Cerebral Palsy and Speech Development

Cerebral Palsy and Speech Development Mayra Naranjo EDSP 502, Fall 2013 Dr. Jennifer Mahdavi

Introduction In my line of work I see children with various developmental delays. Usually the delays are in a single developmental domain; language, gross/fine motor, cognitive. But in some cases there are overall delays that are caused by a neurological damage, one of them being Cerebral Palsy (CP). I wanted to find out what language/speech teaching strategies I could use to make language acquisition possible. Speech is usually affected by CP due to lack of control of the muscles needed for speech and in some cases cognitive impairment (Straub & Obrzut, 2009). According to research done by Nordberg, Miniscalo, Lohmander, & Himmelmann (2012) children with CP may suffer from a variety of language delays. It is important to know how CP effects language acquisition in order to better formulate a lesson plan that will assist in the child s ability to communicate. Nordberg, et al. (2012) stated that CP can affect various speech functions, respiration laryngeal 1, velopharyngeal 2, and articulatory movement (p.161). Nordberg and her colleagues study sought out to describe the various speech problems that children with CP may have by identifying the type of CP each child suffers from. Once the type of CP is identified it is easier to understand the type of speech delay a child may have, which may be dysarthria/anarthria 3 or apraxia/dyspraxia 4. Having this information can point the therapists working with the child in the right direction in terms of what would be effective for the 1 Laryngeal (larynx)-the part of your throat that contains the vocal cords http://www.merriamwebster.com/dictionary/larynx?show=0&t=1386529381 2 Velopharyngeal- of or relating to the soft palate and the pharynx (digestive and respiratory tract) http://www.merriam-webster.com/medical/velopharyngeal & http://www.merriamwebster.com/medical/pharynx 3 Characterized by slow, weak, imprecise and /or uncoordinated movement of the speech musculature. Nordberg, et al (2012) 4 Disturbance in the motor planning and programming of speech movements. Nordberg, et al (2012)

child. For example before a child can be taught sign language therapists would need to work on the child s limb control. A delay in language can also affect a child s social development with their peers and their parents. McFadd & Hustad (2013) tested the social function using the Pediatric Evaluation of Disability Inventory (PEDI) in order to see the relationship that CP and the type of language deficit have on social function. The findings suggested that children with severe language deficits had a lower social function scores. Overall the results to this study give insight on the importance of having language interventions that target a child s social/emotional development (p 108). What is Cerebral Palsy? Cerebral Palsy (CP) is chronic non-progressive disturbance that primarily affects an individual s balance and gross/fine motor movements (McFadd & Hustad, 2013). There are three main group classifications for CP; spastic 5, dyskinetic 6, and ataxic 7. Those with CP may have issues with their movement and posture in some cases there can also be an intellectual disability, seizures, issues with hearing, vision, and/or speech. Due to the lack of control of the movement of the jaw if becomes very difficult for a child to develop their receptive (what is understood) and expressive (what is produced) language skills. Because CP cannot be cured which is important to find the right forms of therapy that much more important. Individuals with CP usually have a team of therapists working with them 5 Stiff or tight muscles and exaggerated reflexes http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#243673104 6 Uncontrollable movements http://www.cdc.gov/ncbddd/cp/facts.html 7 lack of muscle coordination when performing voluntary movements (poor balance and coordination) http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#243673104

in order to improve quality of life. For many suffering from CP they have a team that includes; physical therapy that works on balance, muscle strength, and motor skills an occupational therapist that focuses on improving upper body function and for some a speech and language therapist that assists in developing speech and ways of communicating. Theory of mind What is theory of mind Theory of mind (ToM) is the ability to understand the different states of mind in ourselves and understand that others have belief and desires that do not always match our own (Apperly, 2012). ToM is an essential part of being a functional citizen of society and social/emotional development. The development of theory of mind begins at a very young age, there are certain milestones in a child s development that can lead to a healthy development of ToM or a deficit. These milestones are gaze following, declarative pointing, joint attention, animacy of objects, and awareness of others as intentional agents. Children with CP many times do not reach these milestones due to their motor abilities. If a child with CP is not able to demonstrate these abilities how would they be able to demonstrate ToM? Research has shown that there are various ways to test ToM in children with CP. Theory of mind and language development A child s language development can be known by evaluating with various assessment tools. But what happens when those tools are not compatible with a child s physical or cognitive delay? There has been minimal research that gives alternatives for assessments that have been standardized for children without severe physical or cognitive delays. In my line of work all the children that receive services must be assessed in order to determine services needed and their developmental level. I find it an unproductive to use assessments that would automatically give

them low scores due to their disability. In the articles I read about theory of mind (ToM) the authors attempt to connect language development and ToM acquisition in relation to children with language impairments (Farrar, Johnson, Tompkins, Easters, Zilisi-Medus, & Benigno, 2009; Dahlgren, Sandberg, & Larsson, 2009) and suggest that assessments be altered, and information be gathered using a child s form of communication like gaze behaviours (Clarke, Longanathan, & Swettenham, 2012). All the articles expressed a correlation between ToM and social language. Theory of mind (ToM) plays a big role in the development of a child s language. According to Farrar et al., 2009; Clarke et al., 2012; and Dalgern et al., 2009 ToM is necessary for children to be able to properly communicate and interact with their peers most importantly it is the ability to understand that others have thoughts, desires, and beliefs of their own. One of the biggest concerns in testing ToM for children with cognitive delays is the testing method, the Sally-Anne assessment is typically used to measure a child s ToM. The Sally-Anne 8 task requires children to follow verbal tasks that require some sort of physical movement (Clarke et al, 2012) something that a child with Cerebral Palsy (CP) would not be able to do due to their limited physical and sometimes limited language ability. One of the limitations for children with CP in attempting the Sally-Anne assessment without any changes would be their inability to form words due to their lack of control of muscle movement. Children with CP have a difficult time forming words due to the lack of tongue and jaw control. One of the ways Clarke et al., 2012 suggest to accommodate children who are limited in their verbalization and body movement is to use their gaze as an indicator for comprehending what is being asked of them. Instead of a child answering a question verbally or by pointing, the child is videotaped in order for the test administrator to decide if the child answered correctly 8 The Sally-Anne assessment that test a child s theory of mind with various scenarios. http://learningneverstops.wordpress.com/2013/02/03/the-sally-anne-test-theory-of-mind/

with their gaze. This method could be used in my line of work in order to test if a child has knowledge for objects and people. The key in this study was to make sure that their language and ToM was tested without concerns over their physical capabilities. Information gathered from Farrar et al., 2009 and Dahlgren et al., 2009 showed correlation between a child with CP and a speech delay in their low performance in ToM assessment. Both papers suggested that a child s developmental/mental age be taken into consideration when administering the test. A ToM assessment is usually administered when a child is chronologically four years old. For a child with a speech delay or a disability like CP administering an assessment without taking into consideration their developmental age would be setting the child up to fail. In addition to their findings both Farrar et al., 2009 and Dahlgren et al., 2009 believe that more studies need to be done on both typically developing children and atypically developing children in order to better understand how an assessment for ToM would better function for children with disabilities. Also the assessment and the concept of ToM are intended for children who are higher advanced in their language skills. It is also necessary for research to discuss how physical disabilities like CP that affects body and muscle movement can also affect a child s early language skills. For example, it would be hard for a child to develop any sort of word formation if the child had no control of their jaw movement. Farrar et al., 2009 stated the importance of exposing children with physical and cognitive disorders that affect their language development to have peer interactions with typically developing children. The authors believe that if children with speech delays have opportunities to hear language in social settings their ToM will develop. A child would be able to enhance their language skills and in turn develop their ToM if teachers and parents are able to generalize

concepts to the child s everyday experiences. Although a child with CP would not be able to physically interact with other children in a dramatic play sequence it would be beneficial for the child to be present during such interactions and participate to his/her ability. Dahlgren et al., 2009 took into consideration the difference of expressive and receptive language. Results for the study conducted were not able to suggest that a child s lack of expressive language correlated to their receptive language skills. This idea gives insight to parents and teachers as to a child s actual language ability. The authors also suggested that due to a child s low expressive language ability they do not receive the amount of verbal interaction needed to build their ToM. Like Farrar et al., 2009, Dahlgren et al., 2009 also believes that children with speech delays need continuous verbal interaction with peers that will connect their understanding of language to the outside world. Effects that Cerebral Palsy has on language development Low muscle tone and speech One of the effects that CP has on many children is jaw-muscle tension, in other words the child s jaw tenses up and they do not have the jaw control needed to form words. There have been studies done in order to determine the relationship between abnormal muscle tone and the effect is has on speech production. Connaghan & Moore (2013) took children with CP, Down Syndrome (DS), and a control group in order to determine the relationship that muscle tone abnormalities have on the orofacial 9 structures of children with CP and DS. The authors hoped to find the difference between speech articulation in children with hypertonia 10 (CP), hypotonia 11 9 Orofacial- of or relating to the mouth or face http://www.merriam-webster.com/medical/orofacial 10 Hypertonia- the condition of exhibiting excessive muscular tone or tension http://www.merriamwebster.com/dictionary/hypertonia?show=0&t=1386478461

(DS) and typically developing children as well as the degree of jaw muscle tension in each set of children (p.125). This study adds information to what is already known about abnormal muscle tone and movement disorders that effect oral movement in order to produce theoretically based treatment (pp. 123-124). Findings for this study suggest that there are differences in jaw-tension and articulation in children with muscle tone abnormalities (CP and DS) when compared with results of atypically developing children (pp.132-133). One finding that suggests this difference is the results when testing where the children placed stressed and unstressed syllables 12. According to their results participants in the control group showed increased jaw displacement and marked stressed syllables longer than the DS group. The CP group had lower jaw displacement and their stressed syllables lasted longer than the control group (p. 130). The movement of the jaw and length of syllables can help determine the needs of children with muscle tone abnormities who also exhibit speech impediments. Parental role in language acquisition When families are given a diagnoses like CP there is a variety of emotions that surface in many cases a diagnoses of CP can lead to parental depression. Parental depression can greatly affect a child s development in their study Paulson, Keefe, & Leiferman (2008) discuss how a child s language development can be affected by either paternal or maternal depression. One of their main points was parental child interaction. Regardless of the cause of depression parents 11 Hypotonia (Hypotonic)- having deficient tone or tension http://www.merriamwebster.com/dictionary/hypotonic 12 Stressed syllables are pronounced slightly louder, for a slightly longer duration, and at a slightly higher pitch than unstressed syllables. http://www.writingrhymeandmeter.com/?page_id=1787

display of affection is disrupted and parents tend to search for others to care for their child in order to avoid contact (p. 254). This study sought out to measure the correlation between depression and parent-child reading frequency and child s expressive language. Their findings show that depression does affect expressive language acquisition in children. Due to parental depression there is no desire to interact therefore parents wouldn t be reading to their children, according to Paulson, et al. (2008) reading in early childhood has future academic gains (p. 258). A narrative review conducted by Topping, Dekhinet, & Zeedyk (2012) shows how important parent-child interactions are for language development. A lot of the research Topping et al. (2012) looked at supported that parents who spoke, played, and read to their child would result in their children having a higher vocabulary than children who did not receive the same attention. They also found research to support that children of depressed parents would lag behind in their language development. There have been many studies that show that parent participation in language intervention produce higher rates of success in language acquisition for children. Children with speech delays will almost always receive a speech pathologist to work with as soon as the delay is known. For the most part this therapy is given with not much participation from the parent or coaching to the parent, Romski, Sevcik, Adamson, Smith, Cheslock, & Bakeman (2011) set out to identify any change that would occur if parents were part of the speech therapy their children received. Three different interventions were set up two interventions used speech generating devices (SGD) and augmentative and alternative communication (AAC) as part of the intervention and the third used speech to communicate. Parents were allowed to observe the intervention being implemented before the parent implanted the intervention with coaching. At the conclusion of the implementation of each intervention parents related positive feelings about how their children

were communicating. An interesting finding was that the two groups that used AAC and SGD in their intervention felt their child s language deficit was less severe than when they started. Parents participating in the third intervention were only speech was used to communicate felt their child s communication difficulties were more severe than when they started. These results show that parents can play an important role in their child s language acquisition and that AAC along with SGD can assist parents and children in communicating with one another. Even when AAC and SCG are in place to help children communicate with parents and peers there can still be some communication breakdown and a necessity for communication repair skills. A study was conducted by Snell, Chen, Allaire, & Park (2008) to measure how well communication partners can breakdown and repair failed communication attempts. Participants in the study reported that many times when the initial communication is not understood they take various steps to understanding the message. Many times parents would just guess what their child is trying to communicate; this is not always the best method if it takes more than two guesses. Snell et al. (2008) found that when communication partners understand the child s personalized or idiosyncratic communication there is a higher change that the message is understood (p. 33). This study supports the importance to have interventions not only for the child but also for the parent and all individuals working with the child. It Takes Two to Talk There are also programs in which parents can take a conscious role in helping their children develop their language skills, in particular It Takes Two to Talk (ITTT) 13 a program built to help parents, children, and in some cases speech therapists communicate better with each 13 Part of the Hanen Programs http://www.hanen.org/home.aspx

other in order to assist the child in language acquisition. This program has been the topic of discussion in various studies (Pennington, Thomson, James, Martin, & McNally, 2009; Pennington & Noble, 2009; Pennington & Thomson, 2007). The main role of the parent in assisting their child to acquire language according to Pennington et al, (2009) is or the parent to initiate language less in hopes that the child would initiate language (p. 1131). After ITTT was implemented researches noted that mothers did initiated language less and children were initiating and exerting more control in interaction (p.1131). Researchers also believed it was important to receive input from parents on how ITTT was impacting their families (Pennington & Noble, 2009). Many parents believe that after using ITTT was an effective way to assist children with language delays who also had motor delays (p. 293). Pennington & Thomson (2007) asked speech therapists to relay their thoughts with implementing ITTT and its effectiveness for child and parent. Depending on the child s motor abilities it is not always the child who benefits the most out of ITTT but the parents. Parents learn to change their style of conversation in order to make it easier for their child to participate in conversation. It also teachers parents to become more aware of their child s communication cues. Augmentative and Alternative Communication (AAC) AAC are forms of communication other than oral speech that individuals with language delays can use in order to communicate efficiently. AAC is not meant to take over spoken language for those who are capable to produce verbal output; AAC can be used to enhance communication. Many children with motor delays can use AAC to better communicate with others, Ko, McConachie, & Jolleff (1998) provide two forms of AAC that can assist in communication low technology and high technology systems (p 199). Low technology systems include body language, schedule boards, and pictures; high technology systems include speech

generating devices (SGD), software, and computers. The study showed results of speech improvement for both low and high technology systems when they were provided early in the child s diagnosis. It is important to know what the long-term outcomes are for children who use AAC. Lund & Light (2006) evaluated the long term outcomes of young men who had used AAC from a young age. All the participants had some sort of mobile disability and had speech delays. This study found that for the individuals that had parental support were part of inclusive classrooms and had continued support with AAC had higher scores in receptive and expressive language and had a higher quality of life. This study shows how parental participation and the right interventions can lead a child who has motor delays and speech delays caused by CP to live a functional life. Another study that supports these results is a study done by Erickson, Koppenhaver, Yoder, & Nance (1997) they followed a young boys literacy learning process from fourth to fifth grade. This child went from having minimal communication abilities to using a Dynavox a SGD to communicating at home and at school. Results from this study show that parental support along with an inclusive classroom and curriculum, teachers that were well informed on how to assist the child in his learning process had a high impact on language acquisition (p. 149). Another form of AAC that children with CP can use to communicate with others is eye pointing/eye gaze. Eye pointing can be used with technology or without technology, devices like the Dynavox is a system that can be used with eye pointing. Instead of the child choosing an option with their finger they would use their gaze to select a phrase or photo to let their want/need known. Children can also use eye pointing when trying to communicate without a technological device (Sargent, Clarke, Price, Griffiths, & Swettenham 2013). In order for eye

pointing to work the communication partner must be aware of the child s gaze and cues. Sargent et al. 2013 give a great example on how eye pointing can be an effective way of communicating; it is a sequence of events where the communication partner provides the speech while the child guides the communication (p. 479). Conclusion It is possible to build a curriculum with children with disabilities like CP that indirectly affect a child s language abilities. One step that could be taken after reading these articles is to take assessments used and theories used to teach typically developing children and rework them in order to fit the needs of children with disabilities. We would be removing obstacles presented due to a child s physical and /or cognitive delay. This would allow for teachers and therapists to assess specific development like language acquisition or ToM. It would also be wise to take into consideration a child s developmental age into consideration and not rely so much on what is assumed a child s abilities should be by solely looking at a child s chronological age. Hustad, Gorton, & Lee (2010) came up with speech classifications for children with CP that would lead to better supporting their needs and providing adequate interventions. It is very important to take each child as an individual in their current development in order to formulate an intervention that will fit their abilities and needs. Parent participation is important in language acquisition; from the articles one could argue that is even more important for parents with children that have language delays to be active in their child s learning interventions/lesson plans. Learning programs like ITTT or a parent intervention like the one presented by Romski et al. (2011) can be of assistance for parents and children. It is important that everyone working with a child with CP be well informed of the

child s type of CP and if present the type of language delay they have. Knowing a child s present level of development is important in deciding was interventions would benefit the child. Further research is needed for the effects interventions have for children who are diagnosed before their first birthday. The earlier children receive intervention the higher their chances are of living a well-integrated life in society. The studies used in this literature review had participants who were already in preschool. It is important to know what methods can be used with children between the ages of 0-3 for language acquisition.

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