Running head: INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 1

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1 Running head: INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 1 Interventions for Communication Impairments in Children with Cerebral Palsy Amy Williams University of Calgary

2 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 2 Interventions for Communication Impairments in Children with Cerebral Palsy Developmental disabilities affect children worldwide; one of the most common childhood developmental disabilities is cerebral palsy (CP) (Rosenbaum, 2003; Krigger, 2006). A neurological disorder, CP is characterized by damage to the brain which causes individuals to experience difficulty producing or controlling movement (Stanton, 2012). According to various researchers, the prevalence of CP in both the United States and internationally is 2 to 2.5 children for every 1,000 born (Krigger, 2006; Jones et al., 2007). There are a number of prenatal, perinatal, and postnatal factors that may contribute to the development of CP. Some of these factors include infection, lack of oxygen (asphyxia), and head injury (Stanton, 2012). Krigger (2006) poses that approximately 80 per cent of children diagnosed with CP acquire the disorder prenatally, and the exact cause is generally unknown. An important aspect with regard to the development of CP is that the associated brain injury occurs before cerebral development is complete (Krigger, 2006, p. 91). Thus an individual can develop CP from birth up until he or she is five years of age (Stanton, 2012). Although CP is primarily a physical disability associated with motor impairments, other impairments often coexist or are the result of these motor impairments. According to Jones et al. (2007), in some children diagnosed with CP, communication skills are impaired because of oromotor, fine motor, and gross motor difficulties; this has potential to affect the child s success both academically and socially (p. 150). Children diagnosed with CP thus require interventions that are designed to promote the functioning of the whole child and that involve the expertise of a multi-disciplinary team of professionals. Communication impairments deserve particular attention insofar as cerebral palsy is concerned. An individual with CP may experience difficulties with regard to communication

3 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 3 when they are younger but also as they enter adulthood, and thus he or she will likely require interventions that are long-term (Pennington, Goldbart, & Marshall, 2011, p. 2). For this reason, it is imperative that psychologists and other professionals who work with individuals with cerebral palsy understand not only the disorder itself but also the impact communication impairments associated with this disorder hold for the child. This paper provides an overview of the key players and components involved in the development of interventions designed to promote the communication abilities of children diagnosed with CP. It also highlights a prominent intervention Augmentative and Alternative Communication (AAC) as well as the research findings on best practices insofar as the treatment of children with communication impairments associated with this disorder is concerned. Interventions to Promote Communication Abilities: Key Players and Components Role of the Multi-Disciplinary Team Because a child diagnosed with CP may experience impairments in areas in addition to motor impairments, it is important that members of a multi-disciplinary team work together to develop and implement effective interventions. Cerebral palsy, however, is generally defined as a disorder of movement (Stanton, 2012); as a result, emphasis is often placed on the physical aspect of CP with regard to assessment and treatment. Children diagnosed with this disorder, however, may also present with other conditions, including developmental delays, intellectual impairments, and sensory impairments (Stanton, 2012). According to Jones et al., (2007), an individual with CP will often experience disabilities that result from damage to a specific area of the brain, and the severity of these disabilities depend on the severity of the actual brain damage. Assessing an individual with CP is thus a complex process that requires the expertise of professionals who are knowledgeable in both the motor impairment aspect of the disorder and

4 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 4 potential co-occurring impairments. In fact, Rosenbaum (2003) cautions that recognizing and managing cerebral palsy s many important comorbidities is as important as treating the motor disabilities (p. 970). For this reason, having professionals work alongside physicians to evaluate and design interventions for children who have been diagnosed with CP is essential. Role of the School Psychologist School psychologists play an important role in the assessment of children diagnosed with CP. A physician or occupational therapist deals primarily with motor impairments associated with the disorder, whereas a school psychologist is concerned with the academic, cognitive, and social functioning of the child. This is particularly important insofar as communication impairments are concerned. According to Bray, Kehle, and Theodore (2002), the psychoeducational evaluation provides a unique opportunity to observe the child s language skills particularly in the areas of oral and written communication, auditory perception, understanding directions, pronunciation, and grammatical errors (p. 1518). The results obtained from this evaluation can then be used in conjunction with the evaluations other professionals have conducted to develop appropriate language-based interventions. The school psychologist should also be involved in the development and implementation of interventions aimed at promoting the communication abilities of children diagnosed with CP; his or her involvement, however, will vary according to the degree of severity of the child s communication impairments. According to Stanton (2012), Difficulty with speech is often associated with general motor problems with the result that the muscles in the mouth that are used for speech are impaired (p. 24). Although expressive language is an area in which the school psychologist is skilled at evaluating and designing interventions, developing interventions that will ultimately facilitate the child s motor problems - which in turn will facilitate the

5 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 5 production of speech is an area in which a speech pathologist would more than likely be involved. Bray et al., (2002) suggest that with regard to treatment, the school psychologist should consult and assist the speech pathologist s delivery of services (p. 1519). This partnership between school psychologist and speech pathologist ensures that the needs of the child are being met. In addition, it reinforces the importance of collaboration amongst professionals in working not only with children with CP but any child presenting with language difficulties. Early Intervention It is important that interventions designed to promote motor development in a child with CP are implemented early in the child s life. According to Woolfson (1999), early intervention programmes are of particular relevance to infants with cerebral palsy because motor difficulties can limit the sensori-motor experiences available to them, affecting subsequent learning and developmental progress (p. 241). Of course, the effect that motor difficulties can have on language development varies depending on the individual child. Stanton (2012) holds that it is possible for children with CP to develop language abilities that mirror the developmental progression of their same-age peers; she cautions, however, that the development of a child with CP is difficult to predict. Nevertheless, the goal of early intervention should be clear: to promote function, to prevent secondary impairments and, above all, to increase a child s developmental capabilities (Rosenbaum, 2003, p. 972). Augmentative and Alternative Communication (AAC) Expressive communication is an important aspect of every child s development and involves both speaking and writing; children with cerebral palsy, however, often experience difficulty with this form of communication. Many effective interventions that aim to promote an

6 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 6 individual s expressive language abilities exist. Contrary to popular belief, not all of these interventions emphasize actual oral narrative. According to Bray et al., (course pack), although focusing on oral narrative is crucial to promoting expressive language, it is difficult to remember, review, and revise (p. 1516). One of the most prevalent interventions Augmentative and Alternative Communication (AAC) supports an individual s actual speech instead (Stanton, 2012). With regard to intervention, there are various forms of AAC. Some forms require an individual to use sign language, body language, or manipulate a tangible device such as a book or a word board to express himself when either speaking or writing presents a challenge; these forms of AAC are considered no tech and unaided ACC, respectively (Stanton, 2012). Stanton (2012) poses that children with CP who have communication difficulties often develop their own sign systems based on movements that they can manage (p. 95). A foundation for an intervention such as the teaching of signing then is already established for many children with CP, thus facilitating the implementation of AAC. AAC can also take the form of electronic devices that have built-in recordings of digitized speech and thus require more sophisticated use of technology; examples include both the ipad and touch screen computers, which are useful AAC devices for children with communication impairments and have recently been increasing in popularity (Stanton, 2012). Parette and Marr (1997) illuminate the positive effect the use of electronic AAC devices has on children with language difficulties: They enable children who are nonverbal, or whose speech is unintelligible, to participate

7 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 7 in regular classroom settings with their nondisabled peers. Such interactions may contribute to academic success, enhanced social interactions, and the development of positive self-esteem. (p. 337) A child s adaptive skills, however, must be taken into consideration beforehand in order to determine the degree to which he or she will be able to use an electronic AAC device independently and thus successfully - in the home and at school (Parette & Marr, 1997). Regardless of whether it requires technology or not, AAC can be used both in the classroom and at home and can ultimately help a child with his or her academic and social functioning. Rosenbaum (2003) holds that augmentative communication systems for children with communicative difficulties make communication possible and often help to promote the development of oral language (p. 972). Best Practice: Review and Implementation of the 12-Step Intervention Process as it Pertains to a Child Diagnosed with CP As aforementioned, the development and implementation of interventions to promote the communication abilities of children diagnosed with cerebral palsy should be the responsibility of a multi-disciplinary team, one that includes a school psychologist. Krigger (2006) holds that this team should be based around the needs of each patient to provide continuously updated global treatment care plans (p. 91). Thus in order for interventions to be successful, they must be designed with the individual child in mind. According to Upah and Tilly (2002), an intervention is a set of procedures and strategies designed to improve student performance with the intent of reducing the student s problem (p. 483). Insofar as a child with cerebral palsy is concerned, this means that interventions should enhance the student s performance in both academic and social areas but at the same time

8 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 8 minimize the student s communication impairments if a child presents with them. Furthermore, these interventions should be developed so that they can help the child meet with success in both the home and at school. In designing quality interventions for a child with CP or any disorder collection of baseline data should follow identification of the behavioral definition of the disorder (Upah & Tilly, 2002). Upah and Tilly (2002) hold that this step allows the professionals working with the child to predict future performance based on the child s current performance when interventions have not yet been put into place. With regard to the child diagnosed with CP, baseline data will shed light on the extent to which the child struggles with communication. This will then enable the speech pathologist and school psychologist to determine the most appropriate AAC or academic interventions to help support the child at home and in school. Problem analysis the fourth step in Upah and Tilly s (2002) best practice plan involves collecting data as well; the data collected during this step can come from a variety of sources, including the instruction the child receives, the curriculum that guides the instruction, the child s environment, and the child himself. Because a child diagnosed with CP will have generally acquired the disorder early in life and thus potential communication impairments will have been evident at an early age collecting data from the child s environment and from the actual child is most effective. As the child reaches the age in which he or she can attend school, data collection in the domains of instruction and curriculum will help inform the multi-disciplinary team and, in particular, the school psychologist. Upah and Tilly (2002) hold that problem analysis and the steps involved in data collection are critical: they provide a link between the information the school psychologist gains and the subsequent development of interventions to help alter the child s behavior. In the case of the child with CP, this behavior is of course communication difficulties.

9 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 9 With regard to goal setting and intervention plan development, members of the multidisciplinary team are not the only people who should play a role. Rosenbaum (2003) holds that insofar as children diagnosed with CP, goal setting should be a join venture between parents (and older children) and healthcare providers (p. 972). Although so much depends on the degree to which the child with CP presents with communication impairments - as well as other comorbid impairments that he or she may have the ultimate goal of the multi-disciplinary team and the interventions they implement is to promote the child s degree of functionality and independence (Rosenbaum, 2003). Plan implementation is a particularly important step in the development of interventions. Upah and Tilly (2002) state that the intervention components addressed at this stage must be logically and empirically related to the identified problem and to the reasons that the problem situation exists (p. 489). In a child with CP that presents with communication impairments, the identified problem is his or her ability to produce language; the reason that problem situation exists, however, is often brain damage in a particular region of the brain or as some researchers pose motor difficulties associated with the disorder (Jones et al., 2007). Thus interventions that aim to facilitate communication yet are developmentally appropriate for the child given the motor impairments that he or she might present with are ideal. For example, if the child with CP is unable to produce speech and has difficulty with accuracy with regard to finger pointing, providing a book or electronic AAC device that includes only a few options on the page or screen in which the child can point to would be a suitable intervention strategy (Stanton, 2012). With regard to progress monitoring, the importance of the multi-disciplinary team in developing and implementing interventions for a child with CP and communication impairments is once again illuminated. The school psychologist must always keep in mind the skills of the

10 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 10 intervention implementers, the reasonability of the intervention selected, and the monitoring requirements of the intervention (Upah & Tilly, p. 489). It is during the step that the school psychologist will work particularly closely with other members on the multi-disciplinary team, particularly the speech pathologist. Together the two professionals will able to evaluate the appropriateness of the interventions they have designed to promote the child s communication abilities. Because cerebral palsy is a disorder that is characterized by variability (Stanton, 2012), formative and summative evaluation of the intervention development and implementation plan can present challenges to the school psychologist and members of the multi-disciplinary team. According to Upah and Tilly (2002): If the data are highly variable, then the school psychologist and other problem-solving team members may need to decide how to motivate the student to more consistently perform the desired behaviors so that the data can then be evaluated against the goal line to determine the interventions effect. (p. 492) This could involve integrating interventions that are designed to promote the development or function of other areas that the child with CP has difficulties with, such as motor or cognitive skills. Thus evaluation of interventions designed for the child with CP is a complex process that requires careful consideration on the part of the school psychologist and other members of the multi-disciplinary team involved in the intervention process. Conclusion Like many developmental disabilities, cerebral palsy does not have a cure (Stanton, 2012). For this reason, professionals designing and implementing the interventions should aim to promote the overall functioning of the individual child. According to Rosenbaum (2003), there

11 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 11 is a need to move beyond efforts to promote normal function in children with cerebral palsy (often an illusory goal) toward the achievement of functional abilities that facilitate independence (p. 972). This holds important implications for the 12 steps involved in designing and implementing interventions that Upah and Tilly (2002) propose, particularly because the impairments presented by a child with CP may be life-long and thus require long-term interventions. Because communication impairments are often the result of motor impairments associated with CP, it is imperative that professionals working with an individual diagnosed with this disorder take all aspects of this disorder into consideration. Krigger (2006) holds that the goal of management of cerebral palsy is not to cure or to achieve normalcy but to increase functionality, improve capabilities, and sustain health in terms of locomotion, cognitive development, social interaction, and independence. (p. 92). In designing and implementing interventions that are aimed at improving an individual s functional abilities, a professional regardless of whether he or she is a physician, occupational therapist, or school psychologist can subsequently improve the overall quality of life of the child diagnosed with cerebral palsy.

12 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 12 References Bray, M.A., Kehle, T.J., & Theodore, L.A. (2002). Best practices in the school psychologist s role in the assessment and treatment of students with communication disorders. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp ). Krigger, K. W. (2006, January 1). Cerebral palsy: An overview. American Family Physician, 73, Parette, H. P., Jr., & Dempsey Marr, D. (1997). Assisting children and families who use augmentative and alternative communication (AAC) devices: Best practices for school psychologists. Psychology in the Schools, 34, Pennington, L., Goldbart, J., & Marshall, J. (2003). Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database of Systematic Reviews, Rosenbaum, P. (2003, May 3). Cerebral palsy: what parents and doctors want to know. BMJ, 326, Stanton, M. (2012). Understanding cerebral palsy: A guide for parents and professionals. London, United Kingdom: Jessica Kingsley Publishers. Upah, K. & Tilly, D.W. (2002). Best practices in designing, implementing, and evaluating quality interventions. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp ). Bethesda, MD: NASP Publications. Wilson Jones, M., Morgan, E., & Shelton, J. F. (2007). Primary care of the child with cerebral palsy: A review of systems (part ii). Journal of Pediatric Health Care, 21, Wilson Jones, M., Morgan, E., Shelton, J., & Thorogood, C. (2007). Cerebral palsy: Introduction and Diagnosis (part i). Journal of Pediatric Health Care, 21,

13 INTERVENTIONS FOR COMMUNICATION IMPAIRMENTS IN 13 Wood, E. (2006). The child with cerebral palsy: Diagnosis and beyond. Seminars in Pediatric Neurology, 13, Woolfson, L. H. (1999). Educational interventions for infants and pre-school children with cerebral palsy: Methodological difficulties and future directions in evaluation research. European Journal of Special Needs Education, 14,