Speech and Communication in Cerebral Palsy
Lindsay PENNİNGTON
Children with Cerebral Palsy do not speak, dubbing, face expression, communicate using gestures and body movements. Cerebral palsy (SP) motor disorders, can affect the movements required to generate any type of communication signal. Range of movements intended to be the same, speed, power and accuracy can vary and as a result communication signals can be difficult to understand. Communication development of children, May also be affected by cognitive or sensory impairments that are also common in CP (1). This article, Describe the speech and communication difficulties that children with CP often experience and summarize interventions found to be clinically effective in this child population.
Keywords: Cerebral palsy, speech, communication, dil, kids
- Speech Disorders:
motor speech disorders (dysarthria) any type of CP- spasticity, associated with dyskinetic and ataxic. With this, Little is known about the prevalence of dysarthria in CP. It is more common in dyskinetic CP than spastic forms. (2, 3) and estimates of the overall prevalence of dysarthria in children with CP. %50 We know you're around (2, 4). With this, because speech is not currently measured in CP surveillance records, Exact prevalence figures for the presence and severity of dysarthria are not currently available.
Children with different types of CP share many speech characteristics and it is difficult for clinicians to distinguish between CP types when listening to speech recordings. (5). Perceptual similarities, may result from the developmental nature of the disorders or the presence of mixed disorders. speech production, respiratory, phonation, relies on a few fundamental processes such as resonance and articulation. produce speech breathing, controlled to force inhaled air from the lungs through the vocal cords into the oral and nasal cavities. in the throat, vocal cords air pressure (aerodynamic energy) vibrates to rotate, vibrations into sound in a process known as phonation. (acoustic energy) turns into. The resonance of the vocal tract is determined by its shape and the chin, soft palate, replaced by movements of the lips and tongue. For example, if the nasal cavity is not closed during speech, nasal resonance is produced and speech sounds are nasalized. articulation, jaw that further shapes acoustic energy to form vowels and consonants, refers to the movements of the tongue and lips. Researchers and clinicians, describing the components of speech production, rhythm of connected speech, they also talk about prosody, which refers to patterns of stress and intonation. Prosody, pitch, which is dependent on respiratory and laryngeal control, respectively, created by changes in syllable duration and loudness.
Speech movements are rapid and require considerable coordination and control. Dysarthria usually affects all processes in children with CP. – respiratory, phonation, resonance, articulation and prosody. Children may have trouble controlling their breathing for speech. They can breathe shallowly and speak with short bursts of air, which can make them mute, especially on long phrases (6). Children may also have trouble coordinating exhalation with phonation.. They can breathe and begin to speak when a significant part of their breath is exhaled.. This can cause them to gasp and no longer speak to the air. The vibration of the vocal cords may be slow or irregular, this is low pitch, can produce monotonous and faint sounds (7). Children's voices may sound harsh or change rapidly at the moment of speaking. Decreased control of the soft palate can cause speech sounds to come out of the nose, and decreased control of the tongue and lip muscles, is evident from the reduction of consonants and vowels that can be produced in speech (8-11). Difficulties controlling the vocal tract, with a slight ambiguity of speech in words and expressions, unable to produce any intelligible speech, but can vary profoundly. Children with CP and communication difficulties are at risk of lower quality of life and lower participation (12-14). The purpose of speech and language therapy, helping children communicate effectively and independently in all situations, thus increasing their access to education and social life.. Speech for children with severe or profound disorders, may not be effective as the main means of communication and alternative and augmentative communication to enable children to express themselves and their ideas clearly (AAC) systems should be applied. For children with less severe disorders, therapy may serve to improve speech intelligibility.
- speech intervention:
Studies, emme, demonstrated the differential motor control required to produce chewing and speaking movements (15). Motor learning theory also tells us that motor learning is task specific. (16). Because, therapy to improve speech production, focuses on speech rather than verbal exercises that use the same body structures. Dysarthria, It affects all processes related to speech production, from respiration to articulation., therapy needs to address each of these processes. Clinicians and researchers, recommends that intervention focus on controlling respiratory effort and coordinating exhalation and phonation, because these processes support the production of a robust acoustic signal (3,17,18). Articulation therapy, only recommended when other aspects of speech production are addressed/affected, because it is uncertain “production of speech sounds (is the most common perceptual feature of dysarthria) it is not just a question of verbal articulation and is often the result, laryngeal, velofaringeal, treatment of respiratory and oral articulatory problems” (18). Like this, development of respiratory control for speech, more precise articulation and improved intelligibility by increasing background effort and slowing speech rate (3,18,19).
Therapy to increase respiratory effort and coordination of exhalation and phonation, clear sound reproduction, begins with the production of isolated vowels and moves into words and sentences so children can practice controlling their voice in functional speech.
Children are taught to provide adequate breathing support for words or phrases and to breathe at appropriate points in sentences. For some kids it's, can be between each sentence in a sentence: “Adam” “feeding” “dog”. other children, “man feeding” “dog” can produce longer words between breaths. Therapy is also curtain for prosody., may include modulating loudness and timing (20, 21). This type of therapy, as it aims to help children learn new motor behaviors, must follow motor learning principles: therapists, should provide frequent feedback to facilitate the production of the target behavior and then, when the goal is reached, should reduce feedback to aid retention.; Therapy should be given intensively so that children can practice target behaviors frequently.; targets should be chosen randomly in the application, single behaviors must be practiced repeatedly; and children should be informed about the consequences (22-25). Therapy focusing on breathing support and sound production following the motor learning principles above, associated with changes in ICF levels of body function and activity. Increase in lung volume and greater muscle effort after treatment (26) has been observed. Decreased pitch fluctuations in children's voices and increased volume
changes have also been observed (27, 28).
With this, clinically more important, is the change in children's speech understanding. For a group of children with mild to severe disorders, An average of 15% increases in intelligibility were observed after treatment..
For some children with more severe disorders, this, meant a doubling of the number of intelligible words in one word and connected speech (21). The above studies, speech and understanding in clinical settings, which focuses on clear voice production
shows that it is effective in changing. It is now important to explore whether the Intervention has a positive impact on children's participation in social and educational activities and facilitates daily interaction. (29). Following or in conjunction with therapy to maintain breath support and increase control of exhalation and phonation coordination, intervention can also address nasality and articulation. There is behavioral therapy for nasality, described in therapy textbooks and includes motor exercises to elevate the soft palate and close the nasal cavities (19). With this, there is currently insufficient evidence to rate the effectiveness of this type of intervention (30). Palatal lifts (acrylic prosthetic orthodontic appliances extending from hard to soft palate to close the velopharynx) Recommended for some people with CP (30), but not widely applied.
Therapy to improve articulation, may include slowing the rate of speech, which allows children time to make precise movements for speech sound production (19). slower speed, may be an additional therapy focus targeting breath support and sound and have an overall effect on articulation. However, The effects of speed change were not specifically addressed for children with CP.. Therapy may also address the production of individual speech sounds.. Some children can make sounds in some, but not all, of the words. For example, 'd' at the end of a word’ they can produce, but 'd' at the beginning of words’ instead of 'g’ they may say. In these cases therapy, ‘d ve ’g’ Can focus on producing antonyms that begin with; e.g. 'passage'’ and 'history'. kids sound a target (usually a consonant) if he can't get it out, therapy with visual feedback, can help them learn to move their lips and tongue to produce the target sound or an approximation of it.
Elektroplatografi (EPG), In a child with CP (31) successfully tried, but not widely evaluated for this group. EPG, involves attaching a removable acrylic plate over the hard palate. There are electrodes embedded in the plate. When the tongue touches the electrodes, shows a visual screen where the contact was made. Bite blocks, which are small blocks held between the upper and lower teeth to stabilize the jaw, It has also been used to help children learn to move their tongues independently of the jaw to produce speech sounds. (32).
Increased intelligibility associated with therapy, may help children communicate by speaking only, or may mean they need to use AAC systems less often to increase verbal communication. In any of these cases, children can become faster in communication exchanges and interaction can proceed more smoothly.
- Communication:
Communication, depends on sending and receiving messages between at least two people. communication signals speech, dubbing, face expression, can be sent using gestures and whole body movements. Each of these communication modes, underlying motion range, strength, as it can vary in speed and precision, May be affected by motor disorders of CP.
In conclusion, verbal and nonverbal signals, their communication with their partner may be difficult to understand. Because CP is often caused by very early damage to the developing nervous system,, communication difficulties may be evident from infancy and there may never be a time in the child's life where communication follows the usual pattern of development. Early interaction between parents and infants without motor impairments is positively reinforcing. Non-disabled babies, generates communication signals that their parents can interpret, and then parents, responds as the child predicts. For example, a pre-speech baby looks at a toy, reaches out to him and makes a sound. Parent, will watch the child associate their attention with the object and when they see that the child is physically unable to obtain the object and is given to the child. So the children will get the object they want and the parents will be satisfied that they behaved appropriately.(33). Children with motor impairments may also try to reach for an object and make a sound.. However, due to primitive reflexes, they may not be able to reach and look at an object at the same time.. Moreover, may not be able to coordinate the timing of their movements to reach and vocalize at the same time. Therefore, communication signals can be difficult for parents to interpret and they may give the child a different toy.. In such a situation, the child will likely not appear satisfied and communication will not satisfy neither the child nor the parents.(34).
Parents and parents to address their children's difficulties and ensure that the interaction is completed smoothly., can successfully manipulate interaction so that their children have opportunities to generate understandable communication signals. With this, for many children with severe motor impairment, understandable signals 'yes', 'No’ and may be limited to requesting objects or activities within sight. As a result of this, parents are limited to asking children closed questions or asking questions that require children to point to a nearby object. For example, Pick up a video and then a toy car and say, 'Do you want the video?? or car?’ Children who vary widely in age and severity of motor impairment Limited speech patterns in which parents choose topics and ask questions to which children give simple answers, limited information observed (35,36). In addition to the difficulties in controlling the communication movements of children with CP,, cognitive impairments that will affect all processing of spoken language and further delay meaningful communication development, delayed language development and sensory disorders (1) it could be.
- Communication Intervention:
Purpose of communication therapy for children, to be active and independent Communicators in all their daily settings. To do this, they need to develop as complete a range of communication skills as possible and have an understandable means of expressing all their needs and ideas. Children without disabilities usually acquire most of the skills they need to converse by the age of two and a half. (37).
Initiating about half of all exchanges with their parents, they take an equal role in the interaction and can negotiate the breakdown of communication. They use communication for the following purposes:
- demand attention
- Requesting objects or actions
- request information
- Demanding clarification of what a speaker is saying when they do not hear or understand
- give information / comment • Clarify when they are not understood by repeating or revising their words
- 'Yes’ and ‘no’ give the signal
- Express their personality, eg humor,
in early childhood, speech and language therapy assessment, should include observing the child in everyday settings to observe what skills they regularly use in speaking, and testing the child through play to explore which of the above skills he or she can use if given the opportunity. Children's communication skills such as gestures, it should also be noted how they convey through vocalization or speech (38, 39).
Skills not acquired through testing or observed in ordinary settings, can be taught through modeling and behavioral techniques. For example, children can be taught to make requests by pointing and/or vocalizing to objects. (40,41). However, not all children are expected to acquire all of the above characteristics.
Skills. For example, Some children with intellectual disabilities are able to make only a limited number of simple comments and may not be able to fix the speech by choosing an alternative way of conveying the message.. Skills acquired through testing but not observed in public speaking, can be generalized by changing the communication medium. This, to provide wider communication opportunities for children, especially parents and nursery workers, teachers etc. will include the training of children's speech partners, including. Training for speaking partners, interaction process, covers the importance of allowing children to lead the conversation and lead others to help them become active and independent Communicators, and how to encourage children to use their individual communication skills. Individually for parents and children (42) or parent groups (43) training available.
Education, has been successful in helping parents steer interaction less and be more responsive to their children's communication, and children take more turns in conversation., associated with initiating more exchange of ideas and asking more questions and giving more explanations in interaction (42,43). Educational programs, can be intense and demanding for parents in terms of time and commitment. For example, In the Hanen parent program, Pennington and others (43) researched by, two people to talk (44) must. group, consists of eight sessions over twelve weeks, with each session lasting two to two and a half hours. In addition to group training, Three individual home visits are made for this program to allow therapists to coach parents on techniques learned in group sessions. With this, parents, for continuing to use the strategies learned in the program as their children grow and communication improves, loyalty, It is seen as an acceptable and beneficial investment for the future of their children. (Pennington ve Noble, in print). Most of the communication skills listed in the above items can be used without language.. For example, children can interpret the size of an object with gestures and signal that they don't understand someone by vocalizing and looking mischievous using the falling and rising pitch. However, The scope and complexity of ideas that can be expressed without language can be very limited. Children whose speech is often incomprehensible, may need reinforcement and alternative speech systems.
Communication to Support Their Natural Modes (AAC):
Purpose of AAC, providing children with all the words they need to communicate independently. AAC systems, helpful – where separate communication equipment such as picture table or audio output communication aid is provided – and where no separate equipment is needed, eg sign, splits into two. Supported systems objects, photos, pictures, pictorial symbols, contains letters and words.
Children who need assisted AAC often start with a light technology system, such as a chart or book with symbols or words.. They can also benefit from high-tech systems with audio output.. Now, to generate a single message from a single key, Many high-tech devices are available, ranging from complex devices that can form thousands of words and sentences into sentences.. System selection children's physical, depends on cognitive and sensory skills (45) and it is important that the AAC system is provided in accordance with the developmental level of the child.
AAC systems are often used by parents of children., will be new to their families and teachers, and to the children themselves.. such as early communication therapy, AAC intervention needs to include both children and their speech partners. to children, in their new system they must be taught how to access words and produce words and phrases at appropriate points in speech. To speaking partners, how to involve the system in verbal interaction, how to model its use in speech, should be taught where words/phrases are found in assisted systems and how to add words and phrases to enable children to keep up with their changing vocabulary needs.. Detailed discussion of AAC implementation is beyond the scope of this article but can be found in many excellent textbooks (eagle(46-49).
Moreover, It should also be noted that communication is a highly emotional issue for parents and the introduction of technology to support communication may not always be welcome at first. (Pennington ve Noble, in the press). However, now supports the introduction of AAC and can facilitate conversation rather than hinder the development of AAC. (50, 51) There is a range of evidence suggesting that some parents may fear. Moreover, surveys involving parents and users of AAC systems, suggests that a family-centered intervention model could increase acceptability, with AAC systems provided to meet specific communication needs as expressed by parents and familiar caregivers. It is important to adopt new communication systems so that children can express all their ideas effectively and take a full and active role in all aspects of their lives.(52,53).
- Conclusion
children with CP, has specific but varied communication difficulties that require an individualized approach to intervention.
Difficulties, can range from mild speech impairment to severe difficulty controlling any movement for verbal or nonverbal communication and severe language delay. The aim of all speech and language therapies, help children develop communication skills as fully as possible and express their ideas clearly. Intervention depending on the severity of the children's motor difficulties and other accompanying disorders, teaching individual communication skills, may focus on speech production or providing AAC to support children's natural forms of communication. Since the communication involves at least two people, not only children with CP, but also children with CP, so that children become active and independent Communicators in all of their daily settings., it is also important to include their parents and other frequent communication partners.
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