Friday, March 29, 2013

Cerebral Palsy (CP)

Waht is Cerebral palsy (CP)?
CP it’s a term that refers to a group of problems with movement that result from abnormalities in brain development or brain damage in the first year of life. Very important feature of the condition is that it is not progressive, meaning that conditions where the brain damage continues to get worse are not included under CP. However, as all parents and professionals who treat CP know, the movement problems suffered by the child certainly change with time, growth and development. Problems with movement are the feature of CP. In addition these children often have other problems, including intellectual disability (from mild to very severe) and problems with sensation (including vision etc). It is believed that CP affects about one in every 500 live births.

When parents are first told that their child has CP, one of their first concerns is understanding how the CP will evolve in the future – its severity, how bad things will become, and particularly whether their child will ever walk. Unfortunately, health professionals have very limited information to base answers upon for any individual child. The course of CP is highly individual and variable.

Types of Cerebral Palsy

Spastic Cerebral Palsy

Spastic cerebral palsy is the most common type of cerebral palsy and accounts for approximately half of all cerebral palsy cases. It is characterized by stiff, contracted muscles and sometimes, by paralysis. Patient has stiff, jerky movements and often difficulty letting go of something in his hand.

There are five types of spastic cerebral palsy:

Diplegia : affects both arms or both legs
Hemiplegia : affects limbs on one side of the body
Quadriplegia : affects all limbs
Monoplegia : affects only one limb. It is very rare.
Triplegia : affects three limbs. It is very rare.

Ataxic Cerebral Palsy

Ataxic cerebral palsy occurs when the muscles are too weak. Patient appiers shaky and unsteady. Approximately 10 percent of cerebral palsy sufferers have ataxic cerebral palsy. The birth injury ataxic cerebral palsy affects balance, coordination, and depth perception. Afected typically walks unsteadily, has poor coordination, and difficulty honing fine motor skills.

Athetoid Cerebral Palsy

Athetoid cerebral palsy occurs when the muscles fluctuate between being too tight and too weak. Patient has involuntary movement in the face and arms, and difficulty holding them in an upright position. Some afected also experience speech problems, drooling, and other difficulty in controlling the facial muscles. Approximately 20 percent of all cerebral palsy sufferers have athetoid cerebral palsy.

If the child's athetoid cerebral palsy was caused by a birth mistake, it may be a cerebral palsy case.

Mixed Cerebral Palsy

Mixed cerebral palsy occurs when the muscles are affected in a combination of any of the types listed above. Approximately 20 percent of all cerebral palsy sufferers have mixed cerebral palsy.

Wednesday, March 20, 2013

Apraxia Treatment

Children Apraxia of Speech (CAS) is a disorder of speech coordination, not strength.

Child with Children Apraxia of Speech (CAS) presents with:

Poor self-monitoring,
Poor imitative skills for articulation,
Many voicing errors.

Resurge proves that:

Child with CAS should receive frequent (3-5 x per week) and intensive treatment.
Child with CAS should be seen alone for treatment.
As the child improves, he may receive treatment less often and be seen in group.
Child with CAS should practice speech often.
Child with CAS needs a supportive environment to feel successful with communication.

The focus of intervention for CAS is on improving the planning, sequencing, and coordination of muscle movements for speech production. Isolated exercises designed to "strengthen" the oral muscles will not help with speech. To improve speech, the child must practice speech. Feedback from a number of senses, such as tactile "touch" cues and visual cues (e.g., watching him/herself in the mirror) as well as auditory feedback, is often helpful. Some kids can benefit from using sign language or Augmentative Alternative Communication system, e.g., a portable computer that writes and/or produces speech. Check my posts about AAC devices

http://slpzone.blogspot.com/2013/10/webinars-to-learn-about-augmentative.html

http://slpzone.blogspot.com/2013/10/list-of-augmentative-and-alternative.html

Once speech production is improved, the need for these systems may lessen, but it can be used to support speech or move the child more quickly to higher levels of language complexity. With this multi-sensory feedback, the child can more readily repeat syllables, words, sentences and longer utterances to improve muscle coordination and sequencing for speech. Practice at home is very important. One of the most important things for the family to remember is that treatment of apraxia of speech takes time and commitment.

REMEMBER TO

Speak up, Talk big, Say it loud and Practice often.

USE rhythmic, melodic, and visually marked syllable presentation.

To improve awareness of oral mechanism :

Use a mirror for visual feedback.
Teach appropriate speech movements using verbal and visual cues, e.g. “Press your lips together”.
Engage in imitation game, “You are a mirror”.
Exaggerate oral and facial postures (first without and after with voicing element).
Use: dry / wet / chewy / liquids, worm / cold snacks, tooth brush, tongue depressor, straws, dental floss, chewy toys, blow toys, bubbles, musical instruments, cold/hot objects/food (i.e. gum, noodles, metal spoon, lotion, own fingers, string).

Work on sounds:

1. Imitating sounds [i.e. bye / baa-baa / peep / bee / oops!].

2. Old/familiar not new words (i.e. go, up, eat).

3. Two syllable words:

The some syllable words (i.e. mama, dada, night-night, bye-bye, oh-oh, ooh-ooh).
Different syllable presentation.

4. Work on phonological skills:

Use the sound a child has already in his repertoire.
Add new sounds:

1. V - vowels

· V-V identical vowels (i.e. /a-a-a/, /e-e-e/, /i-i-i/, /o-o-o/, /u-u-u/)

· V-V different vowels (i.e. /a-i-a-i/, /a-o-a-o/, /a-u-a-u/)

2. C – labial visually marked consonants /b/, /p/, /m/ + V

· CV-CV identical syllables (i.e. /ba-ba/, /be-be/, /bi-bi/)

· CV-CV different vowels (i.e. /ba-be/, /be-bi/, /bo-bu/, /be-ba/, /bi- be/, /be-bo/, /be-bu/, /ba-bi/, /ba-bo/, /ba-bu/)

· CV-CV different consonant (i.e. /ba-ma/, /ba-pa/, / ma-ba/, /mapa/)

· CV-CV different consonant and vowels (i.e. /ba-mi/, /pa-bi/, /be-mi/).

3. C – other less visually marked consonants /t/, /d/, /k/, /g/, /h/ + V.

5. Use phrases to repeat.

6. Use sentences to repeat.

List of words to work on

P Pal, Pam, pan, pat, peg, pen, pet, pie, pig, pill, pin, pit, pod, pop, pot, pup pony,	M Mad, make/ made, man, mat, many, map, mat, men, met, mom, moon, mop, mud, mug, my, music	K Key, kiss, kick, kid/kids, king, kiss, kit, kite, kitten, kitty	T Tag, tail, tall, tan, tap, tape, Ted, ten, tin, tip, top, two, tub	H Hair, ham, hand, hat, has, have, hay, head, hen, he, her, hill, hip, hit, hoe, hop, hot, hug, hum, hut, house, happy
B Bag, bag, bank, bang, bat, ball, bee, Ben, bet, bib, bid, bin, box, boy, bad, bug, bun, bus, but	N Nail, nap, net, nest, nose, not, nut	G Gag, gas, gate, get, gift, goat, gone, goody, gum, gut	D Dad, dam, day, dell, desk, dig, dip, dock, dog, dot, down, duck	L Lake, lamp, lap, left, leg, like, lip, lion, lock, log, long

To learn more about CAS read my post

http://slpzone.blogspot.com/2013/03/childhood-apraxia-of-speech-casis-also.html

Tuesday, March 19, 2013

Childhood Apraxia of Speech (CAS)

Childhood Apraxia of Speech (CAS) is also known as Developmental Verbal Dyspraxia (DVD) or Developmental Apraxia of Speech (DAS.) CAS is a motor speech disorder. There is something in the child's brain that is not allowing messages to get to the mouth muscles to produce speech correctly, therefore CAS is not a muscle but cognitive disorder (although it may have some impact on language as well as speech). The problem occurs when the brain sends muscles an information what to do. Somehow that message gets jumbled. Visually explaining it is almost like trying to watch a cable TV station without a right decoder. There is nothing wrong with the TV station and nor with the set. It is just that the set can't read the signal that the station is sending out. The child's language-learning task is to figure out how to unscramble the mixed message but the child is not able to do it.

Visible symptoms of Childhood Apraxia of Speech

A child presents little or no babbling in infancy and has just few consonants in the repertoire.
A child’s understanding of a language is much better than production.
A child’s speech is slow, effortful, or halting. Sometimes a child seems to struggle.
A child is very hard to be understood.
A child may make slow progress in therapy.

Childhood Apraxia of Speech has much more effect on volitional, voluntary, creative speech than on automatic speech. This means that the more the child wants to communicate a particular message, the harder it becomes! So, if you happen to hear him saying something once when there is no pressure, and than you say, "Say it again!", you can be guaranteed that he won't be able to repeat it again. It is essential to put as minimum communication pressure on a child as possible. Low-pressure verbal activities are the most important thing parents can do to help. These will include: songs, especially repetitive one, finger-plays, poems, verbal routines, repetitive books and daily routines, e.g. social greetings, prayers.

You can make other activities into verbal routines: make up little sayings or poems that you say every time you do the same thing, label instead of counting objects in counting books, e.g. Two cars: car, car, dog, verbalize repetitive activities, e.g. while setting a table, cup, cup, cup, bowl, bowl, bowl, plate, plate, plate, fork, fork, fork, and so on. Don't make a big fuss about whether or not your child is talking or singing along; just provide a supportive environment for him to do so. Never say: You can't have it unless you say it first. That would be a torture for a child.

In a case when a child is not able to communicate effectively use sign language or a communication board. It will decrease child’s frustration and help with speech development. Dyspraxia may affect other motor functions, such as fine motor control, gross motor planning and further language functions like learning grammatical words, e.g. the, is, or, more complex grammatical forms like passive, spelling, putting words together into a sentence or sentences together into a paragraph.

Occupational therapy, physical therapy, and learning disabilities assistance are often helpful for children with Childhood Apraxia of Speech. CAS can be a very frustrating disorder at times. It is common for children with apraxia to make a good progress for a little while, then none, then more, etc. The therapy is helping, even if we can’t see the effects immediately.

To learn more about CAS read my post

http://slpzone.blogspot.com/2013/03/apraxia-treatment.html

Check my posts about AAC devices

http://slpzone.blogspot.com/2013/10/webinars-to-learn-about-augmentative.html

http://slpzone.blogspot.com/2013/10/list-of-augmentative-and-alternative.html

References:

Stackhouse, J. (1992), Developmental verbal dyspraxia: A longitudinal case study, Cambridge, MA: Blackwell Publishers.

Caruso, A. and Strand, E. (1999), Clinical management of motor speech disorders in children, New York: Thieme.

Crary, M. (1993), Developmental motor speech disorders, San Diego Singular.

Hall, P., Jordan, J., and Robin, D. (1993). Developmental apraxia of speech, Austin, TX: Pro-Ed.

Velleman, S.L. and Strand, K. (1994), Developmental verbal dyspraxia. In J. E. Bernthal and N. W. Bankson (Eds.), Child phonology: Characteristics, assessment, and intervention with special populations, New York: Thieme.

Velleman, S. L. (2002). Childhood apraxia of speech resource guide, San Diego: Singular.

The Childhood Apraxia of Speech Association of North America (CASANA) http://www.apraxia-kids.org/

Sunday, March 10, 2013

Selective Mutism Treatment

A friend of mine, a kindergarten teacher, asked me for some suggestions how to approach a student with a selective mutism.

First of all we have to know that Selective Mutism, known also as elective mutism, usually happens during childhood, often before a child is 5 years old. A kid with selective mutism can speak but chooses not to speak in certain situations. Failure to speak is not due to a lack of knowledge or comfort with the spoken language, also not due to a communication disorder (e.g., stuttering) but, due to an anxiety, social phobia, excessive shyness, fear of social embarrassment, social isolation and withdrawal.

Selective mutism is described in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR: pp.125-127).

A silent child after being diagnosed with a selective mutism should be seen and treated simultaneously by professionals: speech-language pathologist (SLP), psychologist or psychiatrist along with teachers and the family members.

It is important to gather all background history, a health report, hearing screening, oral-motor examination, educational review, parent/caregiver interview and a speech and language evaluation. Based on that knowledge we must individualize the best for the child treatment. A treatment, which might apply a combination of different strategies.

In Stimulus Fading Technique you involve the child in a relaxed situation with someone they talk to freely, and then very gradually introduce a new person into the room.

In Shaping Technique you use a structured approach to reinforce all efforts by the child to communicate, (e.g., gestures, mouthing or whispering) until audible speech is achieved.

In Self-Modeling Technique you let the child to watch videotapes of himself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry over this behavior into the classroom or setting where mutism occurs. In addition the child can learn from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.

In Contingency combined with Stimulus Fading Strategy the desired behavior (e.g. speaking out loud) is elicited with a stimulus or prompt; then, the prompt is gradually faded by decreasing the number of prompts, eventually to zero.

In Behavior Shaping Technique combined with Positive Reinforcement the child is rewarded every time he exhibits behavior that is closer and closer to the desired behavior (e.g. speaking out loud). Positive Reinforces can be a token economy or reward system, e.g. a favorite book for perfect attendance at school, a movie for attending social events.

In Systematic Desensitization the child re-learns how not to be upset or anxious. Instead of feeling uncomfortable in a social situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.

Extinction: The undesired behavior (refusing to speak, hiding, refusing to go to school) is ignored, and the lack of attention to the behavior causes the behavior to cease.

In In-vitro Graded Exposure the child imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.

In In-vivo Exposure the situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful, as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.

Aversive Interventions such as forcing the child to speak out loud generally does not encourage the behavior to occur more often.

In Social Problem-Solving Strategy the child is encouraged to view the social interaction that causes anxiety as a problem to be solved; this technique can be especially helpful when combined with the use of positive reinforces and fading of prompts.

Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's self-esteem.

The main Speech Language Pathologist’s role will be to target the problems that make the mute behavior worse. He will try to correct any communication disorders, exercise the voice to make it stronger and use role-play activities to help the child to gain confidence speaking to different listeners in a variety of settings. The SLP may create a behavioral treatment program focused on specific speech and language problems, and/or work in the child's classroom with teachers.

The main teacher’s role will be to encourage communication, first using non-verbal methods (e.g., signals or cards) and gradually adding goals that lead to speech. The teacher will form small, cooperative groups that are less intimidating to the child, gradually increasing number of the members.

The main parents’ role will be to support and cooperate with the team.