SSTA Research Report #91-05
Section I: Effects of Disability on Psychosocial Development: Infancy to Adolescence
|The Student with a Physical Disability in the Regular Classroom: A Handbook for the Classroom Teacher and School Counsellor||Effects of Disability on Psychosocial Development: Infancy
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Mainstreaming of students with disabilities into regular classrooms rather than segregating them in special classes or separate schools had been a major focus of American schools since the mid-1970's (Public Law 94-142, 1975). In Saskatchewan, the Education Act of 1978 provides for the funding of physically and mentally disabled students within the regular school system (Saskatchewan Education Act, 1978).
The regular classroom teacher must have access to accurate information regarding physically disabled students who may he integrated into the regular classroom. A review of the literature shows that regular classroom teachers who are involved in mainstreaming may have a negative attitude towards mainstreaming their fears stem from the feeling that they lack adequate information about disabilities, and that they perceive the disabled student as a burden to them (Hayes & Gunn, 1988; Saskatchewan Teachers' Federation, 1986).
This Handbook is for the use of the classroom teacher, the school counselor, and other school personnel, to help make them familiar with the experiences of the student with physical disabilities. The Handbook will focus on selected mobility disabilities.
The Handbook contains information regarding some physical mobility disabilities which may he encountered when students with these physical disabilities are purposely integrated into the regular classroom. The student who is mobility impaired would usually require the use of a wheelchair or other mobility aid. Mobility may he impaired due to a chronic physical condition, such as childhood rheumatoid arthritis blindness, Cerebral Palsy, spina bifida, etc.
The Handbook hopes to address, also, several psychosocial aspects of the disabled student, such as home environment, medical/hospital experiences, parent support, and interaction with peers and siblings. Because of the complex nature of some disabilities, the classroom teacher may have to deal with more than just the student. Parents, rehabilitation personnel, medical personnel and outside community workers such as social workers may all be involved with the student, as well as other school personnel such as resource teachers and personal aides who may be part of the school team.
The Handbook addresses the outside involvements the student may have and so helps prepare the classroom teacher to deal with the many aspects of the student's life involved in coping on a daily basis with a disability.
The classroom teacher, as well as the school counselor, may use this Handbook as a reference hook to more fully understand the physical and psychosocial aspects of a student with a physical disability. In the process of becoming familiar with the student's experience, the classroom teacher/counselor may become more confident of his/her own ability to deal with a physically disabled student in the regular classroom.
This Handbook may also be a resource for school personnel use in inservicing of teachers regarding mainstreaming in the schools and could possibly he used in the training of teachers, school counselors and personal care workers/classroom aides.
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A definition of mainstreaming that has been widely accepted is that proposed and adopted by the Delegate Assembly of the Council for Exceptional Children:
Mainstreaming is a belief which involves an educational placement procedure and process for exceptional children, based on the conviction that each child should be educated in the least restrictive environment in which his/her educational and related needs can be satisfactorily provided. (cited in Gillet, 1982, p. 1)
Another definition of mainstreaming comes from Turnhull and Schulz (1979): "Mainstreaming in the educational arrangement of placing handicapped students in regular classes with their non-handicapped peers to the maximum extant appropriate" (p. 52). It has become accepted practice to integrate both mentally and physically disabled students into the regular school setting. The Saskatchewan Education Act, Section 184, defines tale handicapped pupil as:
a pupil who is deemed to be unable to participate at an optimal level in the benefits of the ordinary program of the school by reason of personal limitations attributable to sensory defects, mental retardation, communication disorders, neurological, orthopedic or physical impairment or behavioral disorders. (Saskatchewan Education Act, Sect. 184, 1978)
According to Saskatchewan Teachers' Federation publication, "Issues in the Mainstreaming of High-Cost Disabled Students in Saskatchewan," the strongest push comes from the belief that exceptional children receive most benefits from an education which has been normalized as much as possible. It is felt that in regular classrooms exceptional children will receive educational services which are higher in quality than those offered segregated peers, greater variety of experience, increased access to valuable role models among their peers and more opportunities to form relationships. (Saskatchewan Teachers' Federation, 1986, p. 20)
Mainstreaming is not to be viewed as simply "dumping" students with handicapping conditions into a regular school, but requires the student he educated in "the least restrictive environment". This usually means the elimination of special or segregated classes to the greatest extent possible (Savage, 1980).
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As outlined by Meisel (1986) there are some necessary components to successful mainstreaming of both physically and mentally handicapped students:
competent advisory/support serves
appropriate facilities and transportation
advocacy and commitment on the part of the school principal
Teachers often have expressed concern over the integration of a handicapped child into the regular classroom, not because they disagree with the concept of mainstreaming, but because they often feel they are ill-prepared to teach handicapped children (Johnson, 1980; Hill, 1988). They have concerns, as well, about the child's ability to function in the regular classroom, and may believe that a handicapped child will Re a disruption in the classroom. In a 1986 publication, "What Teachers Need, A Report from the Saskatchewan Teachers' Federation Study of Mainstreaming" from the Saskatchewan Teachers' Federation, it is stated, "It was assumed from the resolution ... that members felt the practice of mainstreaming was problematic for teachers" (S.T.F. Annual Council, 1986, p. 12).
Unfortunately, when mainstreaming is thrust upon the classroom teacher without adequate preparation, there may he resentment. The way the teacher responds to the child's need is more important to the success of the program than are any administrative or curriculum considerations; the progress of the student depends largely on teacher expectations (Vargo, 1985).
Teachers have expressed ambivalent attitudes towards mainstreaming, though they may agree with the philosophy. There is throughout the literature an expressed need for increased support through resource material designed for the classroom teacher's use and good quality inservicing (Hayes k Gunn, 1988; Center R Ward, 1987; Hill, 1988). A study by Center and Ward (19S7) found considerable dissatisfaction on the part of the classroom teacher with both the quality and quantity of support services routinely provided. Teacher anxiety is raised when they feel they have little resource and innovative teaching methods are replaced with less effective conservative methods.
Teachers generally feel inadequately trained to deal with exceptionalities (Saskatchewan Teachers' Federation, 1986), and as a group feel that large infusions of resources are required within regular school if exceptional students are to be mainstreamed successfully (Saskatchewan Teachers' Federation, 1986).
Our attitudes towards persons with disabilities are deeply rooted and widespread. There are many ways which these negative attitudes can be perpetuated in the classroom by a teacher who feels pressured, uncertain of their skills with the disabled or feels uninformed about the disability.
Lomhana (1980) suggests that certain attitudes on behalf of the teacher will affect the physically disabled student's peers as well. A negative teacher attitude is the single factor that would cause the most difficulty in mainstreaming successfully (Saskatchewan Teachers' Federation, 1986). Avoidance of the disabled student leads to isolation, anxiety on behalf of the teacher leads to embarrassment for the student, pity leads to self pity in the student with a disability and overprotectiveness leads to dependence.
Parents play a major role in the successful mainstreaming of students with disabilities, and the classroom teacher must be prepared to deal with the family of the integrated student (Center & Ward, 1987). Parents need to be involved from the beginning of the process, and one of their major contributions can be providing background information for the student's needs and describing the major components of his or her handicapping condition (Ottman, 1981).
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One of the major support services in the school for both teacher and parents is viewed as the school counselor (Center R Ward, 1987). One major role for the school counselor should he to learn the counseling needs of students with disabilities and their parents (Hosie, 1982). Both the classroom teacher and the school counselor need access to appropriate resource and support material to confidently perform their roles in successfully mainstreaming of students with physical disabilities. Counselor responsibilities, according to Saskatchewan Teachers' Federation (1986), are to focus on social integration, peer influence, sex role identity and general psychological health of the student with a disability.
Another important role of the school counselor is to provide inservicing for the school personnel regarding the various handicapping conditions, the availability of resources for student, teachers and parents, and an explanation of the appropriate psychosocial needs of disabled students (McDavis, Nutter, & Lovett, 1982).
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It is the author's hope that this Handbook is written in plain English, avoiding medical and educational terminology and jargon. Every effort will be made to present the information in the most positive language possible; the language used in the Handbook could he viewed as the "role model" for the way in which to refer to persons with disabilities.
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Improved medical care and innovative technological advances have allowed the individual with disabilities to take an increasingly active part in the community around them. Individuals with disabilities who, only a few decades ago, would have expected death in childhood or isolation from the community, benefit from this better care. The result is that more persons with disabilities are living longer, more able to take part in their community. There are more individuals with physical disabilities ready to enter the school system, at every level; society has recognized that there is no need for separate or special schooling for the student with physical disabilities. Legislation has made mainstreaming a reality.
The regular classroom teacher, who has a major effect on the success of mainstreaming feels, at times, inadequate and unprepared to deal with the student who is physically disabled. Though there seems to be adequate resources available for the mentally handicapped mainstreamed student, there is a lack of information on the student who is academically normal but physically disabled.
The Handbook will deal with physical needs as well as psychosocial needs of an individual who is mobility impaired or physically disabled, providing accurate information an disability, suggestions on dealing with a student with a physical disability and allow the teacher/counselor to share in the experience of the Student with a physical disability.
The Handbook is designed so that it will be of use to teachers of both children and adolescents with physical disabilities. Ideally, it would also be a tool for the school counselor to help him/her counsel the individual with disabilities, and their families. Individuals who would he hired as classroom aides would also benefit from the use of the Handbook, which would make them more familiar and comfortable with the student's needs. The Handbook will give interested and involved educators, counselors and other support personnel an opportunity for challenging their attitudes and chancing their views of disability.
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Thia section of the Handbook will explore the This of physical disability an the psychosocial development of the individual between the stages of infancy and adolescence. Erikson's stages of psychosocial development are used as a framework; the general influence of Physical disability is suggested and possible interventions for caregivers and educators are explored.
Since cognitive development depends on the physical exploration of the environment, the integration of the individual and the environment is also explored.
Ten per cent of Canada's population has some form of physical limitation (Statistics Canada, 1988) and Provincial and Federal legislation ensures that children with disabilities receive the best treatment and education possible, along with their able bodied peers. It is essential that parents and teachers be aware of the developmental effect of disability so that timely and appropriate interventions he designed and administered.
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Erik Erikson translated Fraud's theory of psychosocial development into "a more relevant format to meat the needs of American culture of mid-twentieth century" (Schuster R Ashburn, 1986, p. 888). Freud's theory of development is primarily based an emotions; to Freud, mental health and healthy development leads to the ability to work and to love.
Erikson's Eight stages of psychosocial development focus on the idea that defined task or crises of each stage must be achieved for full potential in the next stage. Erikson's view is optimistic, focusing on strengths which develop within each stage. With successful resolution the individual will develop the "basic virtue" suggested in the stage. With no resolution or only partial resolution, the opposite counterpart may be the overwhelming outcome, with resulting delays in development (Appendix I).
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Piaget's (1970) theory of cognitive development is age-dependent and is not a theory of emotions but of cognition. Piaget's theory suggests that the ability to reason develops through specific age-stage periods future skills depending on the mastery of those before. It is mentioned briefly here because running throughout Piaget's theory is the need for an individual to move, explore, master, construct through play and movement and the use of language to recall or categorize what has been learned (Anastasiow, 1986). Coupled with Erikson's theory, we can have a more complete picture of the individual's need to interact with the environment. If the environment is safe -- that is if caregivers have provided safety, nurturance, encouragement -- then normal cognitive development can take place along with normal psychosocial development. viewed in this manner, it is easy to see how physical disability can effect the psychosocial development, which, in turn, can greatly effect the cognitive growth of the individual at every stage (see Appendix II).
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Some aspects of maturation may depend solely on hormonal control --growth (size) and sexual maturation may be two sets of such strongly programmed and hormonally controlled developing systems. Severely and profoundly handicapped persons still reach sexual maturation. Among the most damaged of person, one does not find 30-year-old infants but 30-year-old cognitively or socially retarded adults. (Anastasiov, 1986, P. 10)
Some experiences, such as highly attentive mothers interacting with their children, help children acquire vocabulary (Anastasiow, 1986). The environment provides opportunities for learning, or conversely, due to the physical limitations of a disability, the inability to access the environment denies opportunities for learning.
Research with humans and animals show that the organism which is able to act within an environment has the opportunity to develop normal brain functioning. Experience is needed for normal functioning, and experience is provided by the environment surrounding the individual. Since all things are interrelated, the individual, -- in this case we are discussing the child with a physical disability, -- has effect on the caregivers and the caregiver shapes the child's environment positively or negatively.
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Effect of Disability
The child with a physical disability may need assistance in gaining access to a stimulating environment. The child with a disability may need assisted exercise for muscle tone, which would otherwise be achieved through interaction with the environment for a normal child.
The child's social environment may also need special enrichment and it may require extra encouragement for the child with a disability to take part in social activities and achieve mastery of skills through participation. The child with a disability needs special encouragement to explore, and perhaps special equipment. All of this certainly requires special effort on the part of the caregivers.
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Emotions and Disability
When caregivers do not respond to a child's emotional displays (which may be quite different than normal in a child with a disability) distortion of emotions may develop (Anastasiow, 19S6).
Studies have shown that children with handicaps may be slower to develop emotions and that the emotions may be weaker in expression than normal (Emde, 1983 in Schuater 4 Ashburn, 1986). The child with cerebral palsy may jerk or stiffen when touched. This may he interpreted as rejection by the caregiver; in turn the child feels rejected.
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Attachment and Disability
The process of the mother/child relationship is called attachment. Bowlby (1955, in Schuster & Ashburn, 1986), refers to this as the emotional tie between mother and child. It is often referred to as "bonding" of mother and child. The success of bonding is the source of a person's identity, the beginning of security. The attachment process, if successful, becomes the basis for the child to be able to eventually separate successfully when the time comes.
Attachment, or bonding, is necessary for all children and parents. Parents of disabled children may need to be taught more about specific disabilities so that they may react more normally to their children's reactions, which parents may interpret as rejection. Parents also may need to understand more about the specific disability so that they are not fearful of touching the child, which the infant may interpret as rejection.
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As an individual gains mastery and skills, their sense of self enlarges. The child develops a social self, a cognitive self, a physical self and a personal self (Arlastasiov, 1986). Disability may effect development in any or all of these areas through lack of interaction with the environment or rejection by caregivers or Peers. Teachers and Parents must provide support in all areas to facilitate total potential development.
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Relationship of Disability to Developmental Tasks
Disabling conditions interfere with normal growth and development, psychologically, cognitively and physically. The burden of disability may cause the child much anxiety and contributes to the feeling of a lack of control over life's events. This "learned helplessness" may lead to a lack of motivation to do or try any new thing. Since exploration of the environment is linked to cognitive development, physical disability can negatively effect normal cognitive development even when the disability has no direct affect on mental development. Kleinberg (19B2) says, "The child faces a variety of developmental tasks. These are determined by such factors as physical maturation, increasing cognitive and communicative capacities and changing social and affective needs" (p. 23).
According to Erikson's stages of development, tasks which must be mastered at each stage may be short circuited by the intrusion of a disability; lack of mastery of certain tasks at particular stages leads to non-mastery or the negative counterpart of each stage. The disabled child may suffer more from the lack of mastery of certain tasks than from the disability itself.
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Erikson's Psychosocial Theory of Development
Krikson's theory of psychosocial development of the individual is, as mentioned before, a preset developmental plan, where personality develops according to determined steps. Society encourages challenges that arise at predetermined times (Erikson's tasks or crisis). Each stage presents a task which must be completed for a positive outcome. The resolution of one task lays the foundation for growth in the next Stage.
Erikson stresses socialization, culture and history; the resolution of each task depends on an individual's interaction with their culture. Erikson's theory emphasizes continuing development throughout life -- a life span approach which is open to inclusion of theories of cognitive and physiological growth and development.
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Task: Development of Basic Trust
Negative Counterpart: Mistrust
Outcome of Successful Resolution: Hope
The task at this stage is to resolve a "crisis I of basic trust in the world through consistent parenting, versus developing a sense of basic mistrust of the world due to inconsistent parenting or absence of parenting. If the parenting is consistent and of a positive, nurturing quality then, according to Erikson, a sense of hope can develop, sustaining the development of ego identity or self-concept. According to Erikson (1966), development of a sense of hope "does not depend on absolute quantities of food or demonstrations of love, but rather an the quality of the maternal relationship" (p. 133). In other words, it's not the skill with which a child is bathed, dressed or held, but the manner in which love and warmth is expressed. our society's emphasis is on the nuclear two parent, independent family. This cultural norm may not be the only, or best, way to raise children. Margaret Mead, in her studies of other cultures, questioned the "one mother" caretaker (Mead, in Schuster & Ashburnf 1986) and described cultures in which several "mothers" (aunts, grandmothers, neighbors) all take part in child rearing, giving a child greater opportunity to receive nurturing. The child/mother relationship is important to psychosocial development, but more important may be receiving loving attention and care from not only one but many sources.
Fathering is an important factor in psychosocial development. In our culture the accepted norm is a father who is not as involved with parenting as the mother. More modern, androgenous couples may divide caretakinq equally, allowing the child to receive care and comfort from both parents. When a disability is present, a father may be excluded even more than usual.
If the mothering an infant receives is inconsistent, inadequate to their needs or rejecting in nature, the child develops attitudes of mistrust, suspicion, fear toward self and others in the world. Says Erikman (1966), "A sense of mistrust will prevent or delay cognitive development and achievement of other stages of psychosocial development" (p. 134).
An infant, during the first six months, takes in the external world (Erikson, 1966). Tao much stimulation and the infant "tunes out" as a defense, and the integration of experiences for cognitive and affective growth may become impossible, or delayed.
As the infant grows, there is more control over the environment, at least in terms of responding and signals the child can send indicating need for care. The child begins to touch, grasp, and co-ordinates their responses to the environment. The infant becomes a social being, and, according to Erikson (1966): "The infant's first social achievement, then, is his willingness to let the mother out of sight without undue anxiety or rage because she has become an inner certainty as well as an outer predictability" (p. 247).
The child needs to feel that the world is safe, that there is some protection from harm when they begin to explore, needs to trust their own feelings. The child needs experience to master skills (albeit small skills in this stage), and through experience find stimulation far further exploration. An unsafe or unresponsive environment will not stimulate future exploration, nor will an inconsistent environment in which the child has no way of knowing whether or not it is safe or unsafe to explore.
In early infancy, a major factor in the interaction between child and parent is the success or failure of feeding. Feeding is meant to be a source of gratification -- sometimes a disability means this may be a painful procedure (Kleinberg, 1982). If the child is difficult or unresponsive during feeding, the parent feels either successful in the task or not successful. If feelings of success are the result, the parent will feel relaxed and confident; if feelings of failure are the result of the feeding interaction, the parent will be overly concerned and stiff. The infant will reflect the parent's worry with stiff responses or feeding difficulty. The infant's stiff response, in turn, effects the parent's ability to relax. Feeding, rather than having a time of joy and intimacy, becomes a time for worry and consternation. The interaction is not rewarding for either parent or child and negatively effects the building of trust which, according to Erilson's Stages, is mast important at this stage. Kleinberg (1982) says that "without the developmental framework of basic trust the child may grow up to view the world and his or her place in it as fragmented and threatening" (p. 27).
The child needs consistent care to relieve distress of hunger, and pain. Haphazard care that does not co-ordinate with the child's needs does not allow the infant to begin to develop a basic sense of trust. This, according to Erikson (1966), is more than just psychological; "The first demonstration of social trust in the baby is the ease of his feeding, the depth of his sleep, the relaxation of her bowels" (p. 80).
The infant who cannot relax, cannot give over to the caregivers his/her body for care and comfort, does not begin to develop a sense of trust, of hope for future comfort. Along with feeding, the child needs tactile stimulation, with cuddling and stroking. When being changed or dressed, the child can be cuddled and touched lovingly, or, if the caregiver is distant and stiff, the child can be dressed and changed and bathed in a mechanical, distant fashion. It is not the amount of stimulation received but the quality which is most important (Yarrow, 1977, in Schuster & Ashburn, 1986).
Attachment and Rejection
Parents may also be overwhelmed by and fearful of holding or touching the child with a disability. They may fear losing the child through death, and be reluctant to become attached; they may even act as if the child has died, and begin mourning. When such children survive and become strong enough to come home, the process of attachment -- or maybe reattachment -may not happen. There may even he a subtle process of rejection. Reactions of grief and mourning are normal under the circumstances and should not be denied or ignored.
Actual rejection by birth parents may necessitate fostering, with a progression of many caregivers.
All these factors may combine to create a sense of mistrust in an infant, interfering with future attempts to relate and trust in the future
If the parent is distant, or anxious, and limits the amount of stimulation and interaction, the infant may become anxious and stiff, which, in turn, does not encourage relaxed interaction.
If a child is neglected or abused in the first six months, there is a lessening of attempts to communicate, and motor development is retarded (Bowlby in Schuster & Ashburn, 1986), along with cognitive delays. During the second six months, an infant can become withdrawn, apathetic and depressed, as well as whiny and clingy, if parent/child interaction is insufficient. A situation such as hospitalization, due to illness or disability, can cause anxiety through lack of consistent care, or lack of warmth and comfort.
Effects of Disability
Disability can be present at birth or at any time thereafter. The stress for the family is great and often the family needs outside support. Mothers and fathers have had a vision or have imagined an ideal child, and suddenly have to deal with the reality of a child with a disability. This reality may effect parental attachment or rejection.
Hospitalization and prolonged treatments may physically separate the parents and child at crucial times, when maternal bonding is taking place. The physical condition and appearance of the child may actually cause rejection by the parents, and require the necessity of fostering or acute hospitalization, resulting in numerous, inconsistent caregivers.
Infants with a physical disability may undergo a series of painful surgery and other treatments. An infant is completely vulnerable to pain, and cannot distinguish from internal or external pain. Many infants born with disabilities of bone growth may be immobilized in casts or same other restraints.
Consistent caregiving might be impossible for the new born child with a physical disability, due to complications of the disability and hospitalization. At each contact, no matter how brief, the parents and other caregivers should make every effort to "connect" with the infant, stroke and physically touch and cuddle the child. The infant with a disability may well need extra stimulation, eye contact when possible, talking and caresses. Parents and caregivers need accurate information about the specific disability to be able to cope, become comfortable with the infant and to have hope for the future. Especially, they need to understand, in some cases, that the infant's reactions to the parent may be effected by the disability. Physical disabilities from birth may have lifelong psychological consequences. The world may seem threatening and fragmented -- no one, from the infant's view, can be trusted.
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Task: Basic Autonomy
Negative Counterpart: Shame and Doubt
Successful Resolution: Self Will
If an unsafe or inconsistent environment discourages autonomy and exploration of the environment, the child may feel frustration, shame and doubt about their own self identity. "The establishment of independence is the major theme of toddlerhood" (Schuster & Ashburn, 1986, p. 325).
As the child grows to toddlerhood, contacts with other children increase as does the need for independence from parents. The child begins to learn the cultural rights and wrongs of dealing with others -- sharing, no hitting.
The child is beginning to acquire, according to Erikson's stages, a sense of autonomy. They also are beginning to understand that events can be predicted; differentiation of self physically and emotionally comes about through increased cognitive skills. Two processes related to self awareness come into use -individual actions and feelings and the recognition of others as separate. The child is mastering skills as well as reacting to what others do. The toddler must explore and try new things.
Parents need to allow safe activities so that the child can explore. A safe environment is critical to the sense of developing autonomy. The actual mobility of the child -- whether they can move independently or not -- is critical to developing a sense of autonomy as well. The child is beginning to experience their own will, and their struggle is between the need for help and a safe environment and their inner urge for independence of action. Erikson (1966) describes it as a toddler gaining a "sense of self-control without loss of self-esteem" from which experience comes "a lasting sense of good will and pride; from a sense of loss of self control and ... overcontrol comes a lasting propensity for doubt and shame" (p. 251).
The toddler needs emotional and physical safety at this point, balanced against the need to explore and exert self will. According to Erikson, lack of autonomy at this stage creates a lasting sense of doubt about others.
The child first moves toward autonomy from the mother, learning to choose and guide their own personal actions. In this fashion, a child learns socially acceptable ways of handling frustration, learning control of behavior and cooperation with others in play.
Effects of Disability
Physical impairment at this stage will limit the child's interaction with their environment, and in turn, as previously discussed, may adversely effect normal cognitive development.
A child with a physical disability may be overprotected by frightened parents who cannot stand to ME the child struggle or are concerned that the toddler may hurt themselves. More negatively, the parents may have decided that the child cannot accomplish anything in a normal fashion and ignore or show a lack of support and confidence. Such a child will not be encouraged to reach their potential.
The toddler who is not challenged and encouraged to interact with the environment, who is overprotected, or who has seen no confidence expressed in them will doubt their ability and cease to initiate any action; they become passive, demanding and even depressed.
A normal toddler has unbounded energy and curiosity. A toddler with a physical disability may have low energy levels or may have pain when they move. They may have no control over their body, bowel, bladder, or limbs.
Their limited movement may not allow them to develop the simplest of skills such as feeding themselves, moving from one spot to another, reaching a desired toy.
A toddler separated from family through repeated and prolonged hospitalization is often in strange surroundings. They may feel abandoned and regress to infantile actions.
Hospitalization and treatments may physically restrict the active toddler, and they lose any sense of control over their own actions.
Early childhood stimulation programs at special preschools equipped and staffed to handle various disabilities are essential. The parents and caregivers need information about specific disabilities and the toddler needs a stimulating and accessible environment with which to interact. At this stage, if the child cannot move into the environment, then a special, stimulating environment should be moved to where the child is.
A balance of encouragement to autonomy in a safe and stimulating environment is necessary to allow the toddler to begin to reach full potential. Support for the parents and family is also essential, where questions can he honestly answered and fears lessened.
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Negative Counterpart: Guilt
Successful Resolution: Purpose and Direction
The environment may be impossible to control or to approach, and choice may be unavailable to the child with a disability. Limitations due to disability may cause frustration and guilt feelings about forced dependence. The child may have lowered self esteem and lack of initiative.
At this stage, the child begins to recognize him/herself as a separate person. They fluctuate between dependence and independence, needing loving guidance one day and refusing adult supervision or instruction the next. Cognitive and physical mastery is slowly attained and skills are developed. Children are always "daring things", and a healthy child will take initiative in many ways: they begin to assume responsibility for self and attain mare self control rather than needing constant supervision. At this stage role models begin to be important, and play is the focus of their daily activities. According to Erickson (1966), "initiative is a necessary part of every act and man needs initiative for whatever he learns" (p. 255).
Effects of Disability
The limitations of disability often isolate the child from the immediate environment and from normal daily interaction with peers. Continuing medical and surgical interventions may mean long and painful separation from family during hospitalizations, and this in turn may lead to overprotectiveness and guilt on the part of the parents. Rough and tumble play may be prohibited, and peers begin to ask embarrassing or hard to answer questions.
The lack of ability to easily interact with toys and people and the adult attention a child at this stage may receive due to a disability may make the preschooler demanding -- and one who may not have learned acceptable social skills for group play.
Physical disability interferes with the preschooler's increasing need to explore, play and interact. The disability may not allow the child to obtain control over their own body -- their basic care in toiletting may be their parent's responsibility. They may need help with tasks of daily living.
Parents may need to perform intrusive and painful medical treatments; they may be able to attain self care if parents are able to let go of these interventions as the individual matures.
One effect may be infantalizing the preschooler, postponing the mastery of physical independence.
Conflict between parents and the child may begin in this stage, when the preschooler wants to be able to make their own choices.
Preschool age children have a primitive sense of cause and effect. They may have a sense that their disability, and the related medical treatments, are punishment. This punishment may be for real or imaged crimes. Parents may feed into this idea, consciously or unconsciously, by restraining activity with admonitions of "Be careful or you'll hurt yourself" or with threats of "Be good or you'll go back to the hospital" (Kleinherg, 1982).
Medical treatments, hospitalization may he seen as Punishment. X-ray machines, operating rooms, etc. may be seen as monsters. The child's imagination builds these monsters into a frightening fantasy which parents must approach with gentleness and love.
Play and Illness
Play can be a tool to help children master anxiety. Play can normalize otherwise frightening situations. Play, especially when hospitalized, reminds the child of outside situations, home and family.
Therapeutic play can be of great use to the counsellor dealing with physically limited children. Desires, frustrations, fears and angers can be acted out with toys of manipulative size, and the meanings and reasons discussed with the child or student who may otherwise be unable to explain their feelings.
Preschool children, as do toddlers, need stimulation and the ability to explore their environment. Special preschool, or mainstreamed preschools where children with disabilities interact with their able bodied peers, are a necessity so that the preschooler begins to learn social rules. The family will need mare and more support from the community and special needs groups as the child grows, as well as possible peer counseling from families who have had the same experience.
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Negative Counterpart: Inferiority
Successful Resolution: Competence
At this stage the child's identity comes largely through the mastery of skills. Disability may prevent goals being obtained, generates frustration and a feeling of being cheated out of experience may prevail. The child may simply feel helpless and "give up" feelings of helplessness and depression are common, as are feelings of inferiority. Research into the helplessness syndrome shows that "The feelings of helplessness can become a self perpetuating phenomenon ... sabotages the desire to respond to environmental demands, retards the ability to perceive success ... results in a sense of hopelessness" (Seligman, 1975 in Schuater & Ashburn, 1986, p. 329).
The child at this stage has a desire to accomplish and master new skills, and to make meaningful effort. The focus is on mastering tasks which are essential for success in adulthood -- reading, writing, numeracy as well as interpersonal communication skills and physical skills. The focus is on education and competition.
Effects of Disability
According to Erikson (1966), "Many a child's development is disrupted when family life has failed to prepare him for school life, or when school life fails to sustain the promises of earlier stages" (p. 258). Disability can certainly be the "disruption" in the family or the school which prevents the child from being prepared. The inability to compete with peers on all levels elicits feelings of incompetence, worthlessness and helplessness; not only competition but individual mastery of skills is important. Kleirlherg (1982) says,
Being normal, able to be competent in academic pursuits, social interactions and physical sports is very important to the school age child.
Equally important is the desire to be physically independent and chronic illness (and disability) can drastically interfere with these developmental tasks. (p 39)
Disability may make individual mastery of skills difficult or impossible. Success in these areas leads to an increased eagerness to learn, failure to master skills may lead to apathy. The child begins to have a perception of him/herself as a total person with rising emphasis on physical development and body image (Schuster & Ashburn, 1986). The disabled child may now be experiencing rejection from peers due to the disability along with the inability to master physical skills.
According to Erikson (1966), this stage of development deals with mastery, competency and the founding of peer relationships. The goal is tied up with developing a sense of self worth. Individuals need to have success academically, socially and physically.
School-aged children look outwardly to peers and adults outside the family to measure and establish their self worth. Negative attitudes and outright rejection results in anger and self-hatred, and lower self-concept and self-esteem.
Children with physical disabilities come in contact, perhaps for the first time, with the stares and comments of peers. Some physical disabilities result in malformations of the physical body, spasms and obvious differences. Being different, being labeled as weird or abnormal can be devastating to the child who has come from the relative supportive atmosphere of the family and perhaps a special school.
Many physically disabled children may cope by focusing on academic achievement, compensating for the lack in some way by being good in school. They may also learn much about their own condition and seem very sophisticated about their needs and specialized treatment.
On the other hand, many children with physical disabilities may have had their schooling interrupted by illness, hospitalization and lack of transportation and may be lacking academic skills. Their attendance may be inconsistent and combined with their feeling of differentness, often leads to a sense of failure and a resulting fear or dislike of the school setting.
Enforced absences due to hospitalization or illness removes the student with a disability from the flow and rhythm of the school -- missing work and being outside of the cliques formed over time. A child with a disability may have learned that it is easier to fake a symptom and return home, where they are safe and accepted.
Reintegration into the classroom after long periods away becomes more and more difficult (Kleinberg, 1982).
Fear of Death and Mutilation
School age children develop an understanding of their own mortality. They begin to understand that they may never be a 'normal' adult and may come to fear the possibility of death. Because of this fear of both death and possible 'mutilation' the child may become overly dependent on parents, avoid risks involved in taking part in daily life, become overly fearful of medical treatment, unmanageable in school, home or hospital.
Such children may retreat into themselves dwelling on the fear of physical pain and mutilation.
They may react with denial, rebellion, immaturity, overdependence (Kleinherg, 1982) depression, anxiety, helplessness or mature acceptance. Many factors influence the rejection or acceptance of a disability and the alert teacher or counsellor will identify and acknowledge these indicators.
The school takes a bigger role in possible interventions at this point; though parents are still the main caregivers in most cases. Legislation for integration, in some cases, ensures that able bodied children and children with disabilities are able to interact as much as possible. School based curriculum should include awareness programs so that negative attitudes to disability can be dealt with in the classroom.
Family intervention may include counseling with the family members about the child's need for as much freedom as possible; community support for the family on many fronts is a necessity.
Success is important for the child in all grades, and special education teachers may be necessary to design appropriate curriculum. Technology may be the greatest asset a child with a disability has, so that the most severely disabled person can learn to communicate their thoughts to others -- and financial support of schools and individuals is an area of great concern.
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Task: Identity Achievement
Negative Counterpart: Role Confusion
Successful Resolution: Affiliation
Disability may cause tasks of daily living to be very difficult -- an individual may be fully dependent on physical help which effects the self-view as an independent, autonomous person. Physical isolation and constant dependency on others for tasks of daily living may have robbed the young adult of the ability to establish their identity. Roles of student, worker, wife or husband may seem to be impossible to obtain; the attitude that society holds may have a greater effect on the individual at this point than the actual disability. The individual may have a loss of will to try to accomplish any new task, and may be resigned unhappily to not having what others have.
During the adolescent years, career choices and marriage may be the overwhelming focus. Of great importance is the learning of good social skills, so that the adolescent can fit in with their peers, as well as be able to search for a job. There is also the task of transition from school to work. This can he a period of uncertainty and fear, and on the part of the individual with a disability and on the part of their families, who may want to protect them from disappointment and harm. Who and what one is comes through the ways in which we participate in our society -- disability may intrude on each of these areas.
The sexual identity of the adolescent is tied up in the image they held of their bodies -- this is especially difficult for the person with a disability to come to terms with when their body may be distorted by the disability. The physical changes of adolescence constitute a major developmental crisis for the individual (Schuster S Ashburn, 1986), and their concern is body image and peer acceptance.
When tasks which have come before have not been successfully completed or short circuited by disability, the individual may feel a sense of isolation from society, a sense of incompleteness, and a sense of loss.
Effects of Disability
All positive aspects of the stages before this must be established to give the individual a feeling of wholeness. Lack of identity, lack of a sense of trust and hope, a feeling of inferiority may result in isolation and an inability to take part in society. Erikson (1966) says about the adolescent, "In their search for a new sense of continuity and sameness, adolescents have to refight many of the battles of earlier years ..." (p. 261). The disabled individual may have complication of lack of education and poor social skills, and many unresolved psychosocial crises.
For the person with a disability, the normal transition periods are the worst times -- when peers are getting their first jobs, having relationships marrying, having children (Wagner, 1989). The lack of these involvements for the individual with a disability may cause depression and grief.
Lack of Support
Many of the tasks for the individual with a disability may he caused more through a lack of resources rather than an individual lack of skills or will. Disability or the community's attitude to the disability may he a reason for the adolescent to withdraw from interaction with peers and cease trying to be independent; the individual becomes a "patient" or "client" of some social agency
The stress and complications of daily living increase as an individual moves into the adolescent stage. The task of adolescence is to find and establish an identity. They must also strive for emotional, if not physical independence, from parents and family.
In the search for an identity an individual with a physical disability has heard, seen and felt many negative perceptions about body image, abilities and personal worth. The negative reactions by others coming together at adolescence strengthens the normal adolescent feelings of difference.
The adolescent is involved in forming their identity deciding who they are and focusing planning what their future may be. The added stress of a disability enters many dimensions of the adolescent personality; disability has effects on self image, on how an individual relates to the world and on future plans for career, education, and marriage.
The adolescent years are often full of times of great self doubt; the adolescent's body changes quickly, they are very self conscious. Every change or event brings with it a new trauma -- acne, unruly hair, appearance is very important as is the approval of peers. To be different is a problem -- belonging to a group is important.
Physical disability can affect the body growth; a disability such as Cerebral Palsy causes evident and major differences, short stature due to tone deformities makes one obviously different. Having to use a wheelchair, braces or crutches makes an individual stand out as different.
There may he obvious body differences for a student with a disability, as well as other events which mark the individual as different -- drugs, daily injections, medical treatments.
For adolescents, body image is tied into a growing sexual awareness. The real or perceived lack of attractiveness (in normal ways) to the opposite sex begins to effect their social life. A disabled adolescent may be able to maintain normal social relationships to some sex peers but at the onset of puberty may be socially isolated from opposite sex relationships (Kleinberg, 1982). often, social restrictions are more the product of an inability to actually get to functions due to lack of transportation, or to enter the building due to inadequate physical access. The adolescent with a physical disability may exhibit inappropriate sexual behavior for many reasons -- loneliness, attention seeking, self gratification. The individual may not have been taught other social skills and so may use sexual activity as a way to draw attention to their need (Riee, 1990).
There are many types of interventions which would be suitable during the adolescent and young adult stage, hut the suitability depends on the needs of the individual. As people mature, their needs change and vary, and no one program or design will provide the necessary needs. Housing, transportation, work, and career choices all play a role in the decisions an individual must make. Any planned interventions or programs must take into account that the individual with a disability has the right to make their own choices -- and has the right to choose wrongly. Too often, programs are offered by well meaning services which have little to do with what the individuals want -- the individual with a disability is often not consulted by parents, educators of medical personnel, who are used to making decisions for the child, but forget that the adult needs to make their own choices.
Programming and interventions often fall by the wayside due to lack of funds, and the financial situation of the society as a whale has effect on the individual when it comes to many aspects of housing, transportation and employment.
As a young person or adult with a physical disability, the individual must become aware that they have choices and may make more headway with fulfilling their needs through self help groups and consumer advocacy groups than depending on the traditional structures of school and home.
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Stages of Psychosocial Development
Looking at the possible effects of disability on Krikson's Stages of Psychosocial Development can give the teacher, caregiver and parent an idea of what accomplishments a child may achieve at each level, and help support the child at each stage to reach their full potential.
Effects of Disability
The stages of development as suggested by Erikson speak about normal development of the human individual. Physical disability can place limitations on the mobility of an individual, limiting many other aspects of development such as cognitive growth hut physical disability does not mean that a Special "psychology of disability" needs to be invented to deal with the person with a handicap. Vash (1975), a psychologist with a disability, explains it thus: "the notion of "the psychology of disability" seems to have led to gross and unhelpful exaggerations of the psychological difference between folks with disabilities and folks without" (p. 146). Dealing with infants, toddlers, preschooler and adolescents with disabilities is not different than dealing with the development of any individuals; rather it is "the study of normative responses from (psychologically) normal organisms to unusual stimuli" (Vash, 1975). This is an attitude which is often forgotten by parents, and professionals, when dealing with persons with disabilities and needs to be stressed constantly. With assistance and support, personal and technological, many persons with disabilities can accomplish tasks never thought possible a decade ago. Better medical care allows children born with severe disabilities to live longer -- and in turn places a new challenge before parents, caregivers and society to ensure a quality of life for these children.
Suitable interventions must meet the needs of the individual at their developmental level. As well, intervention must touch many levels -- social, cognitive, physical -- and must take into account the many people who interact with the individual. The family, society as a whole and the person share the environment, and each cannot be "treated" alone. Above all, interventions must take into account the individual's right to chose their own destiny, and allow the individual personal power in their life (Buscaglia, 1983).
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