<unk>  is not a progressive disorder (meaning the brain damage does not worsen), but the symptoms can become more severe over time. A person with the disorder may improve somewhat during childhood if he or she receives extensive care, but once bones and musculature become more established, orthopedic surgery may be required. People with<unk>  can have varying degrees of cognitive impairment or none whatsoever. The full intellectual potential of a child born with<unk>  is often not known until the child starts school. People with<unk>  are more likely to have learning disorders but have normal intelligence. Intellectual level among people with<unk>  varies from genius to intellectually disabled, as it does in the general population, and experts have stated that it is important not to underestimate the capabilities of a person with<unk>  and to give them every opportunity to learn. The ability to live independently with<unk>  varies widely, depending partly on the severity of each person's impairment and partly on the capability of each person to self-manage the logistics of life. Some individuals with<unk>  require personal assistant services for all activities of daily living. Others only need assistance with certain activities, and still others do not require any physical assistance. But regardless of the severity of a person's physical impairment, a person's ability to live independently often depends primarily on the person's capacity to manage the physical realities of his or her life autonomously. In some cases, people with<unk>  recruit, hire, and manage a staff of personal care assistants (PCAs). PCAs facilitate the independence of their employers by assisting them with their daily personal needs in a way that allows them to maintain control over their lives. Puberty in young adults with<unk>  may be precocious or delayed. Delayed puberty is thought to be a consequence of nutritional deficiencies. There is currently no evidence that<unk>  affects fertility, although some of the secondary symptoms have been shown to affect sexual desire and performance. Adults with<unk>  were less likely to get routine reproductive health screening as of 2005. Gynecological examinations may have to be performed under anesthesia due to spasticity, and equipment is often not accessible. Breast self-examination may be difficult, so partners or carers may have to perform it. Women with<unk>  reported higher levels of spasticity and urinary incontinence during menstruation in a study. Men with<unk>  have higher levels of cryptorchidism at the age of 21.<unk>  can significantly reduce a person's life expectancy, depending on the severity of their condition and the quality of care they receive. 5-10% of children with<unk>  die in childhood, particularly where seizures and intellectual disability also affect the child. The ability to ambulate, roll, and self-feed has been associated with increased life expectancy. While there is a lot of variation in how<unk>  affects people, it has been found that "independent gross motor functional ability is a very strong determinant of life expectancy". According to the Australian Bureau of Statistics, in 2014, 104 Australians died of<unk> . The most common causes of death in<unk>  are related to respiratory causes, but in middle age cardiovascular issues and neoplastic disorders become more prominent. Self-care For many children with<unk> , parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, and grooming, can be difficult for children with<unk> , as self-care depends primarily on the use of the upper limbs. For those living with<unk> , impaired upper limb function affects almost 50% of children and is considered the main factor contributing to decreased activity and participation. As the hands are used for many self-care tasks, sensory and motor impairments of the hands make daily self-care more difficult. Motor impairments cause more problems than sensory impairments. The most common impairment is that of finger dexterity, which is the ability to manipulate small objects with the fingers. Compared to other disabilities, people with<unk>  generally need more help in performing daily tasks. Occupational therapists are healthcare professionals that help individuals with disabilities gain or regain their independence through the use of meaningful activities. Productivity The effects of sensory, motor, and cognitive impairments affect self-care occupations in children with<unk>  and productivity occupations. Productivity can include but is not limited to, school, work, household chores, or contributing to the community. Play is included as a productive occupation as it is often the primary activity for children. If play becomes difficult due to a disability, like<unk> , this can cause problems for the child. These difficulties can affect a child's self-esteem. In addition, the sensory and motor problems experienced by children with<unk>  affect how the child interacts with their surroundings, including the environment and other people. Not only do physical limitations affect a child's ability to play, the limitations perceived by the child's caregivers and playmates also affect the child's play activities. Some children with disabilities spend more time playing by themselves. When a disability prevents a child from playing, there may be social, emotional and psychological problems, which can lead to increased dependence on others, less motivation, and poor social skills. In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with<unk>  have the capacity to learn and write in the school environment. However, students with<unk>  may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read. In addition, writing may take longer and require greater effort on the student's part. Factors linked to handwriting include postural stability, sensory and perceptual abilities of the hand, and writing tool pressure. Speech impairments may be seen in children with<unk>  depending on the severity of brain damage. Communication in a school setting is important because communicating with peers and teachers is very much a part of the "school experience" and enhances social interaction. Problems with language or motor dysfunction can lead to underestimating a student's intelligence. In summary, children with<unk>  may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally, and interacting socially. Leisure Leisure activities can have several positive effects on physical health, mental health, life satisfaction, and psychological growth for people with physical disabilities like<unk> . Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction. In addition, for children with<unk> , leisure appears to enhance adjustment to living with a disability. Leisure can be divided into structured (formal) and unstructured (informal) activities. Children and teens with<unk>  engage in less habitual physical activity than their peers. Children with<unk>  primarily engage in physical activity through therapies aimed at managing their<unk> , or through organized sport for people with disabilities. It is difficult to sustain behavioural change in terms of increasing physical activity of children with<unk> . Gender, manual dexterity, the child's preferences, cognitive impairment and epilepsy were found to affect children's leisure activities, with manual dexterity associated with more leisure activity. Although leisure is important for children with<unk> , they may have difficulties carrying out leisure activities due to social and physical barriers. Children with<unk>  may face challenges when it comes to participating in sports. This comes with being discouraged from physical activity because of these perceived limitations imposed by their medical condition. Participation and barriers Participation is involvement in life situations and everyday activities. Participation includes self-care, productivity, and leisure. In fact, communication, mobility, education, home life, leisure, and social relationships require participation, and indicate the extent to which children function in their environment. Barriers can exist on three levels: micro, meso, and macro. First, the barriers at the micro level involve the person. Barriers at the micro level include the child's physical limitations (motor, sensory and cognitive impairments) or their subjective feelings regarding their ability to participate. For example, the child may not participate in group activities due to lack of confidence. Second, barriers at the meso level include the family and community. These may include negative attitudes of people toward disability or lack of support within the family or in the community. One of the main reasons for this limited support appears to be the result of a lack of awareness and knowledge regarding the child's ability to engage in activities despite his or her disability. Third, barriers at the macro level incorporate the systems and policies that are not in place or hinder children with<unk> . These may be environmental barriers to participation such as architectural barriers, lack of relevant assistive technology, and transportation difficulties due to limited wheelchair access or public transit that can accommodate children with<unk> . For example, a building without an elevator can prevent the child from accessing higher floors. A 2013 review stated that outcomes for adults with<unk>  without intellectual disability in the 2000s were that "60–80% completed high school, 14–25% completed college, up to 61% were living independently in the community, 25–55% were competitively employed, and 14–28% were involved in
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