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Citation: Moncer R, Ghanmy M, Loubiri I, Hamadou L, Jemni S. School inclusion challenges in Tunisian children affected with

Cerebral Palsy. Jr. med. res. 2023; 6(2):6-8. Moncer et al © All rights are reserved. https://doi.org/10.32512/jmr.6.2.2023/6.8

Submit your manuscript: www.jmedicalresearch.com

Background

Cerebral palsy (CP) is one of the most frequent pediatric neurological

affections. Related psychomotor disorder usually lead to difficult social

integration. The aim of this study was to assess different educational

difficulties in Tunisian children with cerebral palsy.

Methods

A cross-sectional study was performed including children with CP and

their parents. Sociodemographic, cultural and clinical characteristics

were collected using pre-established form. School outcomes were

measured using quality-of-life scale (CPQOL) in its Arabic language

version validated for caregivers.

Results

Sixty-one children were included(33 boys and 28 girls). Mean age was

8 years (6-14). School registration rate was 31%. The enrolment was

in mainstream school in 80% of the cases. The Quality of students life

assessed using the score was objectively altered in 80.8% of cases.

Most of the studied cases were feeling non-competitive.

Conclusions

Few educational outcomes associated with cerebral palsy were

precepted in our study.These findings might be due not only to limited

communicative and intellectual ability but also to variable CP children

environmental factors.

Key words

Cerebral palsy; School inclusion; Communication; Function; Outcome.

1: Department rehabilitation and physical medicine,

Sahloul University hospital, Sousse, Tunisia.

2: Department rehabilitation and physical medicine,

Ibn Al Jazzar university hospital, Kairouan, Tunisia.

3:Faculty of medicine of Sousse, Tunisia.

** Academic editor

* Corresponding author

Correspondence to:

rihabmoncer@hotmail.com

Publication data:

Submitted: April 12, 2023

Accepted: September 8, 2023

Online: November 30, 2023

This article was subject to full peer-review.

This is an open access article distributed under the

terms of the Creative Commons Attribution Non-

Commercial License 4.0 (CCBY-NC) allowing to

share and adapt.

Share: copy and redistribute the material in any

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the work provided must be properly cited and

cannot be used for commercial purpose.

Moncer Rihab

1,3*

, Loubiri Ines

1,3

, Ghanmy Maroua

2,3**

, Hamadou Leila

1,3

, Jemni Sonia

1,3

Abstract

Original Article

School inclusion challenges in Tunisian children affected with Cerebral Palsy.

School inclusion challenges in Tunisian children affected with Cerebral Palsy

Citation: Moncer R, Ghanmy M, Loubiri I, Hamadou L, Jemni S. School inclusion challenges in Tunisian children affected with

Cerebral Palsy. Jr. med. res. 2023; 6(2):6-8. Moncer et al © All rights are reserved.

Submit your manuscript: www.jmedicalresearch.com

Introduction

Cerebral palsy (CP) is the main cause of pediatric motor disability.

It consists of disorders of movement and/or posture, permanent,

not progressive caused by different lesions occurring on developing

or immature brain before the first two years of life. Motor disorders

maybe associated with cognitive, communicational and behavioral

abnormalities [1].

The schooling process and educational pathway of these children

remain poorly codified in Tunisia. These patients are rarely totally

managed in special needs centres. Few are included in the regular

educational system with considerable rate of school leavers [2].

The aim was to perform a comprehensive assessment of challenging

school inclusion of CP Tunisian children.

Non-enrollment of CP children was due to distant or absent school

in twenty-nine cases (47.5%). Parental decision of non-inclusion

was motivated by predicted failure and frequent absenteeism in 7

cases (11.4%).

Table1 : Population characteristics.

Among the nineteen scholarized case, the percentage of normal

educational mainstream schools integration is 78.9% (n=15). None

of these cases has received physical assistance inside the school.

Five children (26,3 %) had adapted priority of examination time.

Regarding the quality of CP cases life, the overall satisfaction rate

was 55.1 (±16.5). The “Emotional well-being and self-esteem”

domain was had highest score of 58.9 (±19.9). Regarding the

domain “participation and physical health” CP children were less

satisfied. The score results by domain items were variable. Highest

scores were noted for “relationship with teachers” (5.47±1.54),

“relationship with peers” (5.74 ±1.52) and for the item related to

the Ability to interact with peers (5.58 ±1.74). Lowest scores were

noted for “the acceptance of peers” (5.26 ±1.79), “ability to

participate in school” (5.05 ±1.51), and for “physical activity”( 4.32

±1.80). these results are detailed in (figure 1).

Material and Methods

I-Study design

This cross-sectional study was conducted over four months in our

physical medicine department (Sahloul university hospital Sousse

,Tunisia). Cooperating children without comprehension difficulties

were included. Study exclusion criteria were:

• Age< 6 years old.

• Non-consenting parents.

• Comprehension difficulties.

• multiple disabilities.

Precalculated sample size of fifty-six was used based on estimated

expected school inclusion rate of 12% (precision (i) =5% ; risk (α)

= 5%).

II-Data collection

Based on data from medical records, we determined the clinical

forms and socio-economic conditions of the included cases. For

children with CP not attending school, we focused on the causes.

For the others, educational difficulties were determined through a

quality-of-life questionnaire( CP QoL scale).

This scale was a self-administered questionnaire for the primary

caregiver. It is composed of several questions exploring 5 domains

(D):

D1= Social well-being and acceptance.

D2= Emotional wellbeing and self esteem

D3= Access to services

D4= Pain and impact of disability

D5= Family health

Each question includes a satisfaction scale according to a Likert

scale from 0 “not satisfied” to 9 “very happy (appendix).

III-Definition of variables

We considered the child satisfied for response greater than 5 for

each domain’s item. The average satisfaction rate was calculated

for school related items. Each statement in the questionnaire was

given a score ranging from 1 to 9. All item scores were converted

to 0-100 score according to the scoring rules detailed the CP QOL

Questionnaire User Manual. Final average score was calculated for

each domain.

IV-Data analysis

Data entry and analysis were carried out by SPSS 26.0 software.

The quantitative variables were described with means ± their and

deviations- standard. Qualitative variables were summarized with

absolute and relative frequencies.

V-Ethical considerations

Approval from the Ethics Committee of the “Ibn El Jazzar” Faculty

of medicine ,Sousse, Tunisia. Anonymity and personal privacy were

respected for data collection. Written consent was obtained from

all the enrolled children parents or legal tutors.

Results

Our specimen included 61 children, 33 boys and 28 girls. Sex ratio

was 1.18. Mean age was 8.56 years (6-14) (table 1). Among the

61 children included, 19 (31,1 %) were registered in a school.

n(%)

Gender

33(54.1)

28(45.9)

Age(mean±SD)

8.56(2.7)

Father’s age

43.1(4.6)

Mother’s age

39.7(4.62)

Parent’s educational level

Illiterate

31(51)

Secondary school

22(36)

High school

8(13.1)

origin

Rural

39(62.5)

Urban

22(36)

Health insurance

Yes

31(51)

30(49)

Clinical form

Diplegia

21(34)

Hemiplegia

26(42.6)

Quadriplegia

14(22.9)

Regular follow up

Yes

14(23)

47(770

Figure 1:CP QoL scores

School inclusion challenges in Tunisian children affected with Cerebral Palsy

Citation: Moncer R, Ghanmy M, Loubiri I, Hamadou L, Jemni S. School inclusion challenges in Tunisian children affected with

Cerebral Palsy. Jr. med. res. 2023; 6(2):6-8. Moncer et al © All rights are reserved.

Submit your manuscript: www.jmedicalresearch.com

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Conclusions

Inclusive schooling is fundamental in children education. This implies that all

children learn together in mainstream schools regardless of any special

educational need. In Tunisia, children with cerebral palsy are still suffering

from poor schooling outcome mainly because of extra-scholar financial ,

organizational and cultural issues. Inclusion in mainstream education system

Had objectively improved the outcome compared to results of special need

centers. However, these findings must be confirmed on larger scale studies.

Conflict of interest: None

Discussion

Education of children with cerebral palsy was exhaustively implemented and

managed in special needs centers for decades.The objective was to deliver

one-to-on patient-centered educational and health assistance to improve the

communicational , cognitive and behavioral associated disorders [3]. Several

studies have examined schooling model impact on the educational outcomes

of children with cerebral palsy. Findings have shown worse educational

outcomes than typically developing children specially in centred educational

systems [4-7]. Universal declaration of human rights about equal education

rights, regardless of physical or social special needs motivated the insertion

of children and adolescents with cerebral palsy in mainstream schools model

[8-10]. However, these children are still facing several inequalities due to

multiple interfering familial and social related factors [11]. Effective schooling

pathway for children with disabilities remains poorly defined in Tunisia. The

aim of our study was to investigate whether CP children have lower school

achievement and if school achievement varies by specific factors. We focused

also on the assessment of the quality of life of CP children enrolled in the

mainstream system. Western and African studies previously conducted in the

same topic were essentially focused on of the physical and communicational

reduced capabilities as leading factor to achievement depletion and difficult

school integration [12-15]. However, there was no objective assessment of

the educational facilities specialized material and human resources was done.

The integration of children with cerebral palsy requires adapted structures

and staff to ensure best school outcome [16].

Cerebral palsy may affect not only children's physical but also indirectly the

intellectual capacities. The educational level of the parents, the availability of

nearby specialized facilities and family resources may affect the integration

and increase the rate of school leaving [17]. Family economic, cultural and

social resources may impact the capital available for these children to face

the challenging schooling step [18,19]. In Tunisia, resources are differently

distributed in families, and these differences have an impact on how and

when the parents invest in their children. Our analysis revealed that children

of highly educated parents obtain higher scores than children who had

parents with a short education. This is valuable in both disability and normal

capacity situations. Confrontation of CP children marks with normal children

marks in mainstream school students showed no significant difference.

Difficult school inclusion are more likely to be related to the conditions of the

preschool age cerebral palsy management. These insufficiencies, once added

to multiple others socioeconomic and cultural factors, may make schooling

of these young patients extremely challenging.

This study had preliminary scale for the assessment quality of life (QoL) of

children with cerebral palsy. Overall Qol is generally poor in children with

disabilities. This condition may also affect QoL of healthy siblings [20,21].

The Limits of our study at this point were multiple specially the short size of

children cohort that didn’t enable the correlation of QoL scale items with the

daily school life variable domains.

Several consistent studies recommended the development of personalized

patient-centered QoL assessment for CP children and adolescents. This scale

may include, in a supportive physical environment and adequate equipment,

the assessment of the acceptance of the disability, emotional well-being and

self-esteem and personal perception of human relationship [22-25].

Acknowledgments:

We thank Pr.Mlayah Souhaiel, Faculty of medicine of Sousse, Tunisia for his

ethical review.