No abstract

Information was collected through the retrospective analysis of records and interview on the characteristics, abilities, challenging behaviours shown and services received by 55 children who attended a behavioural residential special education facility since 1982. Results indicated that, overall, (1) during the mean 2.5 year stay at the facility the children showed significant gains in self-care and communication skills and significant reductions on all indicators of challenging behaviour; (2) that these gains were maintained over the mean 6.5 year follow-up period; but (3) that few additional gains were made during this period. After controlling for initial level of challenging behaviour, greater reductions in challenging behaviour during attendance at the school were observed for children who: prior to entry were living at home; who did not have epilepsy; or who attended the school at a younger age. After leaving school greater improvements were observed by: boys; children who did not have epilepsy; children who were less able; and children who had been followed up for a longer period of time.

Among 108 consecutive patients with myelomeningocele aged 5-12 years initiaily treated by a selective policy, seven (6-5%) achieved spontaneous urinary continence, five with normal micturition and two with urgency. AlU had positive conus reflexes and incomplete cord lesions which, with one exception, comprised motor as weli as sensory sacral sparing.Neuropathic bladder, with urinary incontinence and the risk of renal complications, is a major problem for patients with myelomeningocele and especially for those with smaller lesions whose handicaps otherwise tend to be slight. Reports Among the 11 patients reviewed clinically, four had gross urinary and faecal incontinence. Five had an entirely normal pattern of micturition by day although one had primary nocturnal enuresis. Two children were fully continent but had marked urgency of micturition.Neurological examination ofthe seven children with spontaneous daytime urinary continence showed a primary neurological level (that to which motor and sensory functions were entirely normal) ranging from L3 to S2. All had positive conus reflexes and an incomplete cord lesion which, except for one girl with urgent micturition, comprised motor as well as sensory sparing in the second to fourth sacral segments. None had suffered symptomatic urinary infections; recent ultrasound examinations or intravenous urography had shown normal upper renal tracts. Bowel habit was normal in all cases.The incidence of spontaneous urinary continence in relation to the anatomical level of the cord lesion was thoracolumbar 0/8, lumbar 3/44 (7%), lumbosacral 3/39 (8%), and sacral 1/16 (6%). DiscussionThe incidence ofspontaneous urinary continence in the present series, 6-5%, is far less than that previously claimed of children treated by nonselective' 2 or selective3 policies and lesser still when considering those with entirely normal daytime micturition.Normal urinary control would be expected only of patients with positive conus reflexes and incomplete cord lesions with both motor and sensory sacral sparing, as were the findings in the present series. Incomplete cord lesions are quite common with sacral and lumbosacral myelomeningoceles but unusual with lumbar and exceptional with thoracolumbar lesions. As a rule there is only sensory sacral sparing and when this is accompanied by positive conus reflexes a precarious form of urinary control may be achieved but one which is undoubtedly abnormal.5 Urgent micturition is associated with detrusor hyperreflexia and detrusorsphincter dyssynergia; residual urine is common and upper renal tract complications may develop. A few patients with a combination of detrusor areflexia and moderate urethral resistance manage to stay more or less dry by regular voiding by abdominal straining or compression. Possibly previous reports included as having normal urinary control some patients precariously continent by these abnormal means, others where the casenotes were inaccurate 640 on 12 May 2018 by guest. Protected by copyright.

Information was collected, through follow‐up interviews with parents, on the impact of residential special education on forty‐four children who attended a behaviourally‐oriented school for children with severe learning disabilities and severely challenging behaviours. Parents noted significant improvements in self care and communication skills and reductions in challenging behaviour during their stay at the school. The majority also noted positive changes since their child left the school, although one in five parents noted a deterioration in challenging behaviour since placement ended. Postiive change at the school was attributed to behavioural programmes, staffing ratios and skills, consistency and intensity. However, since leaving, positive changes were attributed by parents to maturity. Accounts of parents are used to illustrate the variable patterns of overall change seen in the forty‐four children.