Cerebral Palsy Studies & Dissertations

Given the devastating nature of cerebral palsy both on the individual and their family, considerable resources have been devoted to getting a better understanding of this condition.  Below are recent studies related to specific parts of cerebral palsy completed by scientists and physicians who have devoted considerable time to this important field of study.

Studies remain one of the most important components in the developing field of cerebral palsy research.  For more information about present and upcoming studies, you may wish to check with:

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Studies & Dissertations about Cerebral Palsy Treatments

Quantitative descriptions of musculoskeletal geometry in persons with cerebral palsy: Guidelines for the evaluation and treatment of crouch gait

Published by Arnold, Allison Suzanne
The goal of this dissertation was to develop guidelines for treating crouch gait, a prevalent movement abnormality among children with cerebral palsy. The outcomes of orthopaedic surgeries to treat crouch gait are unpredictable and sometimes satisfactory.


Outcomes of Children Receiving In-hospital Resuscitation

Published January 15, 2010 by Ebrahim, Shanil
This thesis prospectively evaluated the cognitive and functional outcomes and health-related quality of life of children admitted urgently to a Pediatric Intensive Care Unit (PICU) at the Hospital for Sick Children.


Mechanisms underlying hypoxic ischemic injury to the developing brain: The significance of matrix metalloproteinase 2 and 9

Published January 1, 2009 by Ranasinghe, Himani Sumudumalee
Perinatal hypoxic ischemic (HI) injury is a leading cause of long-term neurological complications in newborn babies. Matrix metalloproteinases (MMPs) are a family of endopeptidases that are capable of degrading the extracellular matrix (ECM) components.


Kinematic analysis of the upper limb during anatomical and functional movements in healthy children

Published by Dwan, Leanne Nicole, Safety Science, Faculty of Science, UNSW
Impairments of upper limb function can negatively impact an individual’s ability to carry out everyday tasks.


The role of zinc in preventing fetal dysmorphology and brain injury mediated by maternal exposure to infection in pregnancy

Published by Chua, Joanne Sing Cheng
Maternal exposure to viral and bacterial infection during pregnancy is associated with fetal dysmorphology and neurodevelopmental disorders including schizophrenia, cerebral palsy, autism and mental retardation.


Adults with Cerebral Palsy: living with a lifelong disability

Published by Sandström, Karin
The overall result is that there is a deterioration of motor function in many individuals already early in adulthood. These deteriorations are preceded and/or followed by musculoskeletal problems such as pain and limited range of motion, often in combination with fatigue. Despite deteriorations many people maintain daily personal activities, but are often forced to prioritize among societal activities.


Preliminary Specifications for an Exoskeleton for the Training of Balance in Balance Impaired Individuals

Published August 27, 2008 by Cass, Allan Brian
There is a small but growing population of people who suffer from impaired balance. The causes range from old age to stroke to cerebral palsy.


Impact of breath group control on the speech of normals and individuals with cerebral palsy

Published January 1, 2008 by Yip, Fiona Pik Ying
Dysarthria is one of the most common signs of speech impairment in the cerebral palsy (CP) population. Facilitating strategies for speech enhancement in this population often include training on speech breathing.


A Patient-Centered Workflow Automation System for Occupational and Physical Therapy

Published January 1, 2007 by Kelley, George
The work introduces a new theoretical system designed to automate the scheduling of pediatric occupational therapy (OT) and physical therapy (PT) appointments across any number of regional service locations.


A discursive analysis of parental resistance towards medical treatment for a seriously ill child : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Palmerston North, New Zealand

Published by Woods, Martin
This qualitative thesis uses discourse analysis to examine parental resistance towards medical treatment of critically ill children


Upper limb Botulinum Toxin-A in children

Published by Redman, Toni Annette
The assessment of any therapy requires not only an understanding of how that therapy works but also how it affects health related quality of life (HRQOL).


Effect of a supination splint on upper limb function of cerebral palsy children after Botulinum Toxin A

Published November 20, 2006 by Delgado, Madalene C.
To investigate the effect a supination splint would have on upper limb function of cerebral palsy children for six months after receiving Botox® injections.


An evaluation of two interventions on the phonetic repertoire of children with multiple disabilities

Published July 1, 2005 by Clements, Hannah
Children who have multiple disabilities often have complex communicational needs (Crickmay 1966; Orelove & Sobsey, 1996; Van Riper & Erickson, 1996; Workinger 2005). To augment or supplement these children’s communication skills some form of alternative and augmentative communication (AAC) may be provided (Beukleman & Mirenda, 2005


Evaluation of clinical outcome measures for children with cerebral palsy

Published June 26, 2005
There are a lack of reliable and valid clinical outcome measures to assess the effects of medical interventions in children with cerebral palsy, potentially compromising research and clinical practice in this area. The objective of this thesis was to identify and develop reliable outcome measures that could be used to evaluate the effects of botulinum toxin A in children with cerebral palsy.


Investigation neuropsychologique des effets de l'oxygenotherapie hyperbare sur divers desordres neurologiques

Published June 25, 2005 by Hardy, Paule
The present thesis aims at assessing the cognitive effects of hyperbaric oxygen (HBO2 ) therapy, a technique known for a certain “medical adventurism” around the world.


Hyperbaric oxygen therapy for children with cerebral palsy : Jebsen-Taylor test of hand function

Published June 23, 2005 by Liebich, Ingrid.
Despite lack of scientific evidence, hyperbaric oxygen therapy (HBO2) has been used as a treatment for children with cerebral palsy (CP). Recently, a multi-centre randomised, double-blind, placebo-controlled trial assessed the efficacy of HBO2 therapy for children with CP.


Barriers to implementing holistic, community-based treatment for offenders with fetal alcohol conditions

Published November 1, 2003 by Mitten, H. Rae
The thesis contends that holistic, community-based treatment is preferable to carceral options for offenders with fetal alcohol conditions, presents emerging support for this contention, identifies barriers to the implementation of community-based treatment, and culminates with analyses of ways of influencing policy reform or of legally mandating non-carceral treatment options.


Using Accelerometers to Quantify Infant General Movements as a Tool for Assessing Motility to Assist in Making a Diagnosis of Cerebral Palsy

Published September 19, 2003 by Conover, Mark Stuart
Quantitative approaches to directly measure infant movement have not utilized miniature electronics technology, nor been used effectively in evaluating neurological dysfunctions’ affect on movement. This thesis presents a new quantitative technique for measuring infant general movements (GMs) using micro-electromechanical accelerometers, while discussing future improvements for this technology and possible benefits to present methods of diagnosing cerebral palsy.


Doktorsavhandling vid Karolinska Institutet

Published May 24, 2002 by Krumlinde Sundholm, Lena
Unilateral arm/hand dysfunction caused by obstetric brachial plexus palsy (OBPP) or hemiplegic cerebral palsy (CP) is most often afflicted on a child in the pre- or perinatal period of life.

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Studies & Dissertations about Cerebral Palsy Research

Effects of Delays to Response Blocking when used as Treatment for Problem Behavior Maintained by Automatic Reinforcment

Published December 7, 2009 by Kliebert, Megan Leigh
Response blocking and response interruption are common interventions for problem behavior maintained by automatic reinforcement in the treatment literature, but these interventions may be extremely challenging for caregivers to implement with fidelity (i.e., immediately blocking each instance)


Examining Individual and Neighborhood-Level Risk Factors for Delivering Preterm

Published January 1, 2009 by Dooley, Pamela A.
This dissertation examines the relationship between several neighborhood and individual-level factors and the probability of delivering a preterm infant. Infants born prematurely, or at less than 37 weeks of gestation, have a greater risk of long-term developmental disabilities, such as cerebral palsy, than infants born at full term.


Rehabilitation strategies to improve upper limb movement quality in children with cerebral palsy

Published by Schneiberg Dias, Sheila
Children with CP are extremely heterogeneous in terms of etiology and clinical features. The diversity of symptoms among CP syndromes is a challenge for different branches of health research. Despite the efforts of many studies in examining rehabilitation strategies to improve upper limb (UL) function in children with CP, the confidence in the validity of these studies’ evidence is still moderate to low.


Investigation of Unintentional Movement in People with Cerebral Palsy to Improve Computer Target Acquisition

Published July 22, 2008 by Sibenaller, Sara Marie
People with Cerebral Palsy (CP) have difficulty using computer pointing devices due to unintentional movement in their upper extremities. Fifty percent of people with CP have impaired arm-hand function which limits their ability to interface with pointing devices and effectively control cursor movement on the computer screen. This thesis involves two studies which utilize an Isometric Joystick in order to access the computer and complete target acquisition tasks.


The Design, Construction and Validation of a New Assistive Walking Device for a Child with Cerebral Palsy

Published June 1, 2008 by Siston, Robert
Cerebral palsy is a neuromuscular disorder that affects movement and posture. It is characterized by poor muscle tone and posture, spasticity, unsteady gait, limited mobility, speech impairments, and a forward displaced center of gravity. A child with cerebral palsy experiences certain impairments towards normal function and development, making typically routine daily functions such as eating, walking and writing a challenge.


Considerations for the Use of an Exoskeleton for Extremity Control and Assistance when Learning to Walk with Cerebral Palsy

Published May 2, 2008 by Burnett, Bryant Whitney Rousseau
Cerebral palsy is an occurrence in which the nerves and muscles if the body may function properly, but there is damage to the brain that causes it to transmit incorrect electrical impulses to the muscles including both too many and too few signals.


Disability policy and practice at the University of Saskatchewan

Published January 1, 2008 by Livingston, Andrew P.
Students with disabilities have to overcome many barriers when attaining post-secondary education. This thesis investigates how programs and policies affect students with disabilities.


Investigation of the effect of intrauterine inflammation and infection on fetal brain injury using human and animal models

Published by Patrick, Lindsay Alexandra Laurentia
In recent years, increased focus has been placed on the role of intrauterine infection and inflammation in the pathogenesis of fetal brain injury leading to neurodevelopmental disorders such as cerebral palsy.


Effect of a supination splint on upper limb function of cerebral palsy children after Botulinum Toxin A

Published November 20, 2006 by Delgado, Madalene C.
To investigate the effect a supination splint would have on upper limb function of cerebral palsy children for six months after receiving Botox® injections.


Quantification of Muscle Fatigue in Cerebral Palsy and Its Relationship to Impairments and Function

Published November 13, 2006 by Moreau, Noelle G.
Three experiments were designed to explore the measurement of muscle fatigue in people with cerebral palsy (CP).


Electrostimulation therapy and selective posterior rhizotomy in the treatment of children with cerebral palsy

Published November 1, 2005 by Helena Mäenpää
Cerebral palsy (CP) is a persistent but not unchanging disorder of movement and posture, appearing early in life and caused by a non-progressive lesion of the developing brain.


Chronic sorrow in mothers of adult children with cerebral palsy: an exploratory study

Published July 2, 2005 by Masterson, Marilyn K.
Chronic sorrow has been defined as a permanent and reoccurring experience of pervasive sadness and loss which underlies the life experience and which recurs over time for the parent of a child with developmental, medical, or behavior issues that prevent him from participating in society in a way previously anticipated by parents.


Attachment theory and the adjustment to school for young children with special needs

Published July 1, 2005 by Schischka, Janice
There is increasing evidence that a positive start to school sets the child up for continued positive educational experiences and future life opportunities(Dockett & Perry, 2007). In an inclusive era, it is important to investigate the processes that promote the success of inclusion.


Environmental Factors that Influence Telecommunications Use by Adolescents with Cerebral Palsy

Published by Carpenter, Sonja Maria
Social participation is essential to well-being for adolescents with and without disabilities. Adolescents with a disability, however, often have fewer friendships and experience social isolation compared to their peers without disability. Telecommunications play a vital role in facilitating social participation for adolescents yet those with a disability experience reduced access. Based on the World Health Organisation’s framework of the International Classification of Functioning, Disability and Health (ICF) this study aimed to identify environmental factors (barriers and facilitators) that impact on participation in telecommunication use, as perceived by adolescents with cerebral palsy and their communication partners.


Long-term follow-up of very low birthweight children: A prospective study from the southeast region of Sweden

Published June 30, 2005 by Gäddlin
The survival rates for very low birthweight (VLBW; birthweight ≤1500 g) children are increasing, but they run a greater risk than controls of developing neurosensory disabilities and other functional problems during childhood.


Selective cerebral hypothermia for term infants following hypoxic ischaemic injury

Published
Perinatal hypoxic ischaemic injury is an important cause of both neonatal death and long-term disability. The sequence of resuscitation followed by a latent phase then a secondary cascade of injury is well documented.


Supra-Postural Task Performance in Children with Cerebral Palsy: The Importance of Functional Context

Published by Schmit, Jennifer Marie
Postural instability is a classical characteristic of cerebral palsy (CP), but it has not been examined in the during simultaneous supra-postural activity.


Outcomes of an upper limb eccentric strength-training programme for adolescents with cerebral palsy / Siobhan Louise Reid

Published June 29, 2005 by Reid, Siobhan Louise
[Truncated abstract] Cerebral palsy is the most common physical disability in childhood (Reddihough & Collins, 2003). The most characteristic features of those with cerebral palsy are the physical disabilities that arise as a result of the brain lesion, including; spasticity, muscle weakness and atrophy, soft-tissue contracture and joint deformity.


'Just Little Things': Nurses' perceptions of quality of life for people with severe multiple impairments

Published June 28, 2005 by Atkins, Chris
Notions of quality of life dictate philosophies and policies for services for people with developmental disabilities. There is an abundance of research on quality of life, much of which has influenced the significant amount of study of quality of life for people with developmental disabilities


Evaluation of clinical outcome measures for children with cerebral palsy

Published June 26, 2005
There are a lack of reliable and valid clinical outcome measures to assess the effects of medical interventions in children with cerebral palsy, potentially compromising research and clinical practice in this area. The objective of this thesis was to identify and develop reliable outcome measures that could be used to evaluate the effects of botulinum toxin A in children with cerebral palsy.


Antenatal causes of cerebral palsy and adverse pregnancy outcomes: investigating associations between inherited thrombophilia, cytokine polymorphisms and viral infections

Published January 1, 2005 by Gibson, Catherine Sue
Antenatal causes of cerebral palsy and adverse pregnancy outcomes: investigating associations between inherited thrombophilia, cytokine polymorphisms and viral infections.

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Studies & Dissertations for Parents and Families

An Evaluation of Group Stepping Stones Triple P for Parents of Children with Developmental Disabilities

Published November 1, 2009 by Roux, Gemma
The primary focus of this research project was an evaluation of the Group Stepping Stones Triple P parenting program for parents of a child with a disability.


The validation of a task-specific measure of parenting self-efficacy for use with mothers of young children

Published September 1, 2009 by Harty, Michal
This research develops and validates a task-specific parenting self-efficacy measure focussing on the following domains: showing affection and empathy, engaging in play, facilitating routines, establishing discipline strategies, providing appropriate learning and development activities, and promoting communication interaction.


A Case Study Investigation of the Physical Activity Levels of Disabled Students at a Small Missoula, Montana Middle School

Published August 14, 2009 by Bond, Chelsea Marie
One of the major goals for the nation, described in the Surgeon General’s Report Healthy People 2010, is to promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S.


Theorizing Information and Communication Technologies for Parents of Children with Developmental Disabilities

Published June 19, 2009 by Campbell, Louise Marie
Studying the challenges faced by families with children who have developmental disabilities has produced a considerable body of literature. Much of this literature focuses on the families’ needs for information and social support.


Access to Dental Care for Persons with Disabilities in Ontario: A Focus on Persons with Developmental Disabilities

Published February 24, 2009 by Koneru, Anjani
This study was undertaken to determine if persons with disabilities encounter difficulties in accessing dental care in Ontario, to identify barriers to accessing dental care and to determine if persons with disabilities and caregivers value oral health.


An Evaluation of the Use of Eye Gaze to Measure Preference for Individuals with Multiple Disabilities

Published January 1, 2009 by Wheeler, Geoffrey M.
This study used duration of eye gaze toward a stimulus to measure preference. The study took place in two schools for students with mental retardation and developmental disabilities.


Examining Individual and Neighborhood-Level Risk Factors for Delivering Preterm

Published by Dooley, Pamela A.
This dissertation examines the relationship between several neighborhood and individual-level factors and the probability of delivering a preterm infant. Infants born prematurely, or at less than 37 weeks of gestation, have a greater risk of long-term developmental disabilities, such as cerebral palsy, than infants born at full term.


Investigation of Unintentional Movement in People with Cerebral Palsy to Improve Computer Target Acquisition

Published July 22, 2008 by Sibenaller, Sara Marie
People with Cerebral Palsy (CP) have difficulty using computer pointing devices due to unintentional movement in their upper extremities. Fifty percent of people with CP have impaired arm-hand function which limits their ability to interface with pointing devices and effectively control cursor movement on the computer screen. This thesis involves two studies which utilize an Isometric Joystick in order to access the computer and complete target acquisition tasks.


Caregiver Strain Among African American and Caucasian Family Members Caring for Children with Emotional and Behavioral Problems: The Role of Race

Published May 8, 2008 by Taylor, Kelly D.
Caregiver strain is a complex phenomenon with the potential to have a deleterious effect on caregivers’ ability to perform their caregiving duties. Previous research has suggests that differences in race influence caregivers’ reported level of strain, with African Americans tending to report lower levels of strain than their Caucasian counterpart.


Music therapy for young children who have special needs : the music therapy experience from the perspectives of carers and professionals

Published January 1, 2008 by Chiang, Jenny Yu Kuan
This project aims to investigate how carers and other professionals perceive the music therapy process over time. Music therapy has been used to address a wide range of diagnoses and developmental issues of young children.


The Experience of Being a Taiwanese Mother of a Child with Cerebral Palsy

Published by Huang, Yu-Ping
Cerebral palsy (CP) is the most common cause of physical disability in children. Disabilities are associated with walking, sitting and hand function. The nature and severity of impairments varies but in all cases the demands placed upon caregivers is significant.


Never-ending caring : the experiences of caring for a child with cerebral palsy : a thesis presented in fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand

Published by Klankaradi, Kuephan
Cerebral palsy is one of the chronic conditions which have become a serious health burden worldwide. Consequently, this health burden involves healthcare as a whole, regardless of whether the focus is on the macro or micro system.


"Time to care": relationship between time spent caring for pre-school children with developmental delays and psychological, social and physical well-being of parents

Published by Crettenden, Angela D.
Advances in medical technologies and changing philosophies of health care have led to a rapid increase in home-based care for children with disabilities. While there are cost savings for health services if children are cared for at home there are extensive additional demands on the time and resources of parents, particularly primary caregivers, who are usually mothers.


Investigation of the effect of intrauterine inflammation and infection on fetal brain injury using human and animal models

Published by Patrick, Lindsay Alexandra Laurentia
In recent years, increased focus has been placed on the role of intrauterine infection and inflammation in the pathogenesis of fetal brain injury leading to neurodevelopmental disorders such as cerebral palsy.


Quantification of Muscle Fatigue in Cerebral Palsy and Its Relationship to Impairments and Function

Published November 13, 2006 by Moreau, Noelle G.
Three experiments were designed to explore the measurement of muscle fatigue in people with cerebral palsy (CP).


Participation and disability : a study of participation in school for children and youth with disabilities

Published September 8, 2006 by Eriksson, Lilly
Participation in everyday life is vital to a child’s development and well-being and is a basic human right. One definition of participation is engagement in life areas.


A Qualitative Analysis of the Experiences and Perspectives of Family Child Care Providers Who Care for Young Children with Disabilities

Published August 10, 2006 by Wayne, Tracey Simone
Increases in the number of parents in the paid labor force and welfare reform have resulted in more families requiring non-parental child care. Most often this care is provided in environments outside of the child’s own home.


Hand functioning in children with cerebral palsy / Le fonctionnement de la main chez les enfants infirmes moteurs d’origine cérébrale

Published February 13, 2006 by Arnould, Carlyne
The purpose of the present work was to study hand impairments and manual ability in children with cerebral palsy (CP) as well as to clarify their relationship.


Phonological representations, phonological awareness, and print decoding ability in children with moderate to severe speech impairment

Published January 1, 2006 by Sutherland, Dean Edward
The development of reading competency is one of the most significant pedagogical achievements during the first few years of schooling. Although most children learn to read successfully when exposed to reading instruction, up to 18% of children experience significant reading difficulty (Shaywitz, 1998).


Maternal stress and coping when a child is fed enterally

Published by Baack, Cathryn J.
While there is extensive literature on parental stress associated with parenting a child with special health needs, few researchers have looked specifically at the stress associated with parenting a child fed enterally.


Attachment theory and the adjustment to school for young children with special needs

Published July 1, 2005 by Schischka, Janice
There is increasing evidence that a positive start to school sets the child up for continued positive educational experiences and future life opportunities(Dockett & Perry, 2007). In an inclusive era, it is important to investigate the processes that promote the success of inclusion.


Environmental Factors that Influence Telecommunications Use by Adolescents with Cerebral Palsy

Published by Carpenter, Sonja Maria
Social participation is essential to well-being for adolescents with and without disabilities. Adolescents with a disability, however, often have fewer friendships and experience social isolation compared to their peers without disability. Telecommunications play a vital role in facilitating social participation for adolescents yet those with a disability experience reduced access. Based on the World Health Organisation’s framework of the International Classification of Functioning, Disability and Health (ICF) this study aimed to identify environmental factors (barriers and facilitators) that impact on participation in telecommunication use, as perceived by adolescents with cerebral palsy and their communication partners.


Supra-Postural Task Performance in Children with Cerebral Palsy: The Importance of Functional Context

Published June 30, 2005 by Schmit, Jennifer Marie
Postural instability is a classical characteristic of cerebral palsy (CP), but it has not been examined in the during simultaneous supra-postural activity.


Occupations in Parenting Children with Developmental Disabilities

Published June 29, 2005 by Hanna, Karen Janelle
This qualitative study investigated the experiences of parents of children with developmental disabilities living in a regional community on the New South Wales coast.


Fathers of Children with Educational Disabilities: The Role of Stress in Life Satisfaction

Published June 21, 2005 by Strachan, Jr., John Weir
Investigating the possible complex role of paternal stress in life satisfaction is essential because of the increasing importance of the role of fathers in our society. There are many difficulties and demands that face not only fathers of typically developing children, but also disabled children in particular.


Efficacy of lycra arm splints : an international classification of functioning disability and health approach

Published January 1, 2005 by Elliott, Catherine
This thesis consists of five experimental studies from seven data collection periods. The first two studies quantitatively analyse children with and without cerebral palsy using upper limb three dimensional (3D) motion analysis.


The Lived Experience of Being a Mother of a Child with Severe Cerebral Palsy

Published by Moore, Linda A.
This qualitative study describes the lived experience of five mothers who care for their child with severe cerebral palsy. The phenomenon was elicited utilizing Roy (Roy & Andrews, 1999) adaptation model of nursing as the theoretical framework and phenomenology implementing Colaizzi’s (1978) method of data analysis


Collection Development in School and Public Libraries: An Analysis of Health Related Topics

Published April 12, 2004 by Clancy, Colleen M.
The selection of resources is one of a librarian’s most important responsibilities. It impacts the level of access to information that patrons have. The selection process becomes more complex when the library’s mission supports a specific population, children and young adults, with distinct needs and limitations.


Teaching imitation skills to preschool children with severe disabilities: The effects of embedding constant time delay within a small group activity

Published January 1, 2003 by Valk, Jennie Elise
Children and adults acquire countless skills through the strategy of imitation. However, some children with disabilities do not demonstrate the ability to imitate in the course of their natural development.


A Game of Cat and Mouse: the Bullying and Teasing Experiences of Children with Cerebral Palsy

Published January 1, 2001 by Tentoglou, Nikie
An exploratory qualitative study was undertaken to determine how ten children, aged 8 to 12, with a diagnosis of Cerebral Palsy describe and experience peer teasing and bullying at school.


Early Home-Based Interventions with Developmentally Delayed Young Children

Published July 1, 1999 by Chippett, Darryl C.
Assessment in early intervention refers to the systematic collection of information about children, families, and environments to assist in making decisions regarding identification, screening, eligibility, program planning, monitoring, and evaluation.


Implications of constructmsm for the counselling of parents of children labelled with disabilities

Published July 1, 1998 by Goddard, Jay K.
This study explores the theoretical implications of a deconstructed view of disability to the counselling and support of children labelled with disabilities.


The effect of neurodevelopmental treatment on gross motor function and ambulation in children with cerebral palsy

Published July 1, 1997 by King, Carolyn Ann
The aim of Neurodevelopmental Treatment (NDT) is to assist individuais with neurological impairment achieve their highest level of functional ability.