will require a good deal of time and patience. Offer a number of toys in succession. The child will grasp each toy in its preferred hand, dropping the previously offered toy. Guide the child's non-preferred hand to take the toy out of its preferred hand. Now offer another toy to the child and repeat the hand transfer.A supplementary exercise is to offer the child a coloured wooden ring which can be held with both hands. This will encourage the use of both the child's hand in concerned movement and transference. Strengthening Hands Let the child play at first with dough, then with plasticine or clay. Rolling and pulling out should be demonstrated. (Moulding and rolling improves hand strength and the coordinated use of both hands and can also relieve aggressive feelings and anxiety. The child can tear, beat and pound clay without ill-effects). Dress him up in a plastic apron and let him get dirty with clay or finger printing, etc. Children who are too nervous about getting dirty may feel inhibited later in any nursery school activity that involves clay, water, sand or print. Exercises involving some thought, as mentioned earlier, such as undoing parcels and unscrewing tops should be taught. The latter is best learned in stages. Young children cannot rotate their hands in opposite directions at first and the child should be shown how to hold the container against him while he unscrews the top (already loosened). Water play is valuable. It prepares the child for painting and getting wet and dirty at the nursery stage. This should have been practised already, but can now be expanded to puring, filling, spilling, tracing with wet fingers and moving hands in water to get the feel of liquids. Stand him on the box and show him how to turn taps on and off. Introduce the toothbrush and demonstrate its use during play if the child is reticent. Some children can manage quite well by themselves at about two and a half and can be made much of when they do. Controlled Pouring - start with pouring from a small container into wide-mouthed one and gradually progress to pouring into smaller and smaller openings. Empty washing-up fluid containers are handy, some complete, some with the tops cut off to make containers of different height. Show the child how to squeeze and squirt water. If the child has been allowed to scribble with a soft crayon for some time, he will be able to hold a brush and splash paint happily onto paper from about two onwards. AIDS TO TRAINING Baby Bouncer A Baby bouncer is of great use in encouraging the child to exercise for itself. The child should be ready for the bouncer by the end of the first month. When the child is suspended in the harness, its feet should be touching the floor, with knees slightly bent. If the bouncer is suspended from a door lintel between rooms, the child can watch housework in progress and spin itself either way to see into both rooms. Between the ages of five weeks and two months, a bouncing cradle can be used to advantage as it will give gentle exercise to the child while it lies down. The child will be able to see a lot more from the cradle than when lying in a cot. Baby Chair A special baby chair is practically indispensable Though it may seem early, the child can be strapped into one of these chairs as soon as it can hold its head for more than a minute or two. The 'Baby Relax''chair is probably the best of its kind. The chair can be set a variety of angles, from almost horizontal to upright, as the child'' development proceeds. It also has a useful tray for toys, a swing arrangement and a potty underneath. If such a chair cannot be obtained, however, the baby can be supported by three cushions and a very low stool as a play table, though this is not ideal. The reason for attempting to seat the child so early is that the seated position gives the child far more scope for movement and play. Also the child can see a lot more than when lying down and will be able to practise adjusting its eyes to various distances. USEFUL TOYS Children with mental handicap are usually less mobile than most babies and need fairly strong stimulation if they are to take an interest in their surroundings. Toys which are brightly coloured and preferably make a noise will play a very important part in the stimulation of the child's senses. For the Cot Quite simple toys can be used, some of them suspended from string coloured ribbon. 1. Hang a string of brightly coloured ball rattles across the cot, not nearer than fourteen inches from the baby's eyes. Move the rattles along the string to different positions whenever you change or feed the baby to provide some variety. 2. Hang a second similar string from the side of the cot, within reach of the baby's hand. Choose rattles that make a noise very easily so that the slightest movement by the baby's hand will produce a sound. 3. Either from the first string or from a window frame, hang a number of coloured metal foil spirals (party decorations). These will revolve in the slightest draught and attract the baby's attention. 4. Baby can also be encouraged to move about by hanging tiny pigeon bells by threads from the edge of the cot blanket. Place 'squeaker' toy which will make a noise with very light pressure beside the baby. 5. Spread a piece of tissue paper, grease-proof paper or kitchen foil across the cot. Place baby's arm outside the sheets on the paper and hold him hand to demonstrate the crumpling sound. After a while the child will make these sounds, accidentally at first, but eventually to amuse himself. 6. Use old wallpaper pattern books and place them on the side rail of the cot, tying the spine of the book firmly to the rail. Then you can turn the development of the visual part of the brain. For the Chair 1. Toys attached to the tray by means of a sucker are useful if they can be moved or rattled by random swings of the child's hands. These movements will steadily grow more controlled and precise. Small plastic windmills can also be set up so that the child may spin them. 2. If the canopy is attached, toys can be hung from threads within the child's reach. 3. Now the child's arms are free, numerous objects should be offered to the child for handling. Many children do not reach out to grasp things but will hold them and wave them. 4. To encourage the child to kick, drape a string of pigeon bells across the child's feet. Random movement of the legs will become deliberate. For the Bouncer 1. Rattles and bells hung from the crossbar may entice the child to clutch at them and lead him to inadvertently swing round. 2. A large rubber rocking toy placed between baby's feet will encourage the child to kick. Games Give the child a wide variety of small objects to hold and manipulate. Most of them will go to the baby's mouth, so these should not be left with an unattended child. Assorted objects need to be used regularly to teach the child the different ways in which things need to be held. In feeding at this age, encourage the child to put its hands to the bottle. Play frequently in front of the large mirror (an old dressing-table mirror and top is ideal) preferably set up on the floor. Show yourself over the child's shoulder to encourage him to recognize first you, then himself. 1. With the child on your knee, clap your hands. 2. Count to five on the child's fingers and toes, increasing the excitement by lifting your voice up to five. 3. Hide toys under boxes in front of the baby and repeatedly show the child where they are, drawing attention to their appearance with surprise and expressions like 'there it is'. Tempt the child to lift the box and reward success with smiling praise. Use three boxes, hiding a toy under one of them and invite the child to find the toy. 4. Hide your face behind a napkin and then quickly remove it to reveal yourself. If you do this very close to the child, he will enter into the game by pulling the napkin down. This indicates anticipation and the ability to grasp that you are still there, though hidden, and helps to develop the child's imagination. 5. Look at the child through rings and holes in toys. Encourage the child to do the same to you. 6. Pass your arm through a large ring and offer the child a toy, withdrawing it slowly through the ring to induce the child to reach through. This is good practise for dressing up later. 7. Using a doll's tea-set, play at tea parties and get the child to offer and accept a cup. Toys At a later stage, the child will enjoy banging on a toy typewriter or a piano. Also, let the child practise blowing into a whistle, recorder or toy harmonica. At bath-time give the child toys to play with, plastic ducks for imaginative play and beakers for pouring, filling and emptying. 2COMMUNICATION, SPEECH AND LANGUAGE DEVELOPMENT Communication, speech and language are different skills, although they are related. All of them are needed in order to talk. Communication is the means by which we convey our thoughts, ideas and feelings to other people. We can communicate verbally, by gestures or by writing. We also communicate subtly through facial expressions body movements and voice intonations. In fact, communication is the means by which we make others understand our needs and desires. For example, the child who is in pain, cries to make its mother attend to its needs. The child who is in a temper throws things around to convey his emotion. Speech is the ability to produce sounds correctly in the right sequence and with the proper rhythm. These sounds are recognized and understood as words and sentences. Language is a set of codes whereby ideas are represented through a conventional system of signals for communication. Language is a convention and grammar the set of rules which define that convention. The grammar of language includes: i. ii. iii. the rules of the rules of the rules of sentences the phenology which describe how words are put together to form sentences; semantics which describe how to interpret the meanings of words, and pragmatics which describe how to participate in a conversation, how to sequence and how to anticipate the information required by the listener. NORMAL LANGUAGE DEVELOPMENT Evidence of the need to communicate is noticed from the moment of birth with the birth cry which is an indication of the infant's attempts to clear the respiratory passages for breathing and also a sign of the unmistakable protest at being disturbed from a most warm and comfortable home!. Learning a language is like learning how to climb stairs. The entire process follows a logical pattern. The list given below represents the average pace of development. Some children may develop fast while others a little slower. Age of child Characteristics Cries, grunts and sighs; ceases activity on loud sounds, cries differently for 0-6 needs like hunger, discomfort. By four months he begins to cry less and months smile more when spoken to, produces vowel sounds involuntarily, turns and looks at people when spoken to. By six months his cooing gradually changes to babbling, (ma, ba, da). Babbling increases and baby enjoys listening to his own voice. Responds to 6 - 8 name, uses tone variation and inflection; combines syllables, attempts to months imitate sounds. Understands the meaning of 'no'. Comprehends few words, vocalizations are mixed with sound play and gurgling; tries to imitate words now; copies adult speech to produce unclear jargon. 1 year First meaningful word, responds to simple commands. By the end of the first year has a vocabulary of 10-15 words. Still uses vocal play, there is a great deal of jargon, comprehension of 1 years commands increases, points to familiar objects when named, may have a vocabulary of 20-30 words. 2 years Combines two or three words to express an idea or need, uses adjectives, prepositions and pronouns. Vocabulary of 200-300 words. Refers to self as 'I'. Language is used freely, sentences are longer, curiosity 3 years leads to questions. Verbal reasoning can be used with him/her, listens to stories. Vocabulary upto 800-1000 words. Asks abundant 'why' and 'how' questions, narrates tales, speech becomes 4 years clear and understandable to most, counts from 1 to 50. Could increase vocabulary to 1500 words. Questions are more advanced, likes to look at books and have someone 5 years read aloud. Names colours, tries to write a letter, can count till 100, could have a vocabulary of 2000 words. 6 years Writes own name and several other words at will, can use the telephone, recognizes coins, reads simple stories from books. LANGUAGE DEVELOPMENT IN CHILDREN WITH MENTAL HANDICAP Most children with mental handicap learn to talk in the same way as most other children but they learn slowly. Their language acquisition is delayed not abnormal. Some face difficulties in imitating sounds, many have poor hearing which adversely affects the development of language and speech skills. It is generally recognized that there is a correlation between the degree of mental handicap and the extent of language development. Children with mild mental handicap have about forty-five per cent impairment in their initial ability to learn and meaningfully utilize a language, the child with moderate mental handicap has about sixty per cent impairment, whilst language development in the severely and profoundly handicapped is minimal. There is an essential difference between language and speech. Speech forms the content of language which, in turn, is used as a means of communication. Thus, some children have speech but not communication skills. Aniket can repeat any word he hears, even a difficult one like 'motorcycle' but he does not know what it means and hence it is not communication. Aniket's only communication is smiling or crying, like the communication of a very young baby. Therefore, it is not speech and language in such form which is of importance but the ability to make others around us understand what we say. For such children the first priority is to increase their ability and desire to communicate. Once children have formed this habit it becomes much easier to develop their vocabulary. The child should be encouraged to interact with others as often as possible by whatever means. Talking skills can be taught at all appropriate times and not only with sessions with the speech therapist or at school. ROLE OF PARENTS Parents play an important role in the life of a child. This role becomes doubly important when the child is mentally handicapped and is in need of special care. Parents often feel 'What can I do to develop speech in my child ? I am only a parent and not a speech therapist or a psychologist'. This is only partly true. The child reflects the vocabulary and language forms of the family. Family members provide a model which the child hears and copies. This vocabulary is gradually built up from the responses of parents and grandparents, brothers and sisters, from what they hear over the radio and T.V. Parents have many plus points as trainers of their children Children are most natural in front of them. Thus, valuable time is not spent trying to get the child accustomed to a professional Parents can teach the child at any time of the day, in all parts of the house and in the appropriate environmental settings. For example, the child could be familiarized with names of utensils in the kitchen, which is the natural place for utensils to be in. This is not possible in a school or clinic setting. Parents can stimulate the development of language skills without interfering with ongoing activities. So, language lessons need not be artificially planned. Guidelines for Training at Home 1. Before you begin, have a complete assessment of speech, language and hearing carried out by a qualified speech therapist or audiologist. Have the child assessed by a psychologist to obtain information of the child's development potential so that you can set appropriate and realistic goals. 2. Plan a home-training programme with the help of a psychologist, a speech therapist and a physiotherapist. This is considered appropriate as it has been frequently observed that children with mental handicap manifest behaviour problems as well as problems in muscular coordination in addition to their speech delay. The need is to integrate all aspects of training into comprehensive sessions so that both parent and child do not feel burdened with the prospect of teaching and responding. 3. Start at the child's level of language development. This is the stage the child is in, in terms of listening and expressive behaviour. Thus, if the child appears to pay no attention to your call ( specially when hearing has been diagnosed as normal) you should start at the sound awareness exercises. If your child shows poor progress use sign language (accompanied by words) to encourage and keep up communication skills. It is very important to couple sign language with words as you will be required to gradually fade the non-verbal signs. 4. Encourage your child to communicate/talk whenever possible and make communication a fund experience. Arrange appropriate and interesting experiences so that your child can have the opportunity of having something to say and to want to say it. 5. Give your complete attention whenever your child is trying to speak or communicate. Respond immediately. 6. Build the child's word power by using the same word in many different situations. For example, if he/she understands the meaning of the word banana, say it aloud when its time to eat one, point it out in the market in picture books and so on. Note: Respond positively to every attempt, however, small. Show your appreciation by praising and hugging, kissing and expressing your absolute joy!. The Basics of Training at Home. Before you begin a training programme at home, you can informally assess the child in order to be aware of: Where to start When to plan the next step How to define the objectives Ways of identifying strengths and weaknesses This assessment is an adjunct to the report you would have probably received from the consulting psychologist, the speech therapist and the physiotherapist. It is very important for you to be able to assess the pace and extent of learning to make you a parent capable of understanding every pertinent need of your very special child. Assessment of language development is in three areas. These are: Visual : The ability to retain the visual impression of the object observed. Receptive language : The ability to comprehend the spoken word Expressive language : The ability to communicate needs and desires by conventional means. TEACHING COMMUNICATION SKILLS Babies communicate by crying , smiling or moving the muscles of the face and parts of the body. For example, a babys smile on seeing the mother is the earliest way of saying 'hello. An older child may point to the object of his or her immediate need and could nod his head in response to whether it is desired or not - when this is repeated ofoten enough, learning by association begins to take place. From this we can understand that thee progression of language is in three stages - visual, receptive and expressive. A child observes actions and begins to associate them with words much sooner than he or she begins to verbalize consequent thoughts and ideas. i. ii. iii. to provide opportunities for your child to observe the actions of others; to stimulate your child to communicate wants and desires by gestures, etc. to encourage your child to communicate by the use of language to make his or her expressions easily understandable to others. Response is a Two-way Process A small baby cries when in distress, i.e. when in hunger or in pain. Initially these are incidental, the intention is not to communicate. However, when these vocalizations and movements are responded to over a period of time the intentional use of these methods of communication become apparent. We can help a child relate to other people by playing, using a lot of physical contact, i.e. hugging, rocking, tickling, with laughter and a lot of eye contact. Eye contact is encouraged by turning babys head towards you while speaking. Teaching specific Skills Make requests : Make a note of things he or she likes and then when the opportunity arises, wait till a sound or gesture is made before fulfilling the demand. When repeated several times, this will help the child realize that to get what is wanted he or she will have to ask for it, be it by physical gestures or by verbalizing. Protest or refusal : Children seem to know instinctively how to say 'no'. For example, have you ever tried to feed baby when baby does not want to feed ? The head will be moved away, teeth will be kept clenched and sometimes even the lips will be difficult to open. Yet another frequently encountered situation arises when you take away a toy the child is happily playing with - the instant protest is unmistakable. Give the child several opportunities to exercise the option of refusing and/or protesting. Greetings : During the day there are many occasions for greeting. Each time you come into the room or near baby - say hello and smile, touch babys cheeks, wave bye-bye before leaving. When repeated often enough, response by imitation will emerge. Keep talking : A child learns to look at and describe things by listening and observing. Draw his or her attention to things in the environment, name them, touch and explore them together. Talk about what is being done, keeping alert for the child response in whatever form. Ask and Answer Questions This usually occurs much later when the child is about two years or older. Make the process interesting by giving the child an option. Try not to say 'What do you want to play with, ask instead, 'Do you want to play with your car or your doll? Pointing to the toys at the same time. Ask questions at the start of each activity and then proceed to do what the child has chosen to do. Ask questions like 'what is this while pointing at a picture in a book, wait a while and then answer it yourself. You help build the receptive vocabulary this way. Other question words could be learnt by participating in turn-taking games, e.g. hiding games where first you and then your child could take turns to hide objects around the room, asking 'where is? When it comes to your childs turn to ask the question, a variation could be introduced to make the game easier by using a sign as a question. After having heard and having seen you play the game several times it would be easier to copy. As in all teaching activities, it is important to combine fun with some challenge - for if a child has to learn well, he or she must enjoy and want to learn. Learning to imitate: Imitation or copying what someone else says or does is an essential first step for communication. A child first imitates actions. To encourage this, it is best to start with actions within the childs reportoire. Thus, the next time he moves his arms, copy him or her and initiate a follow through. Introduce a slight variation and observe reactions. Repetition is the key to learning. For example, Hitting the table, banging on a drum or clapping hands are pleasurable, reward the child whenever an effort is made to copy what you have done. At the same time do remember to describe what you are doing. Once your child begins to imitate actions, try sounds. Here too, remember to start with sounds the child produces on his or her own without prompts. The procedure to encourage sound imitation involves repetition on your part followed by a slight variation - so whenever, the new sound is vocalized the process of imitation has been started. Reward and praise of even the mildest of efforts should be lavish - the intention is to convey the point that imitation makes you happy and it is a good thing to do. Building Vocabulary If your child has not started speaking, your aim would be to build up receptive vocabulary. For example, when we hear the word 'house we conjure a mental picture of it in our minds. How do we teach young children to make such mental pictures? First of all, the child should be taught the difference between two objects. To briefly recap the stages of development - give a nine-month-old a spoon, a shoe and a ball and he or she will do exactly the same things with each of them - in this case, hold them turn them over and then put them into the mouth or throw them around. The responses to each object are exactly the same only because the child is unable to perceive the difference between one object and another. A few months later, when a spoon is given to the child it will be taken to the mouth, he or she will try to put the shoe on and play with the ball. SAMPLE TRAINING EXERCISE Evaluation Before commencing on a training schedule, you must: Assess current functional level Assess the ability to comprehend commands Assess the ability to imitate behaviours. Curriculum Stage I : Identifying familiar objects Point to an apple and give a verbal instruction such as 'Give me the apple. A helpful first step here is to allow the child to carry out the command the best he or she can. The first few lessons could be made simpler by showing a picture of an apple. Expression of your joy is a very powerful reward - so be sure to show it. Stage II : Following simple instructions: o Step One - Place several objects in front of your child - a banana, an apple and an orange and ask him or her to 'pick -up the apple. If he or she does so, praise and in case he fails, then physically prompt him by guiding his hand towards the correct object. Examples of other prompting procedures you could use: Verbal prompts such as - 'No, no 'No, it is not a banana, it is an apple Finger pointing - a cue to follow Modelling - where another person acts out the correct response. o Step Two - Increase the number of objects to be identified. Thus, the complexity of the instruction would increase to two objects - 'Bring me an apple and a banana'. The purpose of this task is to increase comprehension power to understand longer sentences. It has the added advantage of increasing memory span. o Step Three - Put several objects in a box and ask the child to bring one of them. This is a task which requires the child to remember the command without the help of cues or prompts. Therefore, verbal stimuli are the only cues the child can use to respond. Thus, the child must understand and remember the command in order to respond correctly. This task will help the child acquire the attitude of listening carefully to what another person is saying. o Step Four - Preferably use instructions which are frequently used in everyday life such as 'open close the door, 'sit down', and so on. If the child has difficulty in responding use physical prompts. For example, if the command is 'open the window, then take the child to the window, hold his hands and guide them to open the window. The command should be given in different places and under varying conditions. It can be said that learning has taken place only when he or she is able to act upon a request whenever and wherever you make it. Tips to remember Use a similar training schedule to further build the childs receptive vocabulary. The words spoken are heard and stored in the brain. Recall and use of these words will take place when the time comes. Build the childs 'noun vocabulary', that is names of different things, then proceed to 'verbs'. Verbs are a little difficult to learn since they are not easily seen. Proceed training from the immediate environment to the world outside from what a child can explore and feel to what he can merely see at a distance. Teach the names of things the child uses - his body parts, names of people around him, names of eatables etc. Praise lavishly with smiles, hugs and kisses. TEACHING SPEECH AND LANGUAGE There are five stages in learning to use a new word: 1. 2. 3. 4. 5. Recognizing the word as one which the child has heard many times before; Understanding (probably limited to start with); Using words imitatively; Recalling and using the word without help (not always correctly); Forming a mental picture, understanding the word, and using it correctly in many different situations. Different Kinds of Words The childs first words are likely to belong to the following categories. When you decide to each a new word, try to choose words from each of these categories: Names People's names Object names Social words Examples Names of family members, friends Cup, ball, shoe, chair, etc. Bye-bye-, yes, hello, no, thank you Action words Sit, eat, stand, give, wash Describing words More, small, big, fast, red mine At this early stage, try not to use alternative names for the same thing or the same words in ways that have different meanings. Later on, children will begin to learn that the objects may have many names and words may have many meanings. Teach only one language at a time. Sometimes a child may not wish to use a particular word because it is difficult to say, or because someone has laughed at him or corrected him when he tried to say it, making him shy (this can also happen to adults !). Do not force the child to use the word, leave it alone for a few days. The confidence built up while learning other words will help him overcome his shyness. 'Dont' is a very important word to understand. A child may seen disobedient when in fact the problem is that he has not recognized and understood the word. Thus, when you say 'Dont go there he understands only 'Go there. In such cases emphasize negative commands, so that the child clearly hears it. It also helps to give positive and negative commands in rotation in a game --like situation - 'stand up', 'dont move', 'clap your hands', 'dont sit down', etc Action words should be introduced. To teach the child verbs and adjectives, describe the object in use. When the child first uses describing words, he may think of them as the name of the object or action. For example he may talk about the 'red car without knowing the word 'red has a special meaning. When used in a general way, the child begins to understand that describing words can be used anywhere. Use of bad words: You must have noticed that all children have the tendency of picking up 'bad words. The reason for this is simple-bad words are said forcefully and with a lot of emphasis. It is the tone and the voice inflection which make the immediate impression on the childs mind. When this type of situation arises there are a few things that you can do. You could ignore the child when he uses the 'bad words' You could stop using the words yourself You could create a similar impression on the childs mind with other words. LEARNING TO FORM SENTENCES Sentences begin to form when a child has vocabulary of thirty words. Initially the child will put two words together, usually a noun and a verb, to communicate. The child learns to do this by copying word combinations heard. In order to teach your child how to put two words together, talk about the things he is doing. Use words you know he understands, so that his mind is not occupied in trying to work out each word. Speak in simple sentences. Emphasize the two most important words in combination with wellknown ones so that your child generalizes the meaning and builds a mental picture. For example, to practise word combinations of noun and verb; stand before your son or daughter while he/she is eating and say Anand/Bina is eating (emphasizing name and action). Say the full sentence every time. The correct order of words in a sentence differs from one language to another, but the method of teaching is the same. Voice intonation is also very important. Speak in a normal tone with voice inflections of the language being used. This will also be learnt while hearing people speak to one another during conversations. So do give plenty of opportunity for observation. Colours, numbers, shapes and sizes should also be taught. By doing so you will be helping your child use his reasoning abilities. A few examples Teaching verbs (action words) is quite difficult. Try the following games. Moods : While watching advertisements on TV (all children seem to love them more than the programmes), point out a girl laughing, a child crying a man angry or a woman sad. Prepositions: Example... in, on, under, behind, before etc. Take two or three words such as in/on/under. Create a game situation with at least three players. Keep a score card to generate interest and to create a feeling of achievement. Call out one of the words and the first player has to act it out. Thus, if it is 'on, he should sit on a stool or a chair. If it is 'in then the player has to put a ball 'in a box. A correct response gets two immediate rewards: a star on the score card and a second chance. Be lenient when it comes to your childs turn, when it is your turn make a deliberate mistake so that the difference b etween the right and wrong can be pointed out. At a later stage, ask your child to call out the words. As soon as any word is learnt, make efforts to use it frequently in a sentence encouraging imitations. Should the child use an incomplete sentence, complete it for him. MORE TIPS TO REMEMBER When a mistake has been made, dont laugh or imitate - instead use the correct form when you use the word the next time. Teaching too eagerly- When we teach, we often make the mistake of being too eager and may correct the pronunciation of a word immediately by interruping the child. This tends to confuse the childs chain of thought and also makes him feel that he has done something wrong. Such a feeling could result in the child refusing to speak and displaying aggressive behaviour. Expecting too much, too soon: Sometimes children do not react immediately by imitating the word you have spent days teaching. In all probability, he has learnt it and will say it when you least expect it. As a parent, you could continue repeating the word whenever applicable. Give opportunities: While building vocabulary, do remember to make your child interact with you. Ask at frequent intervals 'what is this. If no response is forthcoming, supply it yourself and ask again. He will surprise you a couple of days later. PROBLEMS IN LANGUAGE DEVELOPMENT There are many problems encountered in the language development of children with mental handicap. These could be classified into three groups: in the first are the children who do not speak at all; in the second are the children who have limited vocabulary; in the third are those whose speech has low intelligibility. The first two problems have been dealt with in the previous pages. The third group of problems will be discussed here. Problems of low intelligibility include disorders of articulation, stuttering and cluttering. These are best handled by a speech therapist. 1. Articulation disorders : Articulation is the result of the movements of the speech organs, i.e. lips, tongue, vocal cords and the nose. Articulation disorders need to be treated after the child is able to communicate in two-to four words phrases. There are three types of articulation errors. o Substitution : Example 'R' pronounced as 'I' ,'s' as 't' o Omission : In which part of the word is not pronounced. Thus 'cap' would sound as o Distortion : In which the word being said does not resemble the actual one, e.g. o Stuttering : This is caused by choking, repetition or extension of vocal sounds. 'apple' would sound as 'a-a. With speech therapy, this problem can be overcome. Timely intervention by speech therapy helps to remove the problem before it beings to affect the childs desire to talk. It is important not to attract the childs attention to the problems. While training ensure that he is speaking slowly. 'ca'. 2. Cluttering : Genrally occurs when sounds are distorted or words are spoken too fast. Here again, ensure that the child is encouraged to speak slowly. EXERCISES Do the following exercises with the child for 5-7 minutes in the day: Breathing: Ask the child to breath out. Then to close mouth tightly. Tell the child to breath through his nose Ask him to take a deep breath. Then exhale slowly Tell the child to hold the head up as straight as possible, to close his lips and blow (You can hold a piece of paper so that the child can move it by blowing) You can ask a child to blow out a candle (At first hold the candle or the paper close to the childs mouth. When the child is able to blow it, move it away from the child so he/she has to blow more). Sucking: Tell the child to hold the head up as straight as possible, to close lips and suck. (Put a straw into a glass with tea or water. Let the child try to drink by sucking on the straw. The child can also blow through the straw to make bubbles in the water or the tea). LIP EXERCISES Smack lips tightly Keep lips closed on counts. Increase the counts gradually. Plucker both lips and narrow them (as in whistling) Put a pencil across upper lip and pouch lips upward (towards the nose) . Hold pencil in place for a while. Tell the child to hold the head up as straight as possible, open the mouth and keep the tongue in the mouth, and then to close the mouth tightly. Tell the child to push tongue straight out. Then ask him to pull the tongue into the mouth and close the mouth. Next tell the child to open the mouth, push the tongue out and move it from side to side. MANAGEMENT OF PROBLEM BEHAVIOUR Problem behaviours are a major source of concern and frustration for parents. Problem behaviours are not a part and parcel of mental handicap, neither are they diseases of some sort, but are learned maladaptive forms of behaviour. Such behaviour is more in the nature of unhealthy habit. Here are the answers to some common questions frequently asked about the causes and nature of problem behaviour: WHAT IS THE DIFFERNCE BETWEEN PROBLEM BEHAVIOUR AND MENTAL ILLNESS? Behavioural problem Mental illness Severity Causes Minor deviation of normal Major deviation of normal Behaviour Mainly environmental Learned maladaptive Behaviour Parent counselling, Psychological methods Inherited, biochemical but could also be environ-mental Drugs, and at times psychological therapy. Management ARE PROBLEM BEHAVIOUR A PART OF NORMAL DEVELOPMENT ? Sometimes it is difficult to determine whether an individual child is displaying normal or deviant behviour. Certain problems are common at particular ages and may even constitute a normal part of growing up, e.g. temper tantums between the age of 2 to 4 years. Most children display a mixture of desirable and undesirable and undesirable behaviour. All difficult behaviours are not truly problematic, like fighting with younger sibs. Some problems may be short-lived, others may last longer and begin to interefere with the childs development. It is at this point that remedial measure are sought. HOW CAN WE SAY THAT A PARTICULAR BEHAVIOUR IS A PROBLEM ONE ? To determine whether a particular child has a problem behaviour or not, the following criteria are generally used; Age Appropriateness : A child's age and developmental status are very important in determining the normality of the child's behaviour. For example, bed wetting at height is normal till three years but certainly not at nine years. Frequency: If the problem persists more or less all the time or it can be called a problem behaviour ,e.g. bed wetting by a ten-year-old child every night as compared to wetting once in a month. Intensity: If a particular behaviour occurs in an intense form it becomes a problem e.g. during a temper tantrum the child may hit his head on the wall, break articles and beat other people. Severity, Number and Diversity : Some behaviours may occur once in a while but are dangerous for the child and the people around him, e.g. setting fire to things. Sometimes the child may have problems in more than one area like poor attention, destructive aggression and disobedience. WHEN DO PROBLEM BEHAVIOURS NORMALLY ARISE ? Behavior Disobedience Inattention Negativism Bed wetting Overactivity Specific fears Shyness Lying Oversensitivity Jealousy Age level Years 5 5 5 5 5 5 10 10 10 10 14 14 2 2 3 1 1 2 5 3 10 6 Temper Tantrums 1 .5 Attention seeking 2 HOW DO PROBLEM BEHAVIOURS DEVELOP There is no single cause or process that explains, the development of all behaviour problems. In some instances it is the maturational lag itself that is responsible for the problems, which in time corrects itself. At other times a child's basic temperament may shape his behaviour into aggressiveness or withdrawal, etc. giving rise to problems in behaviour. In our work with children with mental handicap, we have found learning to play the biggest role in the development of problem behaviour. Parents often reward undesirable behaviour in an attempt to stop that behaviour by giving the child all their attention, or by trying to bribe the child with agoody, to stop the behaviour. In most instances, such behaviours are simply learnt through imitation of other people, e.g. abusing. A great deal depends on the disciplining methods and tolerance level of the child's parents. Another important cause of the development of problem behaviour is the inability of the parents to keep the child occupied in some constructive and enjoyable activity. A classic replay of the wellknown adage - an idle mind is the devil's workshop. COMMON PROBLEM BEHAVIOURS AND THEIR MANAGEMENT Some of the problems in the behaviour of the children with mental handicap are related to eating, elimination, hyperactivity, tempera tantrums, head banging, aggressive and destructive behaviour, poor concentration, poor eye contact, and using abusive language. Problems Related to Eating Problems related to eating are of universal concern to the majority of the parents. However, in the case of the child with mental handicap the problems are specific and continue for a longer period of time - making it a source of frustration for the parents. In such instances the difficulty encountered by the parents in handling the child leads to an aggravation of the problem. A child who spills food all over the floor while eating could burden the mother with the additional chore of cleaning up. The eating of the inappropriate foods (referred to as Pica), and a general disinterest in food increases the chances of infections. Hence, controlling such behaviours is of great importance. Causes of Disinterest in Food Physical illness like jaundice, typhoid, and malaria, etc. Eating at various times during the day makes the child eat less at meal-times. Multiple feeders at home like siblings, grandparents, other relatives and friends make it difficult to assess the quantity and nutritional value of the food the child has eaten. Spilling of food is usually due to the lack of appropriate training of children in the technique of eating carefully - also frequently seen when eye, hand and motor coordination is insufficient. Manage a. Physical illness should be ruled out by consulting a physician. b. Parents should keep a record of food intake. This will help them in knowing both the quantity and quality of the food that their child is consuming. c. With reward and punishment techniques children can be trained to eat properly. Care must be taken to teach the child slowly and gradually. Pica Children with mental handicap tend to chew upon inappropriate objects like toys, buttons, pencils, dirt, plaster, hair, rubber, wood, paper which cause physical complications in the form of constipation, anaemia, intestinal obstruction and lead poisoning. Causes of Pica a. Pica is more commonly seen in children from economically backward families. The poor nutritional value of food available produces a craving for unnatural foods. b. Parental neglect - all young children tend to put objects in their mouths. This is a form of exploration and a means by which the child learns more about the article. Management i. ii. Stop the child as soon as he puts an inappropriate object in his mouth, explaining at the same time that he should not do so. Dangerous substances should be kept out of the reach of children. Problems of Elimination The two problems of elimination seen in children are enuresis and encopresis. Enuresis Wetting of bed or clothes by a child over five years of age is known as 'enuresis'. Causes of enuresis Physical causes of enuresis are genitourinary infections, volvitis in girls and meatal stenosis in boys. Lack of timely and appropriate training in good toilet habits. Management Physical causes should be ruled out first It has been seen that a reduction of fluid intake around bedtime is helpful in the case of nocturnal enuresis. Thus, if the child normally goes to bed at around 9 p.m., ensure that he drinks his milk at 8 p.m. and goes to the toilet. Older children could be encouraged to maintain a chart on which dry and wet nights are indicated. A reward for five consecutive dry nights has been found to be effective. To ensure day-time dryness in the child above four years, it is helpful to remind the child to visit the toilet once every two hours. The child should be trained to retain urine as long as possible. This teaches the child to recognize the need well in time and reach the toilet without soiling his clothes. Drugs are given in some cases. Encopresis Regular soiling of clothes by a child over two years of age is termed as encopresis. Causes of encopresis Habitual constipation Incorrect bowel habits due to faulty training Fear of the toilet. Management Since the major cause of encopresis is poor bowel habits and lack of training, parents should immediately start upon a training schedule. At first, record the time when the bowel movement (BM) usually occurs (avoid training on days when the child is not well or has loose motions). Remind the child five minutes before his BM time to sit on the toilet. Ensure that he does so. Encourage him to sit in the toilet till he passes motion. If you feel that he is afraid of being alone then be around within his field of vision, so that he feels reassured. As soon as he has passed motion, clean him and reward him for his action. This reward could be in the form of praise and hugs. When the child has been trained, teach him to go to the bathroom alone and to clean up afterwards. Hyperactivity Hyperactive children have a poor attention span, are overactive and impulsive by nature. Such children do not sit still, are restless and highly distractible. Causes of hyperactivity Lack of an interesting work schedule. Presence of physical factors such as poor eating habits, additives and colouring agents in food. Indirect reinforcement of undesirable behaviour by family members. Management a. Children should be kept occupied by giving them a daily work schedule of activity, and thereafter praised for adhering to the schedule. b. A watch should be kept on the diet of the child. A child whose diet is unhealthy, i.e. too many cold drinks, toffees, chips and other appetite killers which fill up the child's stomach but do not provide adequate nutrition, has been seen to exhibit restless and hyperactive behaviour. c. The 'time-out' technique described in the last section of the manual is effective in controlling hyperactivity. The technique essentially recommends that the parents ignore the child when he exhibits undesirable behaviours. Aggressive Behaviour Negavitism and disobedience are mild forms of aggressive behaviour, while temper tantrums, head banging and destructiveness are more severe forms. No matter what the degree is, this type of behaviour is distressing for parents and other members of the family. Aggression is a means by which the child expresses his anger at the world around him. Thus, management of such types of behaviour would require the parents to examine the situations in which aggressive behaviour tends to surface. Common causes of aggression in children Overcritical attitude of parents towards the shortcomings of the child. Inconsistent disciplining in which demands are met only once the child creates a scene. Thus, when the child encounters a 'no' against a demand he begins to cry (normal enough reaction on the part of the child). At this point a parent might give in. The next time such a 'no' is encountered the child recalls the earlier situation and begins to cry louder when the parents decide to be firm. This is one of the main causes of aggressive behaviour. i. When aggressive behaviour occurs in one particular situation and not in others, 'environmental restructuring' should be considered to prevent the occurrence of such behaviours. Environmental restructuring refers to manipulation of a developing situation to ensure that a point will not be reached which would result in giving the child an opportunity to indulge in aggressive behaviour. The 'Time Out' technique has also been found to be very useful in reducing aggressive behaviour. 'Behavioural contracting' is another technique. In this the child is given tokens for food behaviour and has to return them when he is bad. ii. iii. Temper tantrums Temper tantrums are a part of normal development around the age of two years. Holding of breath is the first sign of a temper tantrum seen in young babies. Hitting, kicking and screaming are the expressed tantrums of the older child. Factors precipitating temper tantrums Physical illness Conditions like hunger and fatigue Critical, anxious and nagging adults in the environment Inconsistent discipline Management i. ii. iii. Physical illnesses should be assessed and ruled out. A weak and ill child is generally cranky and easily provoked. Disciplining at home should be firm and consistent. The 'Time-Out' technique has been successfully used in the management of temper tantrums. In this method the child's wrong behaviour is ignored completely when the tantrum occurs. The child is attended to only when the behaviour has ceased. Head banging Head banging is characterized by repeated striking of the head against solid object like a wall, the floor or bed. Reasons for head banging a. Maternal neglect or deprivation b. Disturbed parent - child relationship Management i. ii. iii. Physical causes of head banging should be ruled out by consulting a physician. The 'Restraint Method' (described later) is effective. Sedatives and tranquilizing drugs are sometimes useful. However, these are only to be administered on medical advice. Masturbation In masturbation the child plays with his or her genitals. Causes a. b. c. d. Irritation from tight clothing Infection of genitals leading to itching and burning Realization that it produces pleasure Boredom Management i. ii. iii. If masturbation is due to infections, then a physician should be consulted. The child should be rewarded for not masturbating. The child should not be allowed to sit alone doing nothing. A well-planned routine is essential. METHODS FOR MODIFYING PROBLEM BEHAVIOUR Time out method Step One: Record the unwanted behaviour by noting down what happened before, during and after the behaviour. Step Two: After a week, examine your records. Do you see a pattern? Does the Behaviour tend to occur in certain situations ? What is the result of The behaviour; what keeps it going. How is the behaviour being Rewarded ? Note: Negative attention has been seen to be a form of reward. Thus scolding or Even slapping the child can also work as a form of reward simply because it is attention. Step Three: Next time the unwanted behaviour occurs, do not discuss, scold or Argue. Just remove the reward from the child. How this is done depends upon the nature of the reward. If the reward is an object, remove it. If the reward is your attention, or giving in to his demands, then stop immediately. If the entire situation seems to be rewarding, remove the child immediately, taking him to another room(one in which he can do no damage) and leave him there for three to five minutes no matter how much he screams. After three to five minutes, let him out at a moment when he is not screaming. Step Four: Repeat Step Three each time the behaviour occurs. Points to Remember when using this Method Be consistent. Once you have begun time-out, use it every time the behaviour occurs. Be firm. Your child may scream but this will do no harm - this is part of learning. Start with a time-out of three minutes and increase to five minutes, it should be not more than seven minutes. Do not discontinue time-out. The behaviour will get worse before it gets better. Try to end the Times Out at a moment when the child is not screaming. Explain to your child beforehand what will happen if he behaves in that way. Combine Time Out with reward for desirable behaviour. Do not discuss or scold. Keep a cool business-like attitude. Make sure your child is not finding the Time Out situation itself rewarding. REMEMBER When using the Time Out method, the unwanted behaviour may first increase before decreasing. Continue using the method and the behaviour will change gradually. Example: A mother wants to change her child's misbehaviour at meal-times. First, she records the behaviour for five days. Then she examines the records and realizes that the child tends to throw food around and play with it. This helps him to get a lot of attention either in the form of scolding or pleading with him to eat properly. Each time the child throws food and plays with it, his mother removes his plate without talking to the child. This should be repeated till the behaviour stops. The Restraint Method: Step One: Record the behaviour Step Two: Each time the behaviour ooccurs, hold the child's arms or hands tightly without saying anything. Step Three: Repeat Step Two as often as the behaviour occurs. Example: A mother wishes to change her child's habit of throwing things. She first records the behaviour, what happens before, during and after it. She finds on analysis that the tantrum occurs when the child's demands are not met. She then holds arms tightly to his sides for a brief period. She continues this procedure till the behaviour stops. The over-correction Method: Use this method for older children and children whose level of mental handicap is Mild. This method can be used to reduce aggressive behaviour. Step One: Record the frequency of the behaviour Step Two: Whenever the behaviour occurs, make the child correct what he has done. In addition the child should be made to do some extra related work. This should be done without any discussion and argument. REMEMBER As little attention as possible must be given when the child misbehaves, because negative attention can also be rewarding. Step Three: Repeat Step Two until the behaviour gradually stops. Remember Make completely sure that the child does not find the over-correction situation itself rewarding. Example: A mother wishes to change her child's behaviour of scattering his books around. She records the behaviour over a period of five days and finds that it tends to occur when the child is not getting his way. Each time the child scatters his books the mother makes him tidy them. In addition, she makes him tidy the whole room. If he refuses she holds his hands and makes him do the job. She does not talk while doing so and neither does she discuss or explain. This is continued till the behaviour stops. The Response Cost Method: This method too is used with an older child and with one whose level of mental handicap is mild. It can be used to change a large variety of behaviours which the child realizes are wrong. Step One: Record the behaviour. You can use the simple counting method. Step Two: When the behaviour occurs, it must cost the child something. He can be made to give up a privilege or a favourite activity. Step Three: This procedure is to be continued till the behaviour stops. Example: A child is careless about doing his homework and usually avoids finishing it. Each Time this happens his mother does not allow him to go out and play. This is Continued till the child stops avoiding his homework. UNDERSTANDING THE CHILD WITH DOWN SYNDROME Personality By the time your Down's child has reached the age of two years, many changes will have already taken place. By now he will have become a clearly defined personality and a definite member of the family. Many of the worries that assailed you when he was born will have proved either unfounded or much less frightening than you had imagined. Most Down's children are far from being repellent in any way, but tend rather to be pretty, affectionate and appealing. One thing will have become evident, your Down's child is now as much a person as anyone else. Whilst he is likely to be 'normal' in many ways, he is, more importantly, a definite individual. It was rather common in the past to regard Down's children as all exactly alike. This is far from the truth. After all, like other children, Down's children have inherited a full genetic message from their father's and mother's families. The addition of an extra chromosome, though it may distort the message and retard development, does not obliterate the genetic message, and you will see family characteristics. Parental Attitude and Discipline You must try at all times to have a realistic picture in assessing your Down's child with his brothers and sisters, or with other children. Even with normal children, little good comes from saying 'Why can't you be like your brother ?' Many parents fall into this trap from time to time, but it is a more common cause of friction and unhappiness than of improvement in the child concerned, because in effect it means 'Why do you have to be YOU !' We can do and influence our children's personalities a great deal in the course of their infancy and and youth, but in a much more subtle manner and this leaves them as real individuals. The maxims of structured, consistent discipline are even more important in Down's children. Always remember that teaching discipline may need more consistency with Down's children. It is important that they have a clear understanding of exactly what you expect of them and what is permissible. CHARACTERISTICS OF DOWN'S CHILDREN Most children, fortunately, are unlikely tobe other than very pleasant, lovable and affectionate, though they have their ups and downs like any other child, and while, like any other, they can at times be temporarily naughty, destructive and wilful, this should usually pass with careful handling. Many of the child's characteristics are, of course, related to the development and function of its brain. As the brain is the most complex of all organs and is still, despite many years of concentrated study, only very marginally understood, it is not very surprising that the brain of a Down's child, which has been very much less studied, is an even more mysterious organ. A certain amount has, however, been tentatively suggested as a result of some of these studies. It may be that the Down's child's brain is considerably less developed before birth than a nonDown's. It may differ in shape and size and some parts may be more developed than others. One theory is that the brain areas dealing with complex thought and reasoning develop last and slowest in the Down's child. This is of some importance to an understanding of the child's personality and actions, and can offer some explanation of certain features that may otherwise appear unexpected and puzzling. Such features as affection, sympathy and sensitivity to the moods of others are related more to the parts of the brain concerned with the basic emotions and drives than with reasoning. To the extent that these are often long-lasting features of the Down's child, it may indicate why the Down's child retains some of the features of the younger child or baby, which gradually change as the normal child develops. Just as very young babies react quite sharply to the moods of those around them, so does the Down's child. This characteristic is important, as it will be evident when he relies very much on a happy and stress-free attitude on the part of his parents. While these are some of the things that make the child so friendly and appealing, it is also important to be aware of the problems sometimes faced by an indiscriminately affectionate nature. One thing which most parents of an older child will be aware of is that the child is unusually trusting. He may happily go with anyone, and as a result will not usually cry when he is losst, an event which may happen as he reaches an age when he can indulge in another fairly characteristic feature of the Down's child - curiosity. It is not uncommon that slow learners, generally due to their lack of ability, may try to compensate through making people laugh. When this is encouraged by compliments it perseveres and recurs for the wrong reasons. Mimicry which is very amusing at three years can be most embarrassing at fifteen. For ourselves, it is sometimes advisable to restrain our amusement in the child's presence and go somewhere out of his sight to chuckle, and to restrain any temptation to encourage the child to clown for the amusement of others. It is equally important, where possible, to make sure that the child is kept as far away as possible from undesirable examples which he may also copy with undiscriminating accuracy. This raises the rather vexed question of the relative advantage and disadvantage of placing the child in a playgroup largely composed of children with other handicaps. The stimulation of being in such a group can be good, especially if there is a skilled and experienced nursery teacher, or one accustomed to dealing with the special learning needs of handicapped children; and many of the children can indeed teach your child through example. If, by any chance, any of the children have particularly marked unusual patterns of behaviour, the Down's child may imitate these and you must be prepared for this. This is one facet of argument which is often put the forward for the integration of Down's children into normal playgroups, nurseries and schools, but must be considered along with numerous other educational and social considerations. They love exploring unfamiliar places and can lose themselves within seconds when taken out or, sometimes, even in the immediate surroundings of their own home. This is something which gradually improves with increasing age and training, but needs to be kept in mind when the child is under eight. As a result, they should not be allowed to go out without supervision until observation of their behaviour when playing has indicated that they will remain in the proper area. In their own area, if neighbours are friendly, the problem is not great, but it is worth bearing in mind in strange places; when shopping, or in crowded spots such as fairs and zoos. It is very desirable to take the child out as much as possible to give him a wider experience of the world around, despite the problems involved on occasions, but at all times you need to keep an eye on the child. Of particular importance in this area is teaching your child that under no circumstances must he ever go with strangers. This is a lesson which needs constant reiteration, especially considering the children's friendly personalities, and often delayed social skills. A characteristic that has been noted by practically every writer on Down's Syndrome and nearly all parents is obstinacy. The degree to which this appear varies, but many Down's children, however advanced, and many adults too, show this to some degree. Most children can be obstinate and pigheaded at times; the Down's child perhaps more than most. There are several reasons for this, which need to be allowed for. Often it is not the child's fault, though some of it may be both conscious and wilful. Some arise naturally from the child's limited understanding of what is expected of him, some from difficulties in communication (especially as the child may not develop very efficient speech until much later than most children), some from the nature of the child's mental processes, which do not permit very rapid changes from one conscious activity to another. Ways of allowing for this and helping the child in the right direction will be suggested later, but it can often be seen quite clearly whether the obstinacy is a natural one or a deliberate one. Like others, the Down's child who is being deliberately naughty or exercising his independence (the latter ideally something to be guided and encouraged, rather than repressed !) may show by his expression that he knows quite well what he is doing. The stuck-out lower lip and the sidelong glance which indicates that he is being wilful and is deliberately testing mother's love or patience, is not too difficult to interpret and needs different treatment from the apparent pigheadedness that makes a child sit down in the road or on the pavement and refuse to move simply because he is too tired to continue further. An ordinary child would complain that he is tired - the Down's child, whose language may not yet be up to the explanation, takes action instead and needs help. Impulsiveness Developmentally delayed children in general, whether they have any known condition or not including the 'normal' slow-learning child at school, tend to act on impulse more than the rest of us. They have a tendency too to be more restless and distractible than most. This may be related to their mental development in that they are more likely to react swiftly to their feelings than to reflect, as the more intelligent do, on the possible results of their actions, as their powers of reasoning are not as well developed as are their emotional powers. Down's children show this characteristic in varying degrees. They may go through a period, often in their first three or four years, when they are especially active, constantly in motion, exploring, turning out drawers, upsetting things and apparently engaged in quite random activity. This is a stage, however, that they need to go through, tiresome though it is for they gain experience of the world around them and find out for themselves the limits it places on them. Of course, while we need to guard them against actions that are potentially dangerous, such as playing with electric light sockets, pulling at saucepans and kettles or switching on the gas, we should not try to overprotect them against milder consequences such as a bumped nose, scratches and bruises, through which they do learn what can profitably be tried and what cannot. What we can do is to try in various ways that will be suggested, to channel their energy and curiosity into directions that are profitable, and to convert random activity into activity of a very similar sort that actually teaches them something. Mimicry Another characteristic, both of young children in general and Doown's children in particular, over a wide-age span, is mimicry. While some have put this down as a useless survival of the habits of infancy, this is far from true. Recent studies have made it clear that mimicry is one of the most valuable strategies of learning available to the child. This is particularly true in the area of speech and language development. It follows, however, that one has to be particularly careful to present the child with useful and correct examples to copy. Many Down's children are remarkably good at mimicry and some can mimic other people's manerisms and actions with uncanny and often very entertaining accuracy. This process has many advantages and some pitfalls as well of which all parents should be clearly aware. Firstly, it should be kept in mind that we are not training our children to be clowns. Many of their actions are indeed truly funny, though this is not, in the beginning, their own conscious purpose. However, we have to walk the delicate tightrope that lies between encouraging a child to learn by incorporating other people's activities into their own real repertoire, and encouraging them merely to entertain others. INTERPERSONAL CONTACT From about one year, the child will benefit greatly from the company of other children of the same age or a little older. Down's children gradually develop an extraordinary capacity for mimicry. They can copy actions and mannerisms with near perfect accuracy. So it is important to provide them with good examples, both in yourself and in those of the company selected. From one year onwards, it is valuable to have the child with the family at meals first in its BabyRelax chair, then in a high chair and finally on an ordinary chair, with cushions if required. The child will be able to observe other's actions and behaviour at the table. Social play can begin with imitative play with a tea-set, as other children will readily enter the game and good manners can be unobstrusively encouraged. In the Home The baby should be moved in its chair from room to room to watch its family engaged in household activities. This offers a valuable change of scenery and will gradually accustom the child to the house and the various rooms. When the child can sit reasonably well when strapped in its chair, place the chair so that the child can join the family at meal-times. The child will thus be introduced to family life and will get used to the routine of the table and to watching others eat. Outside the Home If the weather is suitable, the child should be taken out regularly, propped up in its pram, and should be given the opportunity of seeing other people outside the family. Shops and markets will provide the child with plenty of things to look at. Experience will help the child to keep awake and alert. Many people have no idea of what a Down's child is like and have distorted ideas which often lead to prejudice. It is therefore a big disadvantage to keep the child concealed. This is most important if the child is to grow up in the district and be accepted by other parents when he reaches the age for admission to a playgroup or nursery. DEVELOPING COGNITIVE SKILLS Thinking involves many activities - memory, comparison, choice in particular - and games intended to train the mind need elements of each of these. Memory Make the child find hidden objects after being shown where they are put. Then progress to hiding an object in the child's sight in one of several identical boxes with lids, or if it is easier, in boxes that are different. Comparison Shapes to fit pillar box toy, jig-saws and matching games. Fitting the right lid or top on doll's teapot and kettle and on real utensils, boxes, jars etc. Sorting according to size, colour, etc. for example, piling up objects with the largest at the bottom. This also gives an idea of balance. The abacus is useful from babyhood for a number of purposes, i.e. from lifting the balls to fall with a click, to lifting them right off, then to the more delicate job of putting them back on, then of dropping them gently to practise releasing an object precisely, for putting them on the columns in their right colours and learning the colours themselves, and finally for the idea of the longest rod, shortest rod longer and shorter rods, etc. As mentioned before , most children go through a prolonged stage of casting bricks away instead of building, but once they are past this stage they can be encouraged to build with vertical blocks and cross pieces. With older children you can then go on to make simple patterns with small sets of one-inch bricks of different colours and teach them slowly and systematically to copy the pattern. This is a really educative game as it involves recognition of colour and pattern and concentration. Eventually you may reach the point where you can make up a pattern ( at first of only three coloured bricks), let the child see it, then hide it behind a card and encourage him by repeated practise to make up a copy from memory, a much more difficult feat for children to master. Choice Making a choice involves thinking.A simple exercise is to offer two objects, in one each hand, and to move your hands about until the child settles on one of the objects which should be given to him. This can be played for some time with different objects. Try to encourage choice whenever possible, giving the child alternatives so he must take a decision. Sometimes introduce activities where choice depends on matching or sorting, e.g. Lotto or sequencing, i.e. size-sorting puzzles. As children vary a great deal in their capacity, these suggestion cover wide possible age-range. If a child is not yet ready for a particular item, it may be postponed until later, but it is important to try again from time to time so that each child learns to carry out the activity from the earliest possible time that he is ready to do so. He will generally be your best guide as to how ready he is. Remember that though children need fairly firm treatment to overcome their tendency to obstinacy, the activity should always be good-humoured and fun for the child. Try not to allow yourself to become over-tense and anxious, as your feelings will be 'caught' by the child. Children are often surprisingly sensitive to atmosphere and will readily become anxious, fussy and disturbed if we put emotional pressure on them. It is useful at all times to keep a diary of observations of your child. Before you attempt any thing new, read it through and you will often be able to judge when he is ready for a more advanced activity. Try always to see what he is doing, not from your adult point of view, but from his. It is particularly helpful to work at very close range with him, so that he feels safe and comforted by mother's nearness, and often to get right down on his level too. If you do this, you can often see the world from a level you have forgotten since childhood and can better weigh up his problems, see as he sees and go along with him, rather as though you were a super-intelligent and helpful friend of his own age. You will often spot, in addition, impending dangers that escape us at our own eye-level - the bottle of disinfectant within easy reach, the trailing electricity cable with which he can pull down a lamp, the over-tempting tablecloth, or the heavy drawer that can readily be pulled down onto his head. Doll play is equally important for both boys and girls when they are small, as they gain once more from the body-image practise and it is a mistake to keep dolls only for girls and construction toys for boys. Both sexes can benefit and indeed many of the differences in interests between boys and girls at school are built into them by differences in the toys with which they play, a fact that applies to normal children as well as to children with Down Syndrome. Games of hide-and-seek and peek-a-boo are also popular before and largely through school age. PRACTICAL REASONING Many activities involving sorting by shape, colour, size, etc. are obviously good exercises for practical reasoning. Teaching number concepts as a form of practical reasoning should not be neglected either, though this is much harder for most children than is reading and writing. In this respect, the text-books are by and large correct. Teaching them numbers is a much more arduous job, as it is a more abstract idea than reading and needs a great deal of early practise if a child is to grasp the idea. Some can well begin with nursery rhyme number games, matching the actions with counting on the fingers. Later, one can progress to counting by correspondence where a child counts a line of bricks with his forefinger once he has mastered the idea that he can count on his fingers up to five and then ten. Practise this, making sure that the child does not skip any of the bricks when counting as young children are apt to do. As time goes on, gradually extend the line of bricks to five, ten and eventually up to twenty. To teach the idea of subtraction, get the child to pull away one brick at a time from the same, counting down as he does so from five down to one, then from ten down to one. Older children who have seen a count-down for a rocker or spacecraft on television often enjoy the exercise of saying 'five-four-three-two-one, BLAST OFF !. READING AND WRITING Picture books, as mentioned earlier, are of extreme importance as they teach all sorts of ideas and new words if you go over them with the child and point to everything, and this is the first step towards reading. Initially, children grow used to the fun of handling and looking at books, though their attention is very fleeting: The book should not be forced on them when they get restless, second, and most important, a picture is a symbol, one step away from reality and can lead the way to the more abstract symbols we call words. Not all children are likely to read for many years but those who do have often been brought up with books from a very early age and have had many ' pre-reading' exercises, such as naming toys and objects around them, looking at pictures, putting simple jig-saw pictures together, playing matching games. With older children who are beginning to read and can understand language much better it is also useful to show that in a picture some things are close to us, others further away and others in the distance; and you can even introduce the words foreground, middle distance and far distance. With some children it is quite practical to introduce large-letter word cards as early as at three years of age. Some early readers with large-letter cards with very common words such as Mummy and Daddy and names of parts of the body can be very handy.This must, however, be a game and under no circumstances must the pace be forced or any element of stress under no circumstances must the pace be forced or any element of stress allowed to creep in. It is better to play for five minutes before the child goes to sleep than to try to 'teach reading'. If the pace is forced you may give him a permanent distaste for words and spoil later reading training altogether. As a game, however, it can pay surprising dividends. Picture books can often be used for discussion long before the child is ready to read the words and offer very good clues as to what the words say later on. A fair number of children do learn to read, some only a little, but enough to be useful in some ways; others may become quite fluent readers and enjoy reading. Later, those who cannot succeed in actually reading books are often taught to recognize longer words, such socially useful words as open and shut, danger, ladies and gentlemen, etc., but this is quite another process from actual reading. Even writing can be prepared for from quite an early age by letting the child scribble at first, then gradually getting him to draw a horizontal line, then, a vertical line, and then a horizontal line across a vertical to make a cross. Later, as the child gets more control, you can begin guiding his hand to make basic letter shapes such as arches and circles. Note that in writing, circles go anticlockwise. Later you can introduce 'ladders'. First draw two lines down the page to make the ladder sides. Show the child a finished picture of a ladder and guide him into drawing lines horizontally and let him draw vertical lines for the rungs of a ladder, a more difficult exercise, to be only tried when the child can already copy a vertical stroke. Later you may try to get him to do zig-zags, as these again are a preparation, years in advance, for the time when the child may eventually have training in writing. Some children are ready before school age for what would normally come rather later, that is the drawing of circles, squares and ladders. Though all children follow the sequence of drawing indicated here, some pass through them much faster than do others and it is recommended that your child be encouraged to do a great deal of drawing and painting (even if this does mean at ages between five and ten that they like to decorate the walls with designs of their own, a somewhat expensive practice for the houseproud parents, but a minor irritation if it teaches the child eventually to draw and then to write). Though many children are not ready for writing preparation much before school age, you can always try things as early as you can. To move from drawing to writing, first draw the uprights of a ladder and let your child draw in the rungs from a copy put before him, or copy you in doing so with a ladder of your own. At first the rungs will be crude and either be too short or too long and overlap the edges of the side pieces. Encourage your child by repeated efforts once or twice a day to keep the rungs within the lines. Once a child can do this, try drawing the ladder on its side and letting the child draw in the r ungs vertically. If he can do this successfully, this is the first step towards writing and you can go on to get your child to copy or trace zig-zag lines between the two horizontals and then continuous loops all along between the lines. To vary the game, as children have limited concentration at this age, start to teach them, if possible to colour in black and while pictures in children's play books. It will probably be years before your child can keep the colours neatly within the shapes of the picture, as they do not grasp the idea of a picture as a real representation when they are little, but gradually they will achieve this and if they learn to read, they can learn by repeated tracing over large round lettered words written by your using tracing paper to form words that they can already say clearly. Drawing is something that many parents are not very good at, but if you show your child that a 'man' can be made up of a circle for the head, an egg for the body and two carrots for each limb, adding triangles for the hands and feet, the children can often learn to draw quite a reasonable man and will enjoy sticking clothes cut out from women's magazines onto their man. To help with their own body image, early work with a large mirror pays off, beginning at the point where children can point to Mummy's nose, dolly's nose, and until the child can point to every part of his or her body. A child who knows how to identify every part of his body, even if he cannot name them yet is easier to dress than one who has no real body image. Toy shops and educational suppliers generally stock wooden human figures cut out of plywood with heads, arms and legs separate to that they can be put together with pegs running through the holes in the parts, on a wooden base. You can also help your child by lying him on the floor and drawing round his figure on a large sheet of wrapping paper. When this has been done, teach him to lie down on the cut-out , which can be painted black, matching his limbs to the layout on the floor. Then this 'model' can be cut into parts and the child can be encouraged to put Arun together. Later, you can have colour photos of the whole family taken full face and get a spare print of these about ten inches by eight inches in size and cut the spare print out into heads, arms, legs, hands and feet to teach your child to make Arun, make Mummy etc. In this way he will enjoy playing with pictures of people he recognizes, even if very often he fits Mummy's head onto Daddy's body, as can be done for fun with certain similar card games made up by educational toy shops. Another useful trick is to place your child's shoes a sheet of card, draw round them and get him to fit his shoes to the pattern which can be blacked in.This can be very helpful for children who commonly put their shoes on the wrong feet and can introduce the idea of right and left. Long before your child can speak fluently or even at all, it pays to 'read' little stories with many pictures to him, pointing out what is going on in the picture. We have tested many children who have clearly had little of this experience of description, and though they can name a lot of separate objects in large picture, they cannot say what is happening in the picture in sentences until quite a late age. You can encourage this skill by regularly demonstrating it. PRE-SCHOOL EDUCATION Not less important is the fact that the child who is not used to the company of other people may not do well at all in the assessments carried out by a psychologist with a view to determining the best form of educational placing for the child. While, as mentioned earlier, many children go willingly with strangers, they are rather shy in some ways than might appear and may not perform at their best in unfamiliar surroundings when mother is not present. Some who have spent all their early life in the company of their mother may prove very unhappy and withdrawn at school when she is not there. Most nursery schools require mother to be present for some time at first, or take the child for only a few hours or half a day to start with, and this practice should be encouraged. In some areas perhaps the only playgroup available to the young child is one for children with miscellaneous handicaps. Provided that the parent is present with the child and can tactfully place him with children who will offer stimulation without undesirable examples, there is probably much to be gained. However, don't forget if you have a large family of mixed age near your Down's child, in age either slightly younger or slightly oder, he will also gain much from them (assuming of course that your other children fully accceeppt him into their own games and do not simply leave him to his own devices). For most families, however, there comes a time when the child is mobile and fairly reliable in bowel and bladder control, when he is ready for introduction to a wider circle. After the age of about three, few parents can afford the facilities or have room or the training to offer the child what can be offered by a good playgroup of nursery class.