Fran Redstone, Ph.D., CCC-SLP, C/NDT
Editor of Effective SLP Interventions for Children with Cerebral Palsy: NDT/Traditional/Eclectic
Is it reasonable to expect a child with shallow breathing, open-mouth posture, and a tongue thrust, whose body is fixed in extension, to manipulate toys or interact with peers in a stimulating home or school environment? Of course the answer is “no.” It is an exercise in frustration for the child and in futility for the child’s unprepared speech-language pathologist (SLP). I know this because I’ve been there.
When I am asked why I, as a speech pathologist (SLP), should “handle” the child’s body, I am reminded of a second grade class observation I conducted recently of a child with spastic diplegia. This child was ambulatory and cognitively intact but was in a small class for children with language disorders. He was helped to function within the classroom with a one-to-one aide. The youngster began to demonstrate some negative behaviors stemming from the frustration of not being understood. This had resulted from a loss of stability, which led to poor trunk support, leading to poor oral control. I quietly asked the aide if I could intervene and adjusted the foot support and pelvic positioning. The child sat upright and communicated better immediately.
In addition, over 80% of children with cerebral palsy demonstrate poor oral skills leading to dysphagia (Rogers, Arvedson, Buck, Smart, & Msall, 1994). Without head and trunk alignment coordination between the respiratory movements and the laryngeal movements, they are at risk which is a danger during feeding. While infants are protected during feeding due to their small structures (Wolf and Glass, 1992) and intact reflexes, maturation leads to a decrease of safety due to an increase of pharyngeal space. For physically typical children this is positive since it means an increase of movement options, but for the child with cerebral palsy and swallowing issues, this means a greater risk of poor nutrition and possible aspiration. If the SLP does not address alignment prior to feeding and during feeding, fewer oral movements for mastication and propulsion of food posteriorly will occur and safety during swallowing may be compromised.
Although speech and feeding are two different functions, both require integration of movements among several systems: respiratory, phonatory, and articulatory (Mysak, 1976). Without stability and alignment fast, coordinated movements among and within systems are not possible (Seilel, King, & Drumright, 2005). Children with cerebral palsy cannot always attain stability and alignment by themselves. It is up to the SLP to have the knowledge and skills to help young clients to function and participate in communicative activities typical for their peers. Neurodevelopmental Treatment (NDT) is one approach that acknowledges all of this and trains therapists, OTs, PTs, and SLPs in the skills to provide improved motor skills: gross, fine, and oral, to children with cerebral palsy (Howle, 2002). For the SLP, the goals of these improved motor skills are to benefit speech, AAC, and feeding. These are all within the scope of practice for the SLP and are important skills for active participation in peer activities. Graduate school prepares speech practitioners for dealing with the communication disorders of physically typical children, but this preparation seldom equips them to treat children with cerebral palsy who have motor impairments central to their speech/language/feeding disorder.
Nothing fully prepares a therapist for the child described in the first paragraph. Graduate training, continuing education, the reading of appropriate texts and journals, along with NDT, allowed me to problem solve and provide speech and feeding therapy to this child. Within a short period of time (6 months) the child was upright, eating solid food, vocalizing, beginning AAC, and enjoying interaction with peers in a classroom. Addressing stability and alignment, while working within the context of specific functions (speech, feeding, interaction, and communication) allowed the greatest participation in age-appropriate activities. Equally important was the inclusion of parent training in the program.
It has long been acknowledged that carry-over is difficult. This is often the primary purpose of homework. SLPs working on a team treating children with cerebral palsy and communication or feeding disorders need to address carry-over through parent and school staff training. For example, the SLP can suggest the appropriate positioning along with vocabulary that can be easily used by the child, either through AAC or through oral communication. SLPs should also suggest ways for this vocabulary to be used throughout the day. The important concept here is to make it easy for the child to communicate. Another example may entail the SLP suggesting the appropriate positions, foods, and procedures for the parent or school staff to use during feeding. The most critical concept here is safety as well as the ease and enjoyment of nutritional intake for the child.
What has just been described is a two-pronged approach to therapy for a child with cerebral palsy. The therapist must be more than a coach. SLPs should use all of their training to push the child to the next level of functioning. Once the child reaches a higher level, the therapist should be prepared to suggest how these functional skills can be practiced and used in other settings and with other people. The therapist working with a child with cerebral palsy should never work in a vacuum and always work on functional skills.
I am fortunate to have received extensive, special training for working with youngsters with cerebral palsy. I have also researched posture and its influence on the respiration, speech, and AAC usage of this population. More importantly, I have worked as an SLP for more than 40 years and have used all of my skills to help children with cerebral palsy. I feel strongly that knowledge of movement, stability, and alignment are as important for the SLP working with children with cerebral palsy as they are for the other disciplines treating these children. I hope that I have been able to convince you of this as well.
Howle, J. M. (2002). Neurodevelopmental treatment approach: Theoretical foundations and principles of clinical practice. Laguna Beach, CA: NDTA.
Jones-Owens, L. (1991). Prespeech assessment and treatment. In M.B. Langley & L. J. Lombardino (Eds.), Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction (pp. 49-80). Austin, TX: PRO-ED.
Mysak, E. D. (1976). Pathologies of speech systems. Baltimore, MD: Williams & Wilkins Company.
Rogers, B., Arvedson, J., Buck, G., Smart, P., & Msall, M. (1994). Characteristics of dysphagia in children with cerebral palsy. Dysphagia, 9, 60-73.
Seikel, J. A., King, D. W., & Drumwright, D. G. (2005). Anatomy and physiology for speech, language, and hearing (4th ed.). Clifton Park, NY: Delmar, Cengage.
Wolf, L. S., & Glass, R. P. (1992). Feeding and swallowing disorders in infancy: Assessment and management. Tucson, AZ: Therapy Skill Builders.