Inclusive Education PDF

2.8. Barriers to Inclusion societal values and beliefs- particularly the community and policy makers negative attitude towards students with disability and vulnerabilities. Economic factors- this is mainly related with poverty of family, community and society at large Lack of taking measur...

2.8. Barriers to Inclusion societal values and beliefs- particularly the community and policy makers negative attitude towards students with disability and vulnerabilities. Economic factors- this is mainly related with poverty of family, community and society at large Lack of taking measures to ensure conformity of implementation of inclusion practice with policies Lack of stakeholders taking responsibility in their cooperation as well as collaboration for inclusion Conservative traditions among the community members about inclusion Lack of knowledge and skills among teachers regarding inclusive education Rigid curricula, teaching method and examination systems. Fragile democratic institutions that could not promote inclusion Inadequate resources and inaccessibility of social and physical environments Large class sizes Globalization and free market policy that make students engage in fierce completion, individualism. Using inclusive models that may be imported from other countries  UNIT TWO: SENSORY, MOTOR, HEALTH AND COMMUNICATION IMPAIRMENTS 2.1. Children with visual impairment 2.1.1. Definitions of visual impairments:
VI can be defined from different points of view differently.
It can be defined from medical (clinical)or legal and educational perspectives.
The definitions given to visual impairment are of two types. Such as: 1. The legal definitions focus on the measure of visual acuity and field of vision 2. Educational definitions is whether there exists a residual vision that enables an individual to learn using his/her sense of sight or not.  Cont… This sensory impairment can be classified into two in terms of severity : partially sighted and blind. Partially sighted/low vision learners are those having significant visual problems but still use their vision as their primary sense for learning and Blind learners are those whose visual impairment is so severe that they must rely on senses other than vision to function adequately.  Cont… Measurement units typically are expressed in reference to Snellen chart notations of visual acuity. This chart consists of symbol (number or letters) that decrease in size; it is read at a distance of 20 feet. Symbol size corresponds to the standard distance at which the people with normal vision can recognize the symbol. Acuity of 20/20 means that a person can read the symbol at a distance of 20 feet, a ratio considered representative of normal vision.  Cont… In other words, an object that a person with a normal vision (20/20) can see at 200 feet must be brought to 20 feet before the person with 20/200 acuity can read it. Blind : visual acuity of 20/200 or less in the better eye, with correction/ or whose visual field of less than 20degree or less in the better eye. Partial sight individuals are with visual acuity ranging between 20/70 – 20/200 When vision is more significantly impaired (20/400 or worse) or when very young or handicapped persons are tested, it is frequently necessary to test vision at distances of less than 20 feet. In these cases, the numerator is less than 20, usually 10 or 5. A reading of 10/200 means that an object distinguished by persons with normal activity at 200 feet must be brought as close as 10 feet for recognition.  Cont… As the denominator in the measure of visual acuity increases, visual acuity decreases while the severity of visual problem increases.  Cont… Field of vision- refers to the angular distance or space, which is covered by vision. The normal field of vision is 180o. The legal definition of visual impairment relies heavily on the measurement of visual acuity and range/field of vision. Legally, it is defined blindness as having central visual acuity of 20/200 or less in their better eye with correction, or having the peripheral vision contracted to an extent in which the widest diameter of the visual field covers an angular distance not longer than 20 degrees.  Cont… The term blindness educationally typically refers to vision loss that is not correctable with eyeglasses or contact lenses. Blindness may not mean a total absence of sight. However, some people who are considered blind may be able to perceive slowly moving lights or colors. The term low vision educationally is used for moderately impaired vision. People with low vision may have a visual impairment that affects only central vision the area directly in front of the eyes or peripheral vision the area to either side of and slightly behind the eyes. It can be corrected with corrective lens/enlarged print.  2.1. 2 Major causes of Visual Impairments 1.Refractive errors: Myopia or nearsightedness: is caused by increased curvature of the eyeball (where the eyeball is longer than normal from front to back) resulting The refracted image comes into focus in front of the retina instead of on it. Nearsighted glasses, contact (concave) lenses, and laser refractive surgery are all used to move the image from in front of the retina to on the retina itself! Hyperopia or farsightedness: is caused by a decreased curvature of the eyeball (the eyeball being shorter than normal from front to back) resulting in light rays focusing beyond the retina, causing difficulty in seeing objects that are nearer. Farsighted glasses, contact (convex) lenses, and refractive surgery are all used to move the image from behind the retina on to the retina itself! Astigmatism: Is the outcome of irregularities or unevenness in the cornea, causing light to be refracted differentially rather than at one point where part of the image is correctly focused, resulting in blurred or distorted vision. Glaucoma: Glaucoma is a condition that is related to a significant increase in the pressure exerted by the fluid (aqueous humor) within the eye itself. Usually the fluid is secreted and circulated in the eye. If the pressure of this fluid becomes too high, internal damage (damage of the optic nerve) which can result in severe loss of sight or tunnel vision. The person sees only the central of the visual field. This can lead to permanent loss of vision. But, if it has been detected early enough, glaucoma can be treated by controlling the pressure in the eye. Cataract: is a condition where the lens becomes Opaque (cloudy) instead of remaining transparent. This results in a loss of visual acuity with light perception being adversely affected. This can be surgically corrected.  2. Muscle Disorder or Defects Disorders relating to ciliary muscles around the eye are: Nystagmus: A circular or side-to-side, rapid involuntary movement of the eyeball. Strabismus: An inability of the muscles to pull equally, resulting in crossed eye (internal strabismus) or eyes pulled outward (external strabismus). Surgery can correct many of these conditions. Amblyopia: A loss of vision due to muscle imbalance that results in double vision. Here the brain attempts to reduce the confusion thus created by repressing the vision in one eye and the unused eye may therefore atrophy, resulting in loss of sight. Here the child can put a path on the unaffected eye to force the affected eye to focus. Surgery also helps.  3. Diseases  the potential causes of visual impairment. The causal factors may be of viral, bacterial, or enzymatic abnormalities. Some might be treated; while others cause permanent and complete damages on our vision. It can include the following: Diabetic Retinopathy: A disease of the small blood vessels that nourish the retina is the most common eye complication of diabetes mellitus, a disease in which glucose or sugar is not properly used by the body, along high levels of sugar to build up in the blood and urine. It is impaired vision due to hemorrhage (great flow of blood) and the growth of new blood vessels in the area of the cornea. Sickle-cell retinopathy Retinopathy of prematurity (retrolental fibroplasias) in its advanced stages causes an abnormal fibrous condition in the eye of a premature infant. Sickle- cell retinopathy involves blockages and hemorrhages of retinal blood vessels that occur in association with sickle-cell anemia. Infectious diseases: Trachoma, syphilis, measles, small pox can cause visual impairment. 4. Accidents and lack of nutrition (vitamin A): Exposure for very powerful light, being hit by bullet or any other thing, acid attack,… are among the accidents we may encounter and face visual impairment.  2.1.3 Symptoms and Identification of VIS: Rubbing eyes: - The rubbing may be observed in excessive amounts or during close visual work. Shutting or covering one eye: - a student who is having difficulty seeing may close one eye, tilts, or thrust the head forward. Light sensitivity: - Some students with an undetected vision problem may demonstrate unusual sensitivity to bright or even normal light. Difficulty with reading: - Unusual amount of difficulty in reading or other work requiring close use of the eyes. Losing place during reading: - A tendency to lose his/her place in a sentence or page while reading. 14 Unusual facial expressions and behaviors: - Unusual amount of squinting, blinking, frowning, or facial distortion while reading or doing things. Achievement disparity: - disparity between expected and actual achievement is one of the indications of visual problem.  Cont…. Eye discomfort: - the student who complains of burning, itching, or scratchiness of the eyes may be experiencing a vision problem. Holding reading materials at an inappropriate distance holding reading materials too close or too far or frequently changing the distance from near. Discomfort following close visual work: - the student why complains of pains or aches in the eye, Headaches, dizziness, or nausea following close visual work may need corrective glasses. Difficulty in distance vision and Blurred or double vision Reversals: - a tendency to reverse letters, syllables, or words may be an indication of impaired vision Letter confusion: - a student who confuses letters of similar shape (o and a, c and e, similarly n, and m, etc) may have impaired vision. Poor spacing: - poor spacing in writing and difficulty in “staying on the line” may be an indication of vision problem.  2.1.4 Support Systems of Children with Visual Impairments Educational support for children with VI: Educators believe that the most important visual consideration is functional visual efficiency, or how well children use their vision, rather than the particular measure of visual acuity. Teachers of children with visual impairment are often taught of in conjunction with specialized equipment and materials such as Braille, canes, tape recorders and magnifying devices. Whatever the range of visual deficit, it is crucial that any remaining vision is utilized to a greater extent possible. The child needs to be encouraged to optimally utilize his/her tactile sense or auditory modality similar to that of hearing children. Both the parents and the schools make their own contribution in intervening to the difficulties of children with visual impairment. Yesseldyk and Algozine (1995) have stated ten tips for teachers of students with visual impairments.  Cont…
Reduce distance between student and speaker as much as possible.
Reduce visual distracting as much as possible.
Reduce disorder on classroom floor and produce free access to door and key classroom spaces.
Seat students near chalkboard or overhead projections, or give them the freedom to move close areas of instruction.
Avoid partially opening cabinets, storage areas, and classroom doors; ascertain that fully opened or closed doors as sager.  Cont….
Use auditory cues when referring to objects in the classroom and during instructional presentations,
When presenting visually dependent material, verbalize written information, describe pictures, and narrate non- verbal sequences in videotapes or movies.
Use complete sentence to provide additional content.
Reduce unnecessary noise it helps focus cement of instructional presentations.
Keep instruction materials in the same place so students can find them easily,
Make sure glasses and other visual aids are functioning property.  2.2 Hearing Impairments 2.2.1 Definition of Hearing Impairments (HI): Passonella and Care (1998), defined hearing impairment as a generic term indicating a continuum of hearing loss from mild to profound, which include sub classifications of hard of hearing and deaf. Any kind and level of obstruction faced by our sense of hearing is collectively named hearing impairment.  Cont… In Ethiopia, there is no document which helps to understand both the terms hard of hearing and deafness. Instead, it is described with a single term consisting negative notions such as “idiots” which is to say those who cannot be educated or do not at all understand. Such an erroneous understanding of the hearing impaired is evident by the widely used Amharic term “Donkoro” meaning as described in Amharic Dictionary; an individual whose hearing organ does not at all function; mentally handicapped; and who lack the ability to understand any language.  Cont… In modern world, there are two perspectives or ways of defining hearing impairment: physiological and educational definitions. Physiological definition:
Deaf: is a condition of hearing loss about 90 Decibel (dB) or greater.
Hard of hearing: is a condition of hearing impairment of less than 90 dB. Educational definition of hearing impairment:
Hard of hearing: is a term that describes persons with enough residual hearing to use hearing (usually with hearing aid) as a primary modality for the acquisition of language and in communication with others. This condition can affect the child’s educational performance to some extent.
Deafness: is a term that described people whose sense of hearing cannot process linguistic (verbal) form of information.  2.2.2 Major Causes of Hearing Impairments: Hearing impairment is caused by various congenital and acquired conditions of outer, middle and inner ears
congenital conditions of the middle ear Include:  chromosomal and skeletal abnormalities  Malformation of pinna is a known congenital condition of outer ear that causes hearing impairment.  like rubella ( German measles). Cytomegalovirus and bacterial infection such as syphilis., circulatory disorders and infections
Acquired conditions of outer ear.  Injury of the pinna,  foreign bodies: pocking an object into the middle ear  excessive wax,  Noise damage  ineffective conditions like otitis media ( inflammation of the middle ear); and facial paralysis)  infection of the outer ear, and  Tumor/cancer  ototoxic drugs, and conditions involving vertigo (Tirussew, 2000).  2.2.3 Symptoms and Identification of HIs: There are several symptomatic behaviors that are used to determine whether a hearing impairment may be present. Once a child is suspected and determined that he/she has a HI, Then, parents or teachers must refer the child for further audio-logical or medical evaluation to determine the type or degree of hearing loss. These evaluations will help to decide: on the type of hearing aid needed, and on the nature of school placement. In order to understand the symptoms of hearing impairment, it is helpful for parents and teachers to have knowledge of the normal auditory development.  Some behavioral warning signs of HI  Inattention, restlessness, distraction of others, more responsiveness in quiet conditions  Complaints of earache, popping a visible discharge from the ear  Giving inappropriate answers to questions, watching and following what other children do  Louder or softer voice than is usual  Slowness in responding to simple verbal instruction, with frequent requests for repetition  Searching visually to locate a sound source or turning head to give one side an advantage  Needing to sit nearer a sound source that is usual or asking for volume on TV, tape or record player to be tuned up.  Some irritability or typical aggressive outbursts more frequent behavioral upsets in school  Reluctance to participate in oral activity and little interest in following story  Failure to turn immediately when called by name unless other visible signals are given  Tiring easily, poor motivation, some stress signs such as nail-biting  Particularly difficulties in verbally related skills such as reading sound blending and discrimination and writing with better skills in practical areas  Speech limited in vocabulary or structure and use of gesture  Best work in small group.  Yesseldyke and Algozzine (1995) also listed ten potential signs CWHI in the school.
Difficulties following oral presentations and directions
Watches lips of teachers or other speakers very closely
Turns head and leans toward speaker
Uses limited vocabulary
Uses speech sounds poorly
Shows delayed language development
Does not often respond when called from behind
Generally inattentive during oral presentation
Constantly turns volume up on radio or television
Complains of earaches, has frequent colds or ear infections, has ear discharge.  2.2.4 Support Systems of Children with Hearing Impairments Once a hearing problem is detected and diagnosed, intervention should follow. Early intervention is largely accepted to revert the problem before it develops worse, both parents and teachers can play a significant role in the intervention process but here teachers (school) interventions are focused. It should be stressed that the appropriate teaching environment for hard-of hearing should be more or less similar with that of the hearing students. It is always important to remember that placement in regular schools (less restrictive programs) is a function of the degree of hearing loss.  Cont… According to Heward&Orlansky (1988), the following characteristics are among these considered most critical to the effective teaching of hearing impaired students. Providing language instruction  Teaching small groups of SWHI, who function on different levels.  Developing and adopting instructional materials and enhancing positive self-concept  Using information from various assessment procedures to develop individualized educational program (IEP) and Dealing with crisis calmly an effectively.  Cont… In practical instructional process, the teachers should pay attention for PWHI to the following ten tips (Yesseldyke and Algozzine, 1995).
Reduce distance between student and speaker as much as possible
Speak slowly and stress clear articulation
Reduce background noise as much seat student near center of desk arrangements and away
Use face-to- face contact as much as possible
Use complete sentences to provide additional context during conversation or instructional presentations
Use visual cues when referring to objects in the classroom and during instructional presentations
Have classmates who take notes during oral presentations for student to transcribe after the lessons
Encourage independent activities, co-operative learning and social skills
Be sure that the hearing and the hearing impaired are functioning properly  2.3 Physical and Health Impairments 2.3.1 Definition of Physical and Health Impairment physical disability is a condition that significantly limits one or more basic physical activities in life (i.e. walking, climbing stairs, reaching, carrying, or lifting). These limitations hinder the person from performing tasks of daily living. Physical disabilities are difficulties associated with sitting, standing, getting into position, moving, communicating, using and manipulating classroom tools and materials and self-care. Many but not all, physical disabilities are orthopedic or neuromotor impairments.
The term orthopedic impairment involves the skeletal system- bones, joints, limbs, and associated muscles.
Neuromotor impairment involves the central nervous system, affecting the body’s ability to move, use, feel, or control certain parts of the body.  2.3.2 Classifications of Physical Impairments physical Disability can be classified based on two classification systems. First, it is classified based on the degree of severity of the physical disability. This involves: (A) Mild physical disability: individuals with mild physical disability can walk without aids and may make normal developmental progress. (B) Moderate physical disability: individuals with moderate physical disability can walk with braces and crutches and may have difficulty with fine motor skills and speech production. (C) Severe physical disability: individuals with severe physical disability are wheelchair dependent and may need special help to achieve regular development  Cont… The second classification system is primarily based on the affected area. This includes: two major types of physical disabilities: 1) the neurological system (which are caused by brain, spinal cord and nerve related problem), and 2) musculo-skeletal system (which are caused by problems in muscles, bones, ligaments and joints due to various causes).  2.3.3 Causes and Types Physical Disabilities Neurological System related problems some of the physical disabling conditions due to problems in the neurological system are the following. 1) Cerebral Palsy (CP): is a group of movement disorders that results from damage to the brain. “Cerebral” refers to the brain. “Palsy” refers to paralysis, which accounts for the lack of muscle control associated with this disability. It is caused by damage to the brain occurring before, during, or shortly after birth. Causes of brain damage may include, but are not limited to mother’s illness during pregnancy (such as German measles), Rh incompatibility (a bloody conflict between mother and fetus),  Cont… There are five types of cerebral palsy, each displaying different symptoms, and each determined by where the damage occurred in the brain. It is possible for people to have a combination of these.
Spastic - tense, contracted muscles. The most common type of cerebral palsy
Athetoid- constant, uncontrolled motion of arms, legs, head, and eyes
Ataxic - poor sense of balance, often causing falls and stumbles.
Rigidity - tight muscles and inability to move them.
Tremor - uncontrollable shaking, interfering with coordination  2) Spina bifida a condition that affects the spine and is usually apparent at birth. It is a type of neural tube defect (NTD). Spina bifida can happen anywhere along the spine if the neural tube does not close all the way. When the neural tube doesn’t close all the way, the backbone that protects the spinal cord doesn’t form and close as it should. Spina bifida happens in the first weeks (21-26 days) of pregnancy, often before a woman knows she’s pregnant. It occurs during the third and fourth weeks of pregnancy when a portion of the fetal spinal cord fails to properly close. As a result, the child is born with a part of the spinal cord exposed on the back. Although folic acid is not a guarantee that a woman will have a healthy pregnancy, taking folic acid can help reduce a woman’s risk of having a pregnancy affected by spina bifida.  Types of Spina Bifida: (1) Spina bifida "Occulta" means "hidden" in Latin is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, spina bifida occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities. (2) Meningocele happens when a sac of spinal fluid (but not the spinal cord) pushes through an opening in the baby's back. Some people have few or no symptoms, while others have problems with their bladder and bowels control. There is usually little or no nerve damage. This type of spina bifida can cause minor disabilities. (3) Myelomeningocele is the most serious type of spina bifida. With this condition, a sac of fluid comes through an opening in the baby’s back. Part of the spinal cord and nerves are in this sac and are damaged. This type of spinal bifida causes moderate to severe disabilities, such as problems affecting how the person goes to the bathroom, loss of feeling in the person’s legs or feet, and not being able to move the legs.  II. Musculoskeletal Related Problems (A) Muscular Dystrophy (MD) a group of diseases that make muscles weaker and less flexible over time. It is caused by a problem in the genes that control how the body keeps muscles healthy. For some people, the disease starts early in childhood. Others don’t have any symptoms until they are teenagers or middle-aged adults. The most common form of MD in children is Duchene Muscular Dystrophy (DMD). The disease almost always affects boys, and symptoms usually begin early in childhood. Children with DMD have a hard time standing up, walking, and climbing stairs. Many eventually need wheelchairs to get around. They can also have heart and lung problems. It is inherited from the mother who has defective gene that regulates dystrophin, which is responsible for the maintenance of muscle fiber. The gene is located on the X-sex chromosome, so primarily males will inherit the disorder than females. Although physical therapy can be very helpful to reduce the worsening of the problem, unfortunately, at present time there is no known cure or therapy that helps prevent the progression of muscle deterioration. (B) Myotonic (also called MMD or Steinert's disease). The most common form of muscular dystrophy in adults. myotonic muscular dystrophy affects both men and women, and it usually appears any time from early childhood to adulthood. In rare cases, it appears in newborns (congenital MMD). The name refers to a symptom, myotonia -- prolonged spasm or stiffening of muscles after use. This symptom is usually worse in cold temperatures. The disease causes muscle weakness and also affects the central nervous system, heart, gastrointestinal tract, eyes, and hormone-producing glands. Those with myotonic MD have a decreased life expectancy.  Health Impairment is having limited strength, vitality or alertness, including a heightened alertness to environmental stimuli that results in limited alertness with respect to the educational settings. This is due to chronic or acute health problems such as asthma, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and HIV/AIDS; and adversely affects a child’s educational performance.  2.3.4 Causes and Types of Health Impairments 1. Epilepsy a disorder that occurs when the brain cells are not working properly and is often called a seizure disorder. It is a neurological condition that involves rapid and unusually brief changes in consciousness accompanied by involuntary movements. There’s no cure for epilepsy, but the disorder can be managed with medications and other strategies. Although the exact cause of a seizure is usually not known, it can result from various conditions, including: (1) Developmental brain abnormalities (2) Infections (3) Brain injury/trauma (4) Hypoxia and Hypoglycemia  Cont… Types of Epilepsy: The following are the three major types of epilepsy. A. Grand mal /Great Illness: is the most complex seizure as compared to the others. It consists of the following four phases: 1. The aura phase: this phase is characterized by unusual sensory signals, such as strange odors, strange sounds, etc. which are warnings of the impending convulsion. 2. The tonic phase: here there is the actual convulsion which is followed by: (1) Body rigidity (2) Loss of consciousness (3) Falling heavily on the ground (4) Opening of the eyes and Suspending of breathing for about 30 seconds 3. The clonic phase: it is characterized by: (1) Secretion of muscles’’ spasms (2) Violent, continuous and jerky movements of limbs and Losing of spinster control 4. The coma phase: in this phase: (1) The individual still remains unconscious (2) The convulsion stops completely and The victim wakes up either immediately or after several hours  Petit mal /absence seizure:- It is characterized by: 1. Sudden head dropping 2. Frequent blinking of the eyes 3. Dropping/throwing of objects at hands 4. Missing parts of verbal instruction 5. May be loss of consciousness for 5-30 seconds 6. It may occur 50-200 times a day and If left untreated, it may be transformed in to grand mal seizure  Psychomotor seizure (complex petit mal seizure):- Here the attacks begin with the subjective experience of sensations, such as peculiar odors, which is accompanied by; Psychic disturbances, such as restlessness, Unusual fear, Aggressiveness, Eye blinking, Lip smacking, Facial grimacing, etc. This in turn is followed by: Climbing up a table/chair (2) undress in public (3) searching things they do not loss and disrobing/laughing or crying for no reason  Diabetes Diabetes is a chronic disorder of metabolism. It occurs when the body/specifically the pancreas either does not produce insulin at all or it does not effectively use the produced insulin. Pancreas gland regulates the level of blood sugar by producing two hormones:  Glucagon that raises the level of blood sugar in the body and  Insulin that lowers the level of blood sugar in the body.
Symptoms of Diabetes: The signs and symptoms of diabetes are: (1) Being very thirsty (2) Urinating often (3) Feeling very hungry (4) Feeling very tired (5) Feelings of pins in your feet (6) Losing weight without trying (7) Sores that heal slowly (8) Dry, itchy skin (9) Losing feeling in your feet and Blurry eyesight  Types of Diabetes: The three main types of diabetes are type 1, type 2, and gestational diabetes. 1. Type 1 Diabetes (IDDM), which used to be called juvenile diabetes, develops most often in young people; however, type 1 diabetes can also develop in adults. In type 1 diabetes, your body no longer makes insulin or enough insulin because the body’s immune system, which normally protects you from infection by getting rid of bacteria, viruses, and other harmful substances, has attacked and destroyed the cells that make insulin. Treatment for type 1 diabetes : (1) Taking injections of insulin (2) Sometimes taking medicines by mouth (3) Making healthy food choices (4) Being physically active (5) Controlling your blood pressure levels and Controlling your cholesterol levels  2. Type 2 Diabetes (NIDDM) , which used to be called adult-onset diabetes, can affect people at any age, even children. However, type 2 diabetes develops most often in middle-aged and older people. People who are overweight and inactive are also more likely to develop type 2 diabetes. Type 2 diabetes usually begin with insulin resistance—a condition that occurs when fat, muscle, and liver cells do not use insulin to carry glucose into the body’s cells to use for energy. As a result, the body needs more insulin to help glucose enter cells. Type 2 diabetes is the most common one, which accounts for about 90 percent of all diabetic cases.  Treatments for type 2 diabetes: (1) Using diabetes medicines (2) Making healthy food choices (3) Being physically active (4) Controlling your blood pressure levels and Controlling your cholesterol levels 3. Gestational Diabetes: Gestational diabetes can develop when a woman is pregnant. Pregnant women make hormones that can lead to insulin resistance. Overweight or obese women have a higher chance of gestational diabetes. Also, gaining too much weight during pregnancy may increase your likelihood of developing gestational diabetes. However, a woman who has had gestational diabetes is more likely to develop type 2 diabetes later in life. Babies born to mothers who had gestational diabetes are also more likely to develop obesity and type 2 diabetes. If left untreated diabetes causes complications that lead to blindness, kidney failure, heart diseases, nerve damage and amputations.  3. Asthma: Asthma is a chronic lung disease characterized by episodic bouts of wheezing, coughing, and difficulty breathing. An asthmatic attack is usually triggered by allergens (e. g., pollen, certain foods, pets, etc), irritants (e. g., cigarette smoking, and smog), exercise or emotional stress and changes in temperature which results in the narrowing of the airways in the lungs. This reaction increases the resistance to the airflow in and out of the lungs, making it harder for the individual to breathe. The severity of asthma varies greatly from mild to profound in which the child may experience only a period of mild coughing or extreme difficulty in breathing that requires emergency treatment. Many asthmatic children experience normal lung functioning between episodes.  Asthma is the most common lung disease of children, estimates of its prevalence range from 6% to as high as 12% of school-age children. The causes of asthma are not completely known, though most consider it the result of an interaction of heredity and environment. Asthma tends to run in families, which suggests that an allergic intolerance to some stimulus may be inherited. Primary treatment for asthma begins with a systematic effort to identify the stimuli and environmental situations that provoke attacks. The number of potential allergens and irritants is virtually limitless, and in some cases it can be extremely difficult to determine the combination of factors that result in an asthmatic episode. Changes in temperature, humidity, and season are also related to the frequency of asthmatic symptoms. Asthma is the leading cause of absenteeism in school. Chronic absenteeism makes it difficult for the child with asthma to maintain performance at grade level, and homebound instructional services may be necessary. The majorities of children with asthma who receive medical and psychological support, however, successfully complete school and lead normal lives.  2.3.5 Assessment and identification of children with physical and health impairments: The assessment and identification process regarding people with physical and health impairments should include the following specific areas. The process must be done by employing a multi-disciplinary approach; it should be an ongoing process; and it considers a holistic nature of the child. A. Activities of daily living: it involves assessment of current and potential skills in self-help and daily living such as eating, toileting, personal hygiene, cooking, travel and public transportation. B. Mobility: it focuses on assessing the student’s current ability and potential to move from place to place and to become independent. C. Psycho-social development: it deals with assessing factors that interfere with social and emotional development and the student’s ability. D. Communication: it deals with evaluation of student’s ability to understand and express language and his/her ability to communicate. E. Academic potential: Modifications in the physical setup, elimination of time tasks, or alternative response modes such as verbal rather than written responses are some of the required adaptations. F. Transitional skills:  Some of them are: (i) Prosthesis is an artificial replacement for a missing body part such as an artificial leg (limbs). (ii) Orthosis is a device that enhances partial functioning of a body part such as leg brace. (iii) Adaptive device is an ordinary item found in the home, office, or school that can be modified.  2.3.6 Intervention of children with physical and health impairments 1. Hand-on-therapy: Physical occupational and other specialists provide direct hands on treatment. 2. Assistive devices: Braces and splints (usually made of molded plastic) are used to give a child movement with stability, to correct abnormal postures, and to control involuntary motions. 3. Medication: Medication can sometimes help to reduce spasticity and rigidity but generally are of only limited usefulness in improving the muscle tone of children with physical disabilities. 4. Surgery: Orthopedic or neurologic surgery also helps, although this often regards as a last resort in the treatment of physical impairment. For the goodness of intervention, however, concentrating on the following points is important. Using special Devices: Many children with physical impairment/disabilities use special orthopedic devices  Using special Devices: 1. Prosthesis: These are artificial replacement of missing body part (most frequently arm, leg or eye). 2. Wheel chair: This is prescribed by a physician for individuals who are unable to ambulate or for those whose ambulation is unsteady, unsafe or too strenuous. 3. Adaptive devices: These include using special eating utensils; such as forks and spoons with custom designed handle or straps. 4. Orthosis: This is a device that enhances the partial functioning of a body part; such as a long brace. 5. Residual functioning: These are procedures to helping children to use some of their skills and abilities to become more independent (e.g. prosthetics, orthotics, adaptive devices). 6. Facilitating communication: This refers to communication boards and electronic devices with synthesized speech output. 7. Writing aids: These include computers with word processing programs and with keyboard adoption. 8. Positioning: This refers to sitting, standing, or other positioning device which provide adequate support without looking the child into a static position.  Modifying the Environment 1. Changing desk and table tops to appropriate height. 2. Providing a wooden pointer to enable a student to reach the upper button on an elevator control panel. 3. Adding adaptive devices (rubber bands, plastic wedges, plastic tubing) to writing instruments to make them easier to grasp/grip. 4. Using study buddies in activities that require extensive writing. 5. Installing paper cup dispensers near water functions so that they can be used by students in wheelchair. 6. Using word processors, computers, typewriters, and calculators rather than handwriting responses. 7. Moving a class or activity to an accessible part of a school building; so that a student with a physical impairment can be included.  2.4. Communication Disorders (CDs) Communication entails receiving, understanding and expressing information, feelings and ideas. It is an integral part of our daily lives that most of us take our ability to communicate for granted. Most children come to school able to understand others and express themselves.  Cont… Their communication abilities allow them to continue developing socially and take part in the lives and activities of their academics. However, some others do have communication problems that adversely affect their social interactions and academic performance. CDs are difficulties in communication and language usage that include a number of speech problems (such as articulation disorders, voice disorders, and fluency disorders) and language problems (such as difficulties in receiving information and expressing language).  2.4.1 Classifications of Communication Disorders broadly classified into two broad categories: Speech disorders and language disorders. 1) Speech Disorder difficulty producing sounds as well as disorders of voice quality or fluency of speech. Speech disorders include disorders of articulation, voice and fluency (rate and rhythm of speech).  Cont… Articulation Disorders are one of the most frequent communication disorders in preschool and school-aged children. Articulation is a speaker’s production of individual or sequenced sounds. Articulation disorders, therefore, are problems in producing sounds correctly.  Cont… Articulation errors or problems can be manifested in the form of substitutions, omissions, additions and distortions. 1. Substitutions: - these are common, as when children substitute d for the voiced th(“doze” for “those”) t for c ( “tat” for “cat”), or w for r ( “ Wabbit’’ for “rabbit”). 2. Omissions: - these occur when a child leaves a phoneme out of a word. Children often omit sounds from consonant pairs (“boo” for “blue” “cool” for “school”) and from the ends of words ( “ap” for “apple”). 3. Distortions: - these are modifications of the production of a phoneme in a word; a listener gets the sense that the sound is being produced, but it sounds distorted. Common distortions, called lisps, occur when s,t,sh, and ch are mispronounced. 4. Additions: - occur when children add extra sounds, making comprehension different or they occur when children place a vowel between two consonants, coverting “tree” into “tahree”, “buhrown” for “brown”.  Cont… 2) Voice Disorders are reflected in speech that is hoarse, harsh, too loud, and too high pitched, or too low pitched. Each person has a unique voice. This voice reflects the interactive relationship of pitch, duration, intensity, resonance and vocal quality.  Cont…. Pitch disorders: - it involves too high or too low pitch, or a pattern of pitch that is so monotonous that it calls attention to itself. Disorders of loudness: - in this case speech is habitually too loud or soft for the setting, or that sporadic bursts or cycles of excessive loudness are observed. Voice quality disorders: - this involves breathiness, harshness and nasality  Cont… Fluency Disorders: Normal speech requires correct articulation, vocal quality, and fluency (rate and rhythm of speaking). Fluent speech is smooth, flows well, and appears effortless. Fluency disorders are characterized by interruptions in the flow of speaking, such as a typical rate or rhythm as well as repetitions of sounds, syllables, words, and phrases. They often involve what is commonly called “Stuttering”, Stuttering occurs when a child’s speech has a spasmodic hesitation, prolongation, or repetition.  2) Language Disorder It is a difficulty in receiving, understanding, and formulating ideas and information. Therefore, language disorders are manifested in a significant impairment in a child’s receptive or expressive language or both.  Cont… Receptive language (RL) involves the reception and understanding of language. CW a RLD has a malfunction in the way they receive information. Information comes in, but the child’s brain has difficulty processing it effectively. Expressive language (EL) involves the ability to use language to express one’s thoughts and communicate with others. A problem in speaking is a common expressive language disorder.  Generally language impairments adversely affect; A Student’s Social Skills And Academic Performance. It includes;  Phonology Morphology  Syntax Semantics Pragmatics  Phonology: - it refers to the use of sounds to make meaningful syllables and words. Students with phonological disorders may be unable to discriminate differences in speech sounds or sound segments that signify differences in words. For example, to them the word “pen” may sound no different from “pin”. Their inability to differentiate sounds as well as similar rhyming syllables may cause them to experience reading and/ or spelling difficulties. Morphology: - it is the system that governs the structure of words. Children with morphological difficulties have problems using the structure of words to get or give information. They may make a variety of errors. For example, they may not use “ –ed” to signal past tense as in “walked” or “- s” to signal plurality. Syntax: - it provides rules for putting together a series of words to form sentences. Syntactical errors are those involving word order, such as ordering words in a manner that does not convey meaning to the listeners. Semantics: - it refers to the meaning of what is expressed. Semantic development has both receptive and expressive components. Children who experience difficulty-using words singly or together in sentences may have semantic disorders. They may have difficulty with words with double meanings, abstract terms, synonyms and idioms. Pragmatics: - it refers to the use of communication in contexts. It focuses on the social use of language–the communication between a speaker and listener within a shared social environment.  2.4.2 Major Causes of Communication Disorders (CDs) The causes of CDs can be classified into two: Classification by the Cause. According to this criterion, causes of CDs are classified into two: (1) organic disorders; and (2) functional disorders.  Cont… Organic disorders caused by an identifiable problem in the neuromuscular mechanism of the person. The causes of organic disorders are numerous; they may originate in the nervous system, the muscular systems, the chromosomes, or the formation of speech mechanism. They may include hereditary malformations, prenatal injuries, toxic disturbances, tumors, traumas, seizures, infectious diseases, muscular diseases and vascular impairments. Functional disorders CDs with no identifiable organic or neurological cause. A functional speech and/or language disorder is present when the cause of the impairment is unknown.  Cont… Classification by the Onset: According to when the problem began, causes of CDs can be classified into two: (1) Congenital Impairment (an impairment that occurs at or before birth); and (2) Acquired Impairment (an impairment that occurs after birth).  2.4.3 Support Systems of Children with Communication Disorders: Since language and speech are integral parts of academic and social development. Team approach, involving the classroom teacher, the speech language pathologist, parents, and other professionals is essential in intervention and management of CDs  Cont... Treating Speech Sound Errors: A general goal of specialists in CDs is to help the child speak as clearly and pleasantly as possible so that a listener’s attention will focus on the child’s message rather than how he/she says.  Articulation Errors: - the goal of therapy for articulation problems are acquisition of the correct speech sound(s), generalization of the sound(s) to all speaking settings and contexts, and maintaining of the correct sound(s) after therapy has ended. This therapy includes: discrimination activities and production activities. Discrimination activities are designed to improve the child’s ability to listen carefully and detect the differences between similar sounds (e. g., the /t/ in “take”, the /c/ in “cake”) and to differentiate between correct and distorted speech sounds. The child learns to match his/her speech to that of a standard model by using auditory, visual and tactual feedback. A generally consistent relationship exists b/n children’s ability to recognize sounds and their ability to articulate them correctly.  Phonological Errors: - when the child’s spoken language problem includes one or more of phonological errors, the goal of therapy is to help the child identify the error pattern(s) and gradually produce more linguistically appropriate sound patter. For example, a child who frequently omits final consonants might be taught to recognize the difference between minimally contrastive words, such as “sea”, “seed”, “seal”, “seam”, and “seat”  Treating Fluency Disorders: For many years, stuttering was widely thought that a tongue that was unable to function properly in the mouth caused it. As a result, it was common for early physicians to prescribe ointments to blister or numb the tongue or even to remove portions of the tongue through surgery. However, in recent years, application of behavioral principles for treating fluency disorders has got strong influence. A therapist using this methodology regards stuttering as learned behavior and seeks to eliminate it by establishing and encouraging fluent speech. This can be done by positively reinforcing the child’s fluent utterances both at home and in school.  Treating Voice Disorders: Voice therapy is often used to teach the child with the problem to listen to his/her own voice and learn to identify those aspects that need to be changed. Depending on the type of voice disorder and the child’s overall circumstances, vocal rehabilitation may include activities such as exercises to increase breathing capacity, relaxation techniques to reduce tension, or procedures to increase or decrease the loudness of speech. Because many voice problems are directly attributable to vocal abuse, behavioral principles can be used to help children and adults break habitual patterns of vocal misuse. For example, a child might self-monitor the number of abuses he/she commits in the classroom or at home, receiving reinforcement for gradually lowering the number of abuses over time.  Treating Language Disorders: This therapy focuses on pre-communication activities that encourage the child to explore and that make the environment conducive to the development of both receptive and expressive language. In addition, because children learn through imitation, it is important for the teacher or specialist to talk clearly, use correct inflections, and provide a rich variety of words and sentences. Speech-language pathologists are increasingly employing naturalistic interventions to help children develop and use language skills. Naturalistic interventions should be provided: When the child is interested for the lesson, teach what is functional for the student at the moment.  Unit Three: Cognitive Impairments/Disabilities 3.1 Intellectual Impairment/Disability (II or ID) 3.1.1 Definition of Intellectual Impairment (Disability) The 1992 AAMR’S DEFINITION: “Mental retardation refers to a disability characterized by significantly sub-average general intellectual functioning, existing concurrently with related limitations in two or more of the following applicable adaptive skill areas( communication, self- care, home living, social skills, community use, self- direction, health and safety, functional academics, leisure, and work). Mental retardation manifests before age 18.”  2. The 2002 AAMR’s Definition: In 2002, the AAMR published a definition and approach for diagnosing and classifying mental retardation that represented a conceptual shift from viewing intellectual disability as an inherent trait or permanent condition to a description of the individual’s present functioning and the environmental supports needed to improve it. “Mental retardation is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18”.  3.1.2 Classification of Intellectual Impairment/Disability (II No Degree of or ID) Educational Characteristics CWID Intensity of Severity of support needed ID 1 Mild-ID Educable: Children with this category; they are: Intermittent (50/55-70
not noticeably d/t from the “normal” ones in their support is given IQ scores physical characteristics and general health and capable when necessary of learning fundamental academics and personal eg. First day of a responsibilities. school, job, and
also able to function within the traditional level loss of as well as curriculum with only minor modification and assistance they face health and be self-sufficient and live independently as crisis productive members of the community as adults.
delayed 1 to 3 years in school performance No Degree Educational Characteristics CWID Intensity of of support needed Severity of ID 2 Moderat Trainable: Children in this category have/are: Limited support e-ID (35-  seriously impaired adaptive capacities and a is given for a 49 IQ functional ability of nearly 1/2-1/3 of long period with scores) expected for their chronological age. specific time eg.  able to master self-care skills, basic language, 3 months of and cognitive concepts. training before  be able to live in community homes and work starting a job with supervised workshop facilities as adults and opportunities to benefit from vocational, occupational and social trainings  No Degree of Educational Characteristics CWID Intensity of support Severity of ID needed 3 Severe-ID (20- Supportable: Children in this category Extensive support 34 IQ scores)
manifest poor motor development is given regularly at and little or no speech before age 7 least in one place
may learn to talk during their later school years and can learn basic hygiene skills and profit little from vocational training.
may be able to perform simple tasks with close supervision No Degree of Educational Characteristics CWID Intensity of support Severity of ID needed 4 Profound-ID (< Life-support: Children in this Pervasive support is 20 IQ scores) category given regularly in all or
manifest only minimal sensory across all environments motor functioning before their age 7.
may show some motor development during their latter school years, and may benefit minimal from self-care training.
may develop some speech, able to take a very limited self- care as adults ;
require constant supervisions in a very structured environment.  3.1.3 Major Causes of Intellectual Impairments/ Disabilities 3.1.3.1 Genetic Causes Genetic conditions abnormalities of genes inherited from parents, errors when genes combine, or from other disorders of the genes caused during pregnancy by infections, overexposure to x-rays and other factors. There are A. Chromosomal Abnormalities/Genetic Defects: There are a number of forms of intellectual disability that are caused by genetic factors. Examples: 1. Down’s syndrome (DS) is an example of a chromosomal disorder which is caused by too many or too few chromosomes, or by a change in structure of a chromosome. The vast majority of cases are caused by an extra copy of chromosome 21, with translocation (when part of this chromosome attaches to another chromosome) and mosaicism (when only some cells include an extra copy of chromosome 21) representing less frequent causes. Down’s syndrome is one of the most common chromosomal disorders, accounts for the largest number of cases of intellectual disability in which extensive and pervasive supports are required. It is caused by the presence of extra chromosomal materials in the cells. The most common form is called Trisomy 21 because of an extra chromosome attached to the twenty-first chromosome pair. The risk of giving birth with Down’s syndrome increases with maternal age after 30 or 35 years. 2. Fragile X-Syndrome (FXS) is a single gene disorder located on the X chromosome and is the leading inherited cause of intellectual disability. FXS is a common hereditary cause of ID associated with genetic anomalies in the 23rd pair of chromosomes. Although less prevalent than DS, FXS is the most common known inherited cause of ID, full mutation of the Fragile X Mental Retardation-1 gene (FMR1). This causes a deficiency in production of the Fragile X Mental Retardation Protein (FMRP), which is thought to be essential for normal cognitive functioning. Common in males  Cont… B. Metabolic Disorders: characterized by the body’s inability to process (metabolize) certain substances that can then become poisonous and damage tissue in the central nervous system. The most frequent and best known forms of intellectual disability resulted from metabolic is Phenylketonuria (PKU). PKU is a condition caused by the inheritance of two recessive genes from parents who are carriers of the condition.  Cont… PKU gene resulted in the lack of the production of an enzyme that processes proteins, there is a building of an acid called phenylpyruvic acid. This building causes brain damage. In other words, with PKU, the baby is not able to process phenylalanine, a substance found in many foods, including the milk ingested by infants. The inability to process phenylalanine results in an accumulation of poisonous substance in the body. If it goes untreated or is not treated properly (usually through dietary restrictions). This damage leads to severe or profound intellectual disability. Broad screening programs and diet therapy may reduce the disorder.  Cont… The second common example of metabolic disorder is Galactosemia. Galactosemia is a metabolic disorder that causes an infant to have difficulty-processing lactose. galactosemia, the child is unable to properly process lactose, which is the primary sugar in milk and is also found in other foods. If galactosemia remains untreated, serious damage results, such as cataracts, heightened susceptibility to infection, and reduced intellectual functioning. Dietary controls must be undertaken, eliminating milk and other foods containing lactose. C. Hormonal Disorders; for example, Hypothyroidism/Cretinism is the best example that can be included under hormonal disorder that may lead to the development of ID. Here intellectual disability results from dysfunction of thyroid gland. Most children with this disorder suffer from sever retardation. However, good results can be obtained if early intervention is made.  Cont… 3.1.3.2 Prenatal, Peri natal and Postnatal Causes: Genetic and chromosomal causes of intellectual disability are present from the moment of conception. Pre, peri and post-natal causes. Problems during pregnancy (prenatal risk factors): - Use of alcohol or drugs by the pregnant mother can cause intellectual disability. In fact, alcohol, smoking in increasing the risk of intellectual disability. Other risks include malnutrition, certain environmental toxins, and illnesses of the mother during pregnancy, Rh factor, blood incompatibility, infectious disease such as toxoplasmosis, cytomegalovirus, rubella and syphilis, etc. Problems at birth (perinatal risk factors): - Prematurity and low birth weight predict serious problems Difficulties in the birth process such as temporary oxygen deprivation, complicated delivery, prolonged delivery, infectious diseases, infections or birth injuries may cause intellectual disabilities. Problems after birth (postnatal risk factors): - Lead, mercury and other environmental toxins can cause irreversible damage to the brain and nervous system. Infectious diseases, child abuse and neglect, accidents, and the like may result in brain damage of the fetus and consequent retardations.  Cont… 3.1.3.3 Cultural-Familial Causes: Cultural-Familial Cause is another major variable of intellectual disability. It is the causes of 75% of the retarded children for whom there is no organic pathology and whose retardation is presumed to be due to the combination of hereditary and environmental factors. Absence of good reinforcement for intelligent behavior, harsh punishment for specific behaviors, homelessness, poverty, severe abuse and neglect, malnutrition, psychosocial deprivations are some environmental factors that can cause intellectual disability. Generally, intellectual disabilities that may be attributable to both socio- cultural and genetic factors is cultural- familial intellectual disabilities. People with this condition are often described as (1) having mild intellectual disabilities, (2) having no known biological cause for the conditions, (3) having at least one parent or sibling who have mild intellectual disabilities, and (4) growing up in a low socio-economic- status or deprived and impoverished environments.  3.1.4 Characteristics of Children with ID A) Cognitive/ Intellectual Characteristics: CWID have limitations on the following intellectual functioning. 1. Memory problem:-PWID have impairments in memory, especially in short- term memory. The problem is said to be due to the inability to use good learning strategies such as grouping items and rehearsal. 2. Transference problem in learning: PWID are said to experience difficulties in applying information to new situations 3. Low Motivation: This low motivation leads them to a problem solving style that is called outer-directedness - distrusting one’s own solutions and looking excessively to others for guidance. 4. Imitation problem: is a skill, which children develop naturally through play and learning experiences at home and with peers. Many PWID have imitation problem and need specific instruction and practice before they can imitate a model. 5. Difficulty in discrimination: CWID are usually in trouble to discriminate between shape, color, size, brightness and positions. 6. Attention problem: CWID have attention deficits. It is manifested in three areas: short attention span, problem of focusing attention, and problem of selective attention. 7. Adaptive behaviors: CWID have limitations in skills needed to function in different environments.  Cont… B) Educational/Academic/ Characteristics: SWLDs show a discrepancy b/n their score on intelligence and achievement tests reading comprehension, in mathematical reasoning, and in basic statistics such as addition, subtraction, multiplication, and division. Professionals in the area pointed out that repeated failure and frustrations in classroom, and inappropriate expectations and tasks are the leading causes of low performance. C) Social/Emotional Characteristics: social and behavioral problems. They show socially inappropriate behaviors from the normal ones. They lack social skills to establish and maintain friendship. Because they are both socially and emotionally immature, behavioral problems such as disruptiveness, attention deficits, poor self- image or self-concept, rigidity, distractibility  Cont… D) Physical/Motor Characteristics: CWID lag behind their normal peers on measures of gross motor proficiency, and physical fitness. They show a marked difference in body coordination, strength, and flexibility. According to Garwood (1983), (1) Sequential patterns of movement (2) Keeping body balance (3) Basic physical abilities ( i.e., strength, flexibility, agility, and endurance) (4) Fine motor activities that are timed (5) Eye-hand coordination (6) Eye- foot coordination and (7) Dexterity E) Language and Communication Characteristics: are very much related and positively correlated. Individuals who show delay in cognitive functioning typically show delay in language and communication skills. The most common speech problems associated with CWID are defects in articulation, voice and stuttering.  3.1.5 Intervention of CWID Special assistance and care are essential for PWID to enable them lead better and sustainable life. Accordingly, the intervention strategies should consider the following two areas: A) Family Support: parents of CWID face many challenges to overcome learning problems and promote optimal development for their children. Hence, parents need training, an intensive counseling, and proper guidance as early as possible. Furthermore, parents need to closely work with professionals. B) School Support: School supports based on their level of ID. Teachers also need to be trained with the necessary skills that help them train, treat and manage CWID. Teachers should use the following SEVEN TIPS while they are teaching/training children with intellectual disability. They are: 1) Using multimodalities (2) Using concrete, varied and familiar examples(3) Providing supportive and corrective feedback (4) Using appropriate assessment (5) Making instruction interesting (6) Breaking lessons in to smaller parts and (7) Employing repetitions  Cont… C) Behavioral techniques (such as operant conditioning), and psychotherapy especially for severely and profoundly intellectual disability. Prevention: - Prevention can be primary, secondary, or tertiary.  Primary prevention is taken to prevent the problem from its occurrence.  Both secondary and tertiary preventions mainly focus on minimizing the severity of the problem.
The following are samples of preventive measures at different periods.  Before pregnancy: good immunization programs, and genetic counseling regarding inheritable disorders  During pregnancy: good nutrition, avoidance of drugs, toxins and the like  After birth: immunizing the child, good and accessible medical care, balanced diet, and the like can reduce the incidence and severity of retardation among children.