possible; the provision of medically recommended optical aids to maximize use of residual vision and medical and dental treatment for other health needs. The Federal Government will share the cost of special items related to the unique needs of the blind. A telephone; guide fees; transportation expenses; extra laundry and dry cleaning allowances; higher food expenses when the handicapped person does the cooking or must take meals in a restaurant; even the food allowance for a seeing eye dog are illustrations of the flexibility that is possible. Safe and sanitary housing is extremely important for the blind as well as safe household equipment to prevent burns and accidents. Hence, moving expenses and higher rent expenditures may be required to assure this protection for the needy blind. The 1962 amendments encourage more comprehensive social services for the blind by providing 75 percent Federal financial participation in their costs. Thirty-eight States are now receiving 75 percent Federal matching for these services. To obtain this additional money, a State's services must encompass the blind who are in need of protection because of physical or mental handicaps or adverse social circumstances. There must also be provision for those who require special help to remain in their own homes or elsewhere in the community of their choice, thus avoiding unnecessary institutionalization. Similar services must be given to enable clients to return to their communities following a period of institutional care. Blind recipients with potential capacity for becoming either partially or completely self-supporting will be assisted with plans to secure training opportunities. All of these service areas include not only the blind client but may be extended to relatives as well when their circumstances influence case planning. Public welfare agencies collaborate with many other agencies toward the joint goal of restoration of blind people to the maximum level of health, employability, and personal satisfaction their capacities permit. By proper referral and provision of needed supportive services, the public assistance agency implements this goal so the handicaps of severe visual limitations may be mitigated or overcome. Illustrative of the foregoing: utilization of vocational rehabilitation services for young adults and those of middle age; special educational provisions for blind young people; casework services for parents of young blind children; encouragement of attendance at adjustment and mobility training centers; use of home teachers; sheltered work opportunities and community recreational resources and acquisition of talking book machines with the wide choice of records available from the Library of Congress. For the past 5 years, the Welfare Administration has held an annual meeting for State supervising ophthalmologists associated with State AB programs in conjunction with the annual sessions of the American Academy of Ophthalmology and Otolaryngology. This has proved to be a valuable opportunity to share information and hear about operation of the State AB agencies who were represented. These meetings will be continued in the future. Cooperation with organizations serving the blind Staff continue to carry on cooperative activities with the Division of Services for the Blind, Vocational Rehabilitation Administration; the National Institute of Neurological Diseases and Blindness, with particular interest in the development and implementation of their task of involving States in the model reporting area for blindness statistics; the National Society for the Prevention of Blindness on the use of their standard classification of causes of severe vision impairment and blindness; the American Foundation for the Blind; National Medical Foundation for Eye Care representing the American Association of Ophthalmology; the American Council of the Blind and the National Federation of the Blind. At the request of the latter, in 1965, the Welfare Administration had the social security titles and sections of the 1962 Public Welfare Amendments relating to the blind printed in braille for use at an annual meeting. AMERICAN PRINTING HOUSE FOR THE BLIND Grants are made to this nonprofit institution in Louisville, Ky., to (1) support the manufacture of special books and teaching materials which are distributed to all public educational institutions for the blind, as well as to regular public schools in which blind children are enrolled; and (2) provide for staff and other expenses of committees which advise the Printing House relative to administration of the Federal funds. Numbers of blind children served by the program are as follows: 1963, 16,841; 1964, 17,330; 1965, 18,093; 1966 estimate, 18,700; 1967 estimate, 19,250. CEREBRAL PALSY THE PROBLEM It has been estimated that of every 100,000 persons in this country 400 have cerebral palsy, a brain-centered disorder of motor function. Although modern medical advances will give most of these individuals a normal life span, only a few children have a mild, easily treated form of the disease. Almost threefourths of the diagnosed cases are moderately or severely disabled. Each year 20,000 infants with cerebral palsy are born. In a lifetime the total disability cost for each disabled child may be as high as $100,000. As this disease is one of the greatest cripplers-afflicting nearly 600,000 children and adults the cost to the Nation totals billions of dollars. Despite the increased survival rate of these children in the past two decades, complete recovery is found only in exceptional cases. Mental deficiency and epilepsy, which are more common in these children than in the general population, add to the problem. However, the disorder is not progressive. Cerebral palsy is usually a consequence of the damaging effect of the environment on the fetus or newborn. Anoxia-oxygen deprivation or deficiency-is the most important of the many harmful factors in the environment known to contribute to the development of the disease. Other deleterious factors include Rh incompatability, prematurity, and several obstetrical complications. VOCATIONAL REHABILITATION ADMINISTRATION While the number of people suffering from cerebral palsy in the United States is not precisely known, the estimate runs to at least 200,000. Because the cerebral palsies cover a rather broad range of neurological disorders, it is vital for rehabilitation purposes that a careful, individual medical-psychological-social-vocational evaluation be completed at the initiation of the rehabilitation process. An interdisciplinary approach is essential, and it is particularly important that family reactions and needs be carefully considered in case management. The following table indicates recent and projected trends in rehabilitating cerebral palsy cases under the State-Federal program of Vocational Rehabilitation. Total reha- Cerebral palsy 1 Fiscal year: 1963. 1964. 1965. 1966. 1967. 1 Data are actual for fiscal years 1963-65; estimates are used for fiscal years 1966-67. Under its training program, VRA has in recent years supported short-term courses such as: (1) vocational rehabilitation methods for professional staff of local affiliates of the United Cerebral Palsy Association; (2) rehabilitation counseling techniques with the cerebral palsied client for the State rehabilitation agency counselors; and (3) executive development for administrators of cerebral palsy programs. In addition, instructional content on cerebral palsy is incorporated into the various long-term professional training courses VRA sponsors at universities for rehabilitation counselors, nurses, phyciatrists, psychologists, physical therapists, and occupational therapists. The Vocational Rehabilitation Administration has consistently supported a number of research and demonstration projects related to cerebral palsy. ples are the following: Cerebral palsy work classification and evaluation project Exam This project was a closely coordinated community effort which involved the New York State Division of Vocational Rehabilitation, the New York Employment Service, United Cerebral Palsy of New York City, United Cerebral Palsy of Queens, and the Institute for the Crippled and Disabled. Its purpose was to investigate the reasons for the high proportion of cerebral palsied adults who were unable to adjust vocationally. Its findings outlined the kinds of services which, if available, could enhance the employability and adjustment of the cerebral palsied. An evaluation of "total push" program in a specialized agency for the cerebral palsied.-United Cerebral Palsy Association, Los Angeles County, Calif. This project made an intensive review of 76 persons handicapped by cerebral palsy. It was determined that a comprehensive assessment program should precede rehabilitation efforts so that the best use could be made of both the abilities of cerebral palsied and of the professional time and services given to them. The techniques found valuable in the assessment and rehabilitation programs were described. The cerebral palsied youth who attends college: His social-psychological and environmental physical problems and solutions.-College of Education, State University, Iowa. This project was an intensive study of a sample of young adults with cerebral palsy who were attending or were recent graduates of colleges or universities. Many of the grants made by VRA to State rehabilitation agencies for the extension and improvement of rehabilitation services within a State have been in the area of cerebral palsy, frequently with the active involvement of voluntary agencies and groups. For example, a grant of this kind enabled United Cerebral Palsy of New York City, Inc., to initiate a program of services encompassing new evaluation and training techniques for cerebral palsy cases who had been unable to achieve a satisfactory job adjustment through existing services. It is expected that the innovation grants authorized under the Vocational Rehabilitation Act Amendments of 1965 in place of the former extension and improvement grant system will also have a strong emphasis on expanding and intensifying services for the cerebral palsied. This new program of innovation grants is designed to introduce methods or techniques in a State for providing rehabilitation services to particularly severe disability categories, including the cerebral palsied. PUBLIC HEALTH SERVICE NATIONAL INSTITUTE OF NEUROLOGICAL DISEASES AND BLINDNESS Cerebral palsy is a term descriptive of the clinical status of many children who suffer from a wide variety of diseases. The common denominator is damage to areas of the brain controlling motor function. Medical research in cerebral palsy branches into many fields. Investigations of kernicterus, asphyxia, prematurity, and a number of other disorders which may cause cerebral palsy are oriented toward prevention. Obstetrical advances have improved methods of avoiding the complications of pregnancy and delivery. Modern obstetrical and pediatric techniques have saved a large number of children from irreparable brain damage. Ironically, these same skills have preserved the lives of many infants who sustained injury to their nervous systems. Repair of such injury, though now seldom feasible, is one of the most important longterm goals of current research in neurology. Through the study of the complex phenomenon known as brain damage, Institute scientists ultimately hope to learn how to reverse damaging processes and thereby cure manifestations such as cerebral palsy, epilepsy, and mental retardation. While even the most optimistic feel that this goal will not easily be reached, a many-faceted attack, employing medical disciplines of embryology, histology, anatomy, physiology, and pathology, is well underway. ADVANCES THROUGH RESEARCH Basic studies: Anatomy, physiology, pathology What is amiss in the damaged brain? The first step in answering that question is to determine how the nervous system of a cerebral-palsied child differs from the normal development, structure, and function. The study of the development of the nervous system from the time of conception until birth is conducted by embryologists at the Institute's Laboratory of Neuroanatomical Sciences. As part of this research, drugs are being administered to chick embryos to determine the effect, if any, on developmental processes. Of Neurological development of human infants is being investigated by the anatomists in this laboratory. They are currently conducting detailed examinations of the brains of infants who have died with the diagnosis of cerebral palsy. the 16 brains examined last year, 11 had porencephaly or microgyria, that is, small cysts or seemingly abnormal convolutions. Meticulous analysis of these abnormalities has led the scientists to hypothesize that both of these lesions might be directly involved in impairment of the fetal circulation. This study is providing clues to the causes of cerebral palsy. Researchers within the Institute also envision extended clinical, genetic, and laboratory studies of children suffering from organic brain syndromes. While many children with cerebral palsy are mentally retarded, it has been found that a great many others merely appear to be subnormal due to an inability to communicate adequately. Grantees have evaluated the structural basis of athetosis (slow changing spasms in face, neck, and extremities) in cerebral-palsied children. In cases of athetosis of unknown cause they suggest that brain damage is due to perinatal anoxia associated with occlusion of the great vein of Galen, vital to blood circulation in the brain. These investigators believe that the clinical picture of athetosis does not necessarily reflect a more specific focus of damage in the brain. The role of structural alterations in the cerebellar area of the brain has also been studied. At autopsy, 1 grantee found only 8 brains with apparently abnormal cerebellar structures in 126 cases of cerebral palsy. He concluded that cerebellar evidences of disease represent a small proportion of all manifestations. Other Institute-supported investigators have employed stereotaxic neurosurgical procedures to guide microelectrodes into exact areas deep in the brain. Here, low voltage current similar to that of the body's own electrical activators stimulates tremors and uncoordinated movements in patients. Along these lines, physiological studies are being made in an attempt to ameliorate the devastating effects of injuries to the nervous system. These projects in depth electrography are improving our knowledge of the anatomic and functional basis of the disorder. One of the drawbacks in studying cerebral palsy has been the lack of an experimental animal to serve as a model for this disorder. An Institute investigator is now attempting to create neuromuscular disorders in animals resulting in deformities similar to those found in cerebral-palsied children. Through studies of brain structures Institute pathologists are trying to correlate the observed symptoms of cerebral palsy and the actual damage to the brain. One investigator has studied the pathological consequences of asphyxia in the monkey. His findings in animals of lesions associated with cerebral-palsy-like symptoms and retardation have directed the attention of neuropathologists to finding similar lesions in humans. The attempt to elucidate developmental, structural deviations of the brain in cerebral palsy has led to formation of a cerebral palsy brain registry and to work on computers which it is hoped will rapidly and efficiently perform the tedious task of counting and differentiating the billions of nerve cells and supporting cells in human nervous tissue. Physiologic and pathologic investigation is laying the foundation for collating the clinical manifestations of central nervous system disorders with the type, location, and severity of damage to the brain. These basic scientific studies, taken as a whole, are creating a solid framework of knowledge about the damaged brain. With our increasing comprehension of the nature of the disease process, we are drawing closer to the day when it will be possible to explore ways of altering the course of this disease. This is the great challenge to basic neurological research of the future. The collaborative perinatal project The search for effective preventive measures in cerebral palsy is one of the principal objectives of the collaborative perinatal research project, which is discussed more fully in another background report. This project is a vast, prospective, multi-disciplinary, and multi-institutional study of the circumstances and events of the perinatal period. Its purpose is to identify the various conditions and factors in the mother and fetus and their environment which exert unfavorable influence on the nervous system of the child. The goal of registering 60,000 pregnancies has been achieved, and already over 50,000 resulting children are being followed. Their followup will extend at least until they are 7 years of age and perhaps to 12 years of age. Fourteen institutions are collaborating with the National Institute of Neurological Diseases and Blindness in this perinatal study. Genetic, infectious, toxic, socioeconomic, psychological, and physiological factors are being evaluated. During the birth process the details of labor, delivery, and resuscitation are being recorded. The scope and intensiveness of this study will allow a highly scientific analysis of various perinatal factors. Valid comparisons of these factors in normal mothers and those with cerebral-palsied infants are made possible. The significance of the differences found between the two groups can be evaluated. This research already has demonstrated, for example, that a twofold increase of cerebral palsy occurs among children born to mothers over 40 years of age. The Laboratory of Perinatal Physiology This Institute's search for effective prophylactic measures in cerebral palsy is by no means confined to the collaborative project. Experimental animal studies, retrospective methods, and individual investigations on many facets of the problem complete the research picture. Much of the experimental research in animals is being performed at the Laboratory of Perinatal Physiology in San Juan, P.R. More than 1,000 free ranging and caged monkeys are now available at this facility. At present several hypotheses concerning perinatal factors in cerebral palsy and mental retardation are being evaluated. Among the potential causes being investigated are umbilical cord compression, asphyxia, intoxications, and modifications of neural behavior occasioned by specific brain damage. Other research projects Investigators of the Institute's laboratories in Bethesda recently have designed a retrospective study of cerebral palsy and other neurological diseases of infancy and childhood to determine the relationship between defined perinatal or postnatal events and damage to the nervous system. Anoxia, toxic chemicals, metabolic influences, trauma to the head, infections, genetic and familial patterns, and socioeconomic status all are being investigated. More than 300 medical records of mentally damaged children at Georgetown University Hospital, Washington, D.C., have been abstracted for this purpose. This research is leading to a better understanding of the causes of some forms of cerebral palsy. One of the important facets of this study is a careful evaluation of the effects of compression of the umbilical cord on the infant. Animal studies have shown that if the umbilical cord is clamped for over 20 minutes many of the animals will show classical signs of cerebral palsy. The proposition that spastic diplegic (affecting both sides of the body) cerebral palsy is strongly associated with prematurity is being examined by Institute grantees conducting extensive epidemiological studies. Six thousand consecutive live births and the clinical records of 1,000 cases of cerebral palsy in children |