CONTENTS
CHAPTER 2: TYPES OF CEREBRAL PALSY
CHAPTER 3: DIAGNOSIS AND ASSESSMEN
OF CEREBRAL PALSY
CHAPTER 4: ASSOCIATED PROBLEMS
OF CEREBRAL PALSY
CHAPTER 5:PROBLEMS WITH SPEECH
PRODUCTION, BREATHING,
AND FEEDING
CHAPTER 6: SPEECH IN CEREBRAL PALSY
CHAPTER 7: PHONOLOGY OF CP SPEECH
CHAPTER 8: PARALINGUISTIC SPEECH
CHAPTER 9: WORD IN CEREBRAL PALSY
CHAPTER 10: SPEECH TRAINING FOR
THE CEREBRAL PALSIED
CHAPTER 11: COUNSELLING FOR
THE PARENTS, CAREGIVERS,
AND SOCIETY
We have been studying the language and speech behavior of cerebral palsied children for a number of years. In this book we present an overall view of the verbal communication aspects of cerebral palsied children. We believe that this profile will be useful to parents, caregivers, and students of cerebral palsy, whether they are speech pathologists or therapists, medical and caregiving personnel, or students of linguistics and communication.
The linguistic profile of the cerebral palsied presents a complex picture: it varies from child to child. Hence the generalizations suggested here should be carefully reviewed in relation to the condition of the CP child under observation and speech training.
We are thankful to Mike Leeming who reviewed the book and made many helpful suggestions to improve its language and style.
Shyamala Chengappa
M. S. Thirumalai
Characteristics of CP
Cerebral Palsy encompasses a group of childhood disorders in which motor abilities of the individual are affected. This disability results from damage to the brain of the child while in the mother’s womb, during birth, or during the period immediately after childbirth. Cerebral palsy, therefore, is mainly a childhood group of disorders. But the motor disability caused by damage to the brain continues beyond childhood.
Outwardly, cerebral palsy is manifested by a lack of muscular coordination and other physical disabilities. It is also manifested by speech disturbances. The patient has difficulty of articulation, voicing, sentence melody (sentence intonation), fluency of speech, etc. The patient may also have difficulties with other aspects of language relating to use and choice of words, construction of sentences and production of a series of sentences, etc.
A cerebral palsied child may also have cognitive problems. Though estimates vary, 25% of CP children may have some cognitive problems. Cerebral palsy, in most cases, hinders and/or arrests the normal physical and mental development of the child. The cerebral palsied child, generally speaking, cannot help himself or herself in day to day activities of normal life situations. Because of these reasons, communication with the cerebral palsied child may prove difficult. Cerebral palsy was first described more elaborately by Little in 1862. Phelps coined the term cerebral palsy in 1936. The word cerebral indicates a condition related to the brain; and the word palsy refers to the disease or a condition of weakness, paralysis, or incoordination which causes the hands and the limbs to shake, and to a disturbance of the muscles and joints.
Cause of CP Is Brain Pathology
An individual with cerebral palsy is physically disabled primarily because of faulty or damaged links between the brain and parts of the body. The brain damage results not only in a loss of appropriate muscular control and difficulty in control of movements, but also in sensory disturbances. There is paralysis of the body parts, in addition to weakness, non-coordination, or other malfunctioning of motor abilities, because the damage is caused in the motor control centers of the brain. Cerebral palsy may be caused also by abnormal brain development.
In brief, the cause of cerebral palsy is brain pathology. The brain damage, occurring early in the life of young children, whose nervous system is yet to develop fully, results in cerebral palsy. The major symptom of cerebral palsy is the patient’s difficulty to control and perform motor activities and motor coordination. The disorder causes other important characteristics as well, such as speech and sensory disturbances. It also affects mental development.
Variability of CP
There is great variability in the incidence of cerebral palsy. Some cerebral palsied children present only a very mild manifestation of the disorder. On the other hand, many suffer from the extreme severity of the disorder involving both physical and mental aspects of behavior. Cerebral palsy may be found occurring as a mild loss of fine muscular control or as a severe problem involving head and trunk ability, limbs, hearing, vision, and speech.
Language and Speech in CP
Cerebral palsied children may have difficulty with comprehension and expression of verbal and nonverbal communication. Mental retardation, abnormal speech, arrested language development, disorders in auditory perception, visual perception, distractibility, lack of attention, and hyperactivity also may occur in combination with motor malfunctioning in cerebral palsied children.
Many cerebral palsied children have impaired speech in one form or another. Scholars have estimated that over 70 percent of CP children do have some problem with speech production. CP speech is, indeed, a continuum, from a total lack of speech to almost negligible delay and deviations from normal speech.
However, as a whole it tends to be ‘slow, jerky and irregular, labored or effortful, and rather unintelligible.’ But there are also other characteristics which distinguish CP speech from the speech variety found in other types of disorders. There is a general consensus that the spastic speech is more intelligible than the speech of the other two types of cerebral palsy.
Individualized Developmental Stages
The motor, sensory, and cognitive functions in cerebral palsied children develop in a highly individualized and differentiated fashion. The deficiency noticed in one CP child may not be repeated in another CP child in the same manner. Although the CP child may go through the same developmental stages in language acquisition found in normal children, these stages may be disproportionately prolonged and some of the stages found in normal child may be delayed.
Why Sparse Speech?
While motor disability and speech delay form a major part of the characteristics of CP speech, these alone cannot explain the differences between normal and CP speech. There are perceptual difficulties faced by CP children and these also contribute to distinctive CP speech and communication. It is possible that CP children have some intellectual impairment and this could also contribute to the delay. For one thing, CP children’s linguistic performance is heavily influenced by their emotional anxiety. Also note that CP children could feel thoroughly frustrated because often they are not being understood. Lack of stimulation could be another factor for the apparent speech delay. Yet another factor that contributes to the sparse speech found in many CP children is the treatment they receive. More often than not, parents act overprotective, and treat them as if they were infants. The language to which these are exposed is adjusted to the perceived low level of expressive ability in them. This is a result of the continued infantilization of these children by their parents, other caregivers, and visitors.
There is a need to recognize that in these children there is a dicrepancy between the chronological age and their expressive ability. While the children may be able to comprehend in proportion to the chronological age, they may be able to express themselves through speech only at a level lower then their chronological age. All these pose great problems for the speech therapist in training CP children to communicate better via speech and to enable them to acquire the skills they do not have in their speech.
Classification of CP Children
The physical, mental, and linguistic disabilities noticed in cerebral palsied children occur in various combinations, and in various degrees from the very mild to the very extreme. Also along with the maturity of the child’s nervous system from birth to adolescence, there may be changes taking place in the various characteristics of the disorder. For this reason, classifying cerebral palsy patients into watertight types/categories is neither technically correct nor realistic.
Cerebral palsy is described and identified based on the physiological, topographical, and etiological features of the disorder. In addition, the functional capacity of cerebral palsied children and the nature and duration of therapy required are also considered while classifying cerebral palsied children under various groups.
Physiological classification focuses on the neuro-muscular symptoms of the disorder. It takes into account the type and amount of involuntary motion the patient exhibits: muscular straining, threshold of the reflex, contractures, uncontrolled and non-coordinate motions, varying degrees of tension, involuntary holding of distorted positions, tremor, lack of tone, and failure of muscles, etc.
There are three major and several minor types of cerebral palsy under this classification: Spastics, Athetoids, and Ataxics. Spasticity is characterized by a lower threshold stretch reflex. It is marked by a tendency towards greater involvement of contractures, affecting the antigravity muscles.
In athetosis, there is an abnormal amount of involuntary and controlled non-coordinate motions with varying degrees of tension. Disturbance in the sense of equilibrium and depth perception is noticed in ataxia.
Topographic classification of the cerebral palsied is based on the parts of the body involved in cerebral palsy. The symptoms of cerebral palsy distributed throughout the body are considered here. There are seven types of cerebral palsy under this classification:
Etiological Classification is based on the time of the occurrence of brain damage to the young child. The damage may be caused when the child is in the mother’s womb (prenatal), during birth (paranatal), or during the period immediately after birth (postnatal).
In addition, hereditary and acquired brain lesions are also considered to be a factor. Infections and metabolic diseases such as severe anemia, toxoplasmosis (a disease due to toxoplasma gondii, an intracellular animal parasite, the congenital form of which is marked by the central nervous system lesions), and German measles affecting the mother when the child is in her womb are frequently noticed as causes for damage to the brain of the child.
The processes of birth delivery resulting in cerebral anoxia (lack of oxygen to brain tissues) and subdural hemorrhage (haemorrhage between the duramatter and arachnoid, the two membranous outer covers of the brain and spinal cord, leading to brain damage) are some of the major causes of cerebral palsy during child birth.
Excessive pressure on forceps during delivery processes is often cited as a likely cause in this category. Mechanical injury to the newborn child, circulatory defects, infectious diseases, toxic states (condition pertaining to poisoning by a variety of toxins manifesting symptoms of severe infection and thus causing brain damage), and neoplasms (any new or abnormal growth benign or malignant) are some of the causes for the onset of cerebral palsy during the period immediately after birth.
Note that the etiological classification focuses mostly on the role of external agents in causing cerebral palsy.
The classification based on functional capacity manifested by the cerebral palsied child is as follows:
The classification based on the extent of therapeutic efforts required is as follows:
Evaluation of CP
A cerebral palsied patient needs to be evaluated against all the features identified above so that an adequately comprehensive profile of the patient is obtained.
Often a description of the physical status of the patient, his convulsive seizures, if any, postures, locomotive behavioral and eye-hand coordination patterns are presented. In addition, a description of the patient’s visual and auditory status is also sought. However, a psychological assessment and a linguistic description of the speech and language characteristics are also very essential.
Unfortunately, a linguistic description of the patient’s speech and language behavior is often not even attempted or desired. Sometimes a psychological evaluation of a cerebral palsied patient may be asked for by an attending medical practitioner, but a linguistic description is hardly ever asked for.
While a linguistic description may or may not help the medical practitioner to arrive at a proper assessment of the specific type of CP the child is suffering from, caregivers stand to benefit by the description. They will know what specific sounds, word, and communication characteristics they need to emphasize in speech training while at home. However, it is not well established that different types of cerebral palsy lead to significant differences in speech characteristics. While we may be able to identify some broad characteristics of spastic speech, the very same characteristics may be shared also by the athetoid as well as ataxic speech. This question is discussed further in chapter 6.
A Multidisciplinary Team
A multidisciplinary team of specialists is a must for the diagnosis and assessment of cerebral palsy.
The symptoms of motor dysfunction are generally observed very early by parents and/or the pediatricians in the young infantile stage of the child. This is the beginning of the recognition of the problem which needs to be confirmed either as cerebral palsy or something else, by a team of specialists of several disciplines.
The Physician
The physician seeks a detailed history of injuries that might have been inflicted upon the child when in the mother’s womb, during childbirth and during the period immediately after childbirth. These events may have contributed to or caused the disorder.
The physician may also ask for neurological diagnostic tools such as EEG (electroencephalogram, referring to a recording of electrical potentials of the brain cells, the wave forms of which can well be correlated with different neurologic conditions) and/or CAT scan. Now there are several scanning devices for this purpose which contribute to a better assessment of the lesion and the injury to the human brain.
The Neurologist
The neuromuscular symptoms noticed in the child helps the neurologist-physician to locate the injury and the lesion in the brain which, in its turn, helps in classifying the problem as cerebral palsy. The neuro-muscular movements help the neurologist-physician also to subclassify the type of the problem as the spastic, athetoid or ataxic, etc.
The Speech Pathologist
The speech-language pathologist, audiologist, psychologist, physiotherapist, occupational therapist and otolaryngologist (or an ENT specialist) are the other specialists who assist in diagnosing and subclassifying the problem appropriately. They help also in the process of working out a suitable regimen of therapy procedures for the cerebral palsied child.
Diagnotic Tools
Various diagnostic tools are employed, along with systematic observation, to draw a detailed picture of the child’s current abilities.
The audiologist tests the proficiency in the hearing abilities of the child. The clinical psychologist evaluates the child for his abilities for attention, memory, general emotional ability, perceptual abilities and intelligence for both verbal and nonverbal performance. The clinical psychologist will suggest procedures for decreasing the cerebral palsied child’s behavioral problems like distractibility, and hyperactivity, and will suggest other things to help increase the child’s attention span, etc.
The physiotherapist studies the patient’s posture, stability, and locomotion. He tests the head and trunk efficiency, walking abilities, and comfortable postures. He also prescribes adequate physiotherapy for increasing the child’s balancing ability, postural comfort, and mobility.
The occupational therapist examines the patient’s abilities in performing day to day activities such as receiving feeding, self-care, dressing, and the like. Whatever is appropriate for and expected of the normal age group will be the backdrop for this, as well as other examinations listed above.
The otolaryngologist evaluates the ear, nose, and throat functions, whereas the ophthalmologist evaluates the vision. They prescribe treatments if necessary.
Complexity of Early Childhood Disorders
Many of the early childhood disorders such as cerebral palsy, autism, childhood aphasia, mental retardation, and congenital deafness, etc., occur in a complex form. Each of these disorders is generally accompanied by one or more of the other early childhood disorders and other associated problems. For this reason, cerebral palsy is also usually accompanied by one or more of the other disorders.
These associated problems include epileptic seizures, orthopedic bracing and surgical problems, visual problems, hearing deficits, oral nutritional problems, psychological and behavioral problems including mental retardation, poor self concept, hyperactivity, distractibility, and sensory perceptual problems.
Epileptic seizures are due to excessive neuronal discharge of the cortex which may then spread to involve the entire brain. These seizures are common among the spastic type.
Bracing is used primarily (i) to correct and prevent posture deformities, (ii) to support and reinforce the weak skeletal structures, (iii) to control unwanted competing movements, (iv) to correct and prevent the deformity of excessive contracture, and (v) to keep the extremities in relative extension.
Orthopedic surgical problems may require remedial surgical procedures like muscle (or tendon) lengthening and fusion of a joint when the problems of muscle balance and bone stabilization cannot be treated by physiotherapy and/or bracing.
Visual defect is a commonly observed problem in cerebral palsied children. Various visual defects are noticed, of which hemianopia (absence of vision in one-half of the visual field) in a hemiplegia is striking in its frequency of occurrence.
Hearing defects are also found to be more frequent among the cerebral palsied, and more commonly among athetoid children than among normal children. The hearing deficits in these children are more commonly of an auditory perceptual nature than of auditory acuity (where perception of heard speech is affected rather than actual hearing threshold).
Oral feeding control is a problem in most moderate to severely impaired cerebral palsied children. These children exhibit poor oral control and this leads to problems of food in-take. These children tend to push out the food fed to them. They chew and swallow very little. Therefore, malnutrition is frequently observed in cerebral palsied children. Oral control to enhance oral closure, chewing, swallowing, etc., needs to be cultivated.
Mental Retardation is another associated problem. In- vestigations show that about 25% to 35% of cerebral palsied children are found to have normal to superior intelligence, whereas the rest present an IQ of below normal. The motor deficits, sensory perceptual deficits, and lack of normal emotional experience noticed in cerebral palsied children make it imperative that the tests employed to measure intelligence should not rely on the motor performance of the patient. Reliable tests are, therefore, very difficult to devise. The intellectual capacity of cerebral palsied children is found to vary across assessments. This changing ability of cerebral palsied children thus demands a continuos assessment and reassessment over frequent intervals for a long time.
The CP children have several sensory-perceptual problems. Many cerebral palsied children may have difficulty differentiating between foreground and background. They may have the inability to perceive visual stimuli and translate them into motor activities. They may have difficulty in shifting to abstract forms of behavior and may also have a tendency towards stereotyped responses which can be predicted.
There are several Perception and Coordination Problems as well. Eye-hand coordination, figure-ground perception, perception of form constancy, perception of position in space, and perception of spatial relationships also are problematic in varying degrees to the cerebral palsied. All these, however, are to be tested and correlated with the severity of the disorder.
Many CP children are seen to have poor self-concept. Impaired self-concept is one of the serious problems encountered in many disorders and in many disordered individuals. The cerebral palsied child is no exception. This disordered child is constantly experiencing physical disability and this comes in the way of developing normal interpersonal relationships. Many normal responses like smiling and laughing can be interpreted by the handicapped child as derogatory because of poor self-concept.
A cerebral palsied child may also have the associated problem of hyperactivity.
Distractibility is another characteristic of cerebral palsied children. Distractibility is lack of or poor span of attention towards any one particular stimulus. There is a frequent shifting of attention from one stimulus to the other.
Manipulating the Physiological Mechanism
Breathing, feeding and speech are carried out through the very same physiologic mechanism in us. A normal child is able to manipulate, very soon after birth, the physiological mechanism differentially to meet the needs of breathing, feeding, and speech production.
On the other hand, in the cerebral palsied, the damage caused to the brain does not enable the child to control and regulate the physiological mechanism. Hence, the preparatory exercises for speech production, namely, breathing, sucking, swallowing, biting and chewing, laughing, crying, and coughing, phonation and articulation are all affected in cerebral palsied children.
Lack of these preparatory exercises, and the inadequate and irregular nature of their manifestations inform us that the child has certain basic problems, especially in regard to speech production.
BreathingA normal child, quite early in its infancy, acquires an ability to manipulate its breathing mechanism to suit the demands of speech production. The ability to vocalize and to produce speech sounds depends essentially on breathing patterns.
In the CP child, however, the oral, laryngeal, and pharyngeal muscles may have been affected by brain damage, and, as a consequence, respiratory regulation becomes a problem.
In normal, quiet breathing, inhalation and exhalation alternate. But, for normal speech production, in most human languages, exhalation is generally prolonged in relation to inhalation.
The pattern of rapid inhalation and prolonged exhalation is used in producing speech sounds and their sequences in normal language. This pattern is disturbed in cerebral palsy. It is a great obstacle in restoring normal clarity in the speech of cerebral palsied children.
The cerebral palsied child has several kinds of breathing problems such as irregular cycling of breathing, ribflaring (abnormal and spasmodic expansion of the rib cage while breathing), and a process of reversed breathing (depression of the upper chest during breathing which is normal only in the first few months in a child). These problems are not generally found if the CP child is not talking. Because of these problems, the CP child is unable to produce stretches of sounds found normally in his language. The child has problems with the production of combinations of sounds in a normal fashion in his speech.
FeedingSucking and swallowing are directly related to the production of the distinction between nasal and oral sounds. In sucking, the manipulation of the lips is achieved, which in turn is used for the production of speech sounds. In swallowing, the manipulation of the velum (soft palate) is achieved. By raising the velum, the nasal passage to air and food is closed. By lowering the velum, the air coming from the lungs passes through the nasal passage resulting in the nasal sounds.
As the cerebral palsied child exhibits problems with these two processes, the distinction between nasal and oral sounds is blurred in the child’s speech.
Sucking is a reflex activity in the infant, but soon it comes to be manipulated for communicative purposes. It is the communicative purpose that attracts our attention when we wish to train the cerebral palsied child in proper speech production and discrimination of sounds. The same holds true also for swallowing. In other words, these reflex activities have to be converted into deliberately manipulated activities with adequate automaticity.
Biting and chewing function only as a reflex activity in the infant up to about 10 months. However, manipulation of teeth and tongue connected with biting and chewing are essential for the production of consonants and vowels. Opening and closing of the jaw at will and with ease is highly essential for speech production. Biting and chewing are dependent upon this ability to open and close the jaw. In fact, biting and chewing are processes designed to help the infant practice the opening and closing of the jaw.
When biting and chewing, from their initial involuntary character, are changed into voluntary acts, lips, jaw, and tongue operate with adequate co-ordination to produce speech. Since such a coordination is difficult to achieve for cerebral palsied children, training needs to be initiated for this purpose in these children. These children should be exposed to chewing soft and hard food items in a phased manner.
Laughing, Crying, and CoughingLaughing, crying, and coughing involve vocalization (uttering voice). CP children are known to initiate these acts with some difficulty, showing thereby their difficulty with vocalization. There is tension noticed in CP children in laughing, crying, and coughing.
Laughing, crying, and coughing are not simply physiological acts, nor are they simply acts of speech mechanism. These have a sociolinguistic function for inter-personal communication. That is, these rudimentary physiological acts are transferred to the linguistic and sociolinguistic plane with meaning for communication. Since the earliest phase of physiological operation of these acts is affected, use of these as tools in the linguistic and sociolinguistic plane with meaning for communication is also affected.
Restoring the physiological mechanism and using the same for linguistic and sociolinguistic purposes, however, have to be accomplished as a unified act through training. In our assessment, it is the caregiver’s patient and continuous demonstrative manifestation of laughing that will slowly inculcate in CP children a sociolinguistic sense of its use.
The physical discomfort and the handicap that hampers laughing will have to be overcome only through a demonstrative manifestation of laughing in appropriate situations. While loud laughter may be accomplished in some CP children, we should be more satisfied if these children are able to demonstrate a semblance of laughter and smile in relevant situations.
PhonationIn cerebral palsied children there may be laryngeal dysfunction and this dysfunction will lead to dysfunction in phonation. Phonation is uttering vocal sound. Phonation is producing voice at will and on prompting.
A normal child is able to phonate at least for ten seconds at a stretch. When a CP child begins to phonate, he may do so for a shorter time. In some spasms that the CP child has, the vocal cords may be held so tight that the child can only initiate phonation with great difficulty. In some others the vocal cords are held slightly apart and this results in a breathy voice obstruction. In still other spasms the laryngeal muscles may not be held with proper tension and this may result in pitch variations different from normal speech.
Nasality (commonly described as speaking through the nose) is a speech characteristic often noticed in CP speech. The absence of nasality in voice where it should be present in normal speech, an inability to voluntarily vary the pitch to suit the needs of the context, and an inability to interrupt voice or to sustain it when it is needed are the other phonation features of CP speech.
We suggest the following phonation exercises: Controlled inhalation and prolongation of exhalation for increasingly longer periods of time; controlled inhalation and prolongation of exhalation without voicing; controlled inhalation and prolongation of exhalation with voicing; and phonation of /a/ with exhalation initially. The vowel /a/ can be initially chosen with other vowels following either individually or in combination.
ArticulationArticulation is the production of speech sounds proper. It is in opposition to, but is dependent upon, phonation. If phonation is not properly done, articulation of speech sounds will not have any clarity.
In the articulation of speech sounds, lips, teeth, teeth- ridge, hard and soft palate, uvula, tongue, and jaw are involved. The movements of these may be affected in the CP child.
Lips Severely impaired spastic children may have their lips drawn which gives the impression of an unfading grin (“spastic grin”). In some cases, the lips may be kept in a pursed up position. Both the tongue and lips may move forward every time the child swallows. The ability of the child to smack his lips, to purse and to spread, to raise the lower lip to touch the upper teeth, to round and unround the lips and to leave space deliberately between the lips may be affected in CP children.
Note that the movement and position of the lips in sucking are related in some manner to the movement and position of the same in speech production. The problems that a CP child will encounter in the production of labial sounds (sounds produced with lips) can be anticipated to some extent in sucking behavioral patterns of the child.
Tongue The tongue plays a crucial role in speech production. Different parts of the tongue are used for the production of different speech sounds. The tip of the tongue is used in the production of [t] in English in words such as time and tea. The retroflex sound [T] is used more commonly and frequently in major Indian languages, in words such as Topi ‘cap’, kaTTaDa ‘building’, and taTTe ‘plate’ in Kannada. This sound is produced by curling back the tip of the tongue and by touching the dome of the palate by the tip of the tongue. The sound [k] is produced by the back part of the tongue touching the soft palate, whereas [c] is produced by the middle of the tongue touching the hard palate above. In the production of the [l] sound, the sides of the tongue are kept open but the tip of the tongue is held against the upper teethridge. Many more instances of speech sounds that are produced with the active help and deliberate manipulation of the various parts of the human tongue can be cited.
The tongue is most flexible and most versatile in the pro-duction of speech sounds. Unfortunately, in the CP child, the tongue often does not manifest its versatility. In the CP child, more often than not, the tongue is tied, so to say.
For this reason, an essential step towards restoring speech functions in the CP child is to increase the mobility of the tongue. Some voluntary activities on the part of the CP child may be encouraged, if the child is old enough to cooperate.
These activities include protruding, touching the corners of the mouth with the tongue, curling the tongue, touching the upper lip and lower lip with mouth open, touching the ridge behind the upper and lower teeth, drawing the tongue out and then rapidly withdrawing it in, touching a point in an edible item such as a cake with a pointed tongue for practice of forming and using the tip of the tongue, etc.
Some training needs to be given to dissociate tongue movements from the head and shoulder movements and facial grimaces. Some training needs to be given also to open and close the mouth in conjunction with the raising and lowering of the various parts of the tongue.
One simple way to do this is to give a series of syllables such as [ka], [ca], [Ta], and [pa] for repetition.
Initially, the CP child may have difficulty in pronouncing all these syllables and doing so in the sequence in which these are presented to him. When this difficulty is overcome, the speed with which the syllables are asked to be repeated may be increased. Later on, the sequencing of the syllables also may be altered. Note that in the production of the above syllables, various parts of the tongue are involved.
The movements of the tongue should be more rapid than the movements of the lips and the jaw in normal speech. The tongue moves with far greater precision and speed than the jaw in the articulation of speech sounds. If the tongue has a speed that only matches that of the jaw, the level of intelligibility of the sounds articulated will be affected badly. This often happens in the speech of the CP child. Hence the need for the exercises suggested above.
Jaw Regarding the jaw and its movements in the CP child, the jaw is usually found deviated to the side. This deviation is present even when the child opens his mouth. Moreover, the severely impaired CP child holds the jaw tightly clenched and it becomes very difficult to get him to open the jaw.
Soft palate The CP child may not be able to raise and close off the nasal cavity by using the soft palate when it produces non-nasal sounds such as [k], [t], [p], [s], and [l]. This results in nasality where it should be absent. Clarity of speech is thus affected.
The abnormal nasality in the voice of the CP child is an important indication that the soft palate is not functioning properly. If the child is cooperative, he can be asked to open his mouth widely and make a lengthy [a:] so the action of the soft palate can be observed. We suggest the following exercises to reduce the excessive nasality in the CP child’s speech: Opening the mouth wide while speaking; tipping the head back and phonating /a/ where the soft palate will be approximating the correct position; blowing and sucking exercises.
Possible Timing for Training
Early identification and intervention have always been found beneficial. Such procedures can easily be begun from infancy. Those who have observed the times and manner of the utterances of endearments by mothers and caregivers will agree that mothers and caregivers all tend to combine feeding and the utterance of endearments. They also tend to combine playful caressing and touch with their utterance of endearments. Utterances of endearments from the mothers and caregivers precede the onset of sleep in children. That is, linguistic utterances, mostly of soothing and comforting types, generally precede, co-occur, and follow all “basic” activities in early infancy. The very minimal jaw-opening that a CP child will be tempted to make at the time of feeding is the most suitable time for using the small opening for steps towards language development in the CP child.
The ultimate goal is to make the movements of the jaw, lips, soft palate, and tongue voluntary in the CP child. This child may have some physiological abnormalities in all the above or in some of them, or the child may have no abnormality at all in these organs used for speech, but may have other neurological problems that hamper using these parts voluntarily for speech production.
Some of the physiological abnormalities, for example, abnormalities in the dental structure or even in the jaw, can be surgically treated, and normality in the structure restored. In some other abnormalities such as phonation, intensive training has to be given to bring in some semblance of normal voicing so that the clarity of speech may be restored to some extent. But even in the case where structural normality of the parts is restored, we have to insist on and continue speech training.
Motor Disability
As we pointed out in the last chapter, motor disability in cerebral palsy is a primary symptom and it affects the intelligibility of the CP child’s speech. It affects the voice production for speech, the articulation of speech sounds and their sequences, and the production of appropriate sentence melody in sentences. Thus, ultimately the motor disability in the CP child comes to hinder his oral communication.
However, we must always bear in mind that CP itself has extreme variability in its occurrence in individuals. In a manner of speaking, each cerebral palsied child is unique with his own particular abilities for speech production and comprehension. The specific sounds that are missing in a CP child’s inventory may differ from one CP child to another, as well as from one language environment to another.
In other words, the overall profiles of speech disturbances in CP children as a whole may be worked out for a population, but its use in assessing the specific speech abilities of the CP individual, and training the same individual in speech production and comprehension has several limitations.
The Consonant Profile of CP Speech
Our study of the speech of the cerebral palsied children with Kannada (a language belonging to the Dravidian family of languages, and largely spoken in the state of Karnataka in South India) as their language of environment reveals the following characteristics:
Difficulty with Finer Positioning, and Fine Tuning Manners of Articulation
Note that the sibilants, other fricatives and trills, which require relatively finer positioning and deliberate movements of a rapid and repetitive nature, are not acquired.
In general, the CP child does not show much difficulty in the production of vowels and semivowels. In both these cases, no interruption of the breath coming up from the lungs is attempted with the manipulation of the tongue. Rather, an open mouth is the setting in which these sounds are produced. However, these sounds do require raising and lowering the tongue from its usual lying position in the mouth. In other words, the CP child does not usually have any difficulty in raising or lowering the tongue, as the availability of vowels in abundance in the CP child’s speech reveals.
On the other hand, the CP child has difficulty with manipulating his tongue for finer positions such as those we find in the production of fricatives. We notice that the CP child is able to articulate a greater number of stop consonants than other sounds. These consonants involve a single and total constriction in their production.
In comparison, the retroflex, sibilant and fricative sounds require a finer manipulation of the tongue in the sense that these require maintaining a narrow aperture, and an arduous movement (from the CP child’s point of view).
Note that the nasals and laterals that are found in the speech of the CP child are also produced with single and direct constrictions and do not involve maintaining narrow apertures in the straight path of the air stream from the lungs. In any case, all these sounds (stops, nasals and laterals) are distorted because of neuromuscular disturbance. What is most significant is that in spite of the disturbance and distortion, the stops, nasals, and laterals do occur, whereas the CP child does not produce the sibilants and other fricatives at all.
Generally speaking, the generous occurrence of the stop consonants, the negligible occurrence of non-stop consonants, the absence of sounds for the production of which one requires a finer manipulation or handling of the tongue characterize the consonant profile of a cerebral palsied child.
Comparatively speaking, the stop consonants are produced more accurately. On the other hand, even when the non-stop consonants are produced, most of them sound distorted.
The Vowel Profile of CP Speech
The vowel profile of the CP child is characterized by an excessive discrimination of the sounds, more than what is required in the normal language of the environment. In some CP children, there may be an abnormal neutralization of long and short vowels in some positions of the word. The longer vowels in final positions are very rare, and even when present these are comparatively shorter than the long vowels in the normal speech.
Note that even in imitation tasks, CP children have difficulty producing the non-stop sounds with ease. In any case, the moderate to severely impaired CP child uses only a lesser number of sounds compared with the normal child.
Age Factor in CP Speech
It is likely that, as the CP child grows in age, there may be additions to his inventory of speech sounds. We have noticed that whereas the stop consonants, or at least most of them, are available to the young CP child around 4 or 5 years of age, the non-stop consonants which require finer positioning and turning of the tongue begin to appear later. We have noticed that CP children around 7 years of age exhibit a tendency to acquire some retroflex sounds. They also manifest the use of some fricatives including sibilants.
Generally speaking, all such late occurrences of non-stop consonants present only distorted versions of the sounds produced. Nevertheless, this possibility of emergence of several non-stop consonant sounds at a later age gives us some hope that by an assiduous and patient cultivation we may be able to help the CP child to acquire some other speech sounds as well. Thus, age is a significant factor in CP children for the acquisition of speech sounds.
In our study we have seen that younger children do not have retroflex, sibilant, and fricative sounds, whereas the older children in the age group of 7 to 10 years begin to show an acquisition of these sounds.
Moreover, as age increased, clarity also increased to some extent. There was also a change in the number and kinds of consonants produced, but the number and kinds of vowels did not change significantly.
We also noticed more approximations to the normal spoken forms along with the increase in ability to utter syllables clearly, a better distribution of sounds, and a better retention of most of the shape of the forms uttered.
There was also improvement in the quality of paralinguistic features used. Quantity of speech output also increased with an increase in age.
Moreover, production of a greater number of multiple word utterances was noticed, but this increase did not change the fundamental nature of CP speech as characterized by single word utterances. The increase was, however, not very impressive, as it did not drastically improve the quality of speech and language in the phonological, morphological (word), and syntactic inventories and their use. Even in terms of the length of utterances, there is no correlation found between the increase in age and the length of utterance. In almost all the cases, CP children did not go beyond the single word utterances.
Whenever a CP child gave an utterance longer than the single word, it was either an attempt during the imitation task or the multiple word utterance happened to be a rare occurrence. The self-initiated conversation may attempt at going beyond single word utterances, but this also happened very rarely. In essence, since multi-word utterances were few and generally not found in the self-initiated conversations of CP children, they were more comfortable usually with single word utterances and did not generally go beyond that.
Remember that such generalizations are not a hard and fast rule with all CP children. Remember that CP may vary extremely from individual to individual.
Distinctions in Speech between Spastics, Athetoids, and Ataxics
The neuromuscular distinction established between spastic, athetoid, and ataxia is not easy to identify or establish at the speech level. It is not surprising when we consider the fact that in a large number of CP patients, identified predominantly as spastics, athetoid features are found. Likewise, in a large number of athetoid subjects the features of spasticity are noticed.
Years ago Mecham et al (1960), and several others before them, pointed out that ‘speech characteristics are highly variable, both within the groups and within the individual CP from one time to another.’ Investigators generally agree that although we may be able to distinguish between spastic, ataxic, and athetoid speech to some extent, ‘the problems in any one type of cerebral palsy are so diverse that it is practically impossible to draw a single or composite picture of cerebral palsied children.’
While this may be largely true even today, the conclusion of Mecham et al (1960) that ‘differences in the speech of the cerebral palsied children and non-cerebral palsied children are more apparent in degree than in quality’ is not necessarily accurate. There are qualitative differences between normal speech and the speech of the severely/profoundly affected CP child. These differences will become apparent in our discussion in subsequent chapters.
Spastic speech is recognized by its slow rate and labored production. A spastic child faces grave articulatory problems because of the child’s inability to form fine synchronous movements of the tongue, lips, palate, and jaw. The child also exhibits a lack of vocal inflection, has a guttural or breathy voice, uncontrolled volume, and abrupt change in pitch.
These characteristics are shared also by athetoid and ataxia subjects. For this reason, the finer distinctions we wish to make in the speech forms of the subtypes of cerebral palsy may not have any direct consequence for diagnosis and therapy of the neuromuscular subtypes of CP.
The parents/caregivers and the therapists must, first of all, work out a profile of speech sounds already in place in the CP child, and then find out whether any pattern in the acquisition of speech sounds can be identified.
Limitations of CP Phonology
Moderate to severely impaired cerebral palsied children have only a limited number of sounds when compared with normal children. Their phonological system also has only a limited number of significant sound units (phonemes) which are used to distinguish meanings in minimal pairs of words.
Even in the normal language, not all the sounds we use in a language are used to distinguish meanings between words. Take, for instance, the production of aspiration (release of a heavy puff of air) along with the stop/affricate voiced consonants in English. When voiceless stop consonants ([p], [t], [k]) occur in the word initial position, these are always aspirated. When these occur in the middle or final position of a word, these consonants are not aspirated. The [p] in the word [pit] is aspirated, whereas the [p] in words such as cup, stop, stupid are not aspirated. Thus, the aspiration is contextually conditioned. It is interesting to observe how CP children handle phonological rules of this sort.
The limited number of sounds in the repertory of CP children results in a limited phonological system in their speech. A number of significant units of sounds (phonemes) are not found in the language of CP children. For example, the following phonemes are not at all found in the speech of the children we observed: /T/, /D/, /c/, /j/, /s/, /s/, /h/, /f//l/, /r/, /N/, and /n/.
Note also that contrasting minimal pairs for several sounds are not readily found in the spontaneous CP speech. However, the CP child is able to produce the minimal pairs of sounds if these sounds are already found in the sound inventory of these children. The utterances of CP children may not give us the minimal pairs of words, but the children are able to produce the minimal pairs when they are asked to imitate.
In other words, the sounds which occur in the phonological system of CP children do not readily occur in minimal and analogous contrasting positions in their utterances, which is not the case in normal language. However, CP children are able to produce these sounds in minimal and contrasting positions in imitation exercises. The paucity of minimal and analogous contrasting pairs of sounds may be due to the smaller number of words generally found in the CP child’s speech.
A true picture of the phonology of CP speech cannot be drawn based only on the utterances (words) found in CP speech. The smaller number of words used in CP speech does not enable us to correctly characterize the phonological potential of the child.
The smaller number of words used results in the use of a smaller number of sounds, and the smaller number of sounds used results in severe inconsistencies in the distributional patterns of sounds.
The CP children whom we studied demonstrated their potential to produce a variety of sounds in contrasting positions in imitation tasks, but these contrasting positions themselves were not found in usage in the day to day CP speech.
Mismatch, Substitutions and Deletions
The sparse speech coupled with the difficulties in musculature leads to a reduction in the sounds at the CP child’s disposal. However, the CP child who may be cognizant of and sensitive to the environment would need the additional sounds and words in his efforts at communication with the caregivers and others.
That is, a mismatch develops between the CP child’s surface level phonological ability and his cognitive needs. The cognitive needs of the CP child forces him to use the very same sounds which his musculature condition allows him to produce for as many different words as required. This results in free variations and inconsistencies. This also results in a lot of overlapping of speech sounds or correspondence of sounds that are generally maintained distinct in the normal language of the environment.
The substitutions, deletions, and additions in the speech of CP children are only sporadic. These do not follow any regular pattern. However, here and there one may be able to identify some regular substitutions, deletions, and additions. For example, in our observations we found that in a number of CP children a voiceless sound is generally substituted by another voiceless sound, and a nasal sound is generally substituted by another nasal sound.
When the CP child’s sound system does not have a particular sound used in the normal spoken language of the environment, the same may be substituted by one of the sounds available in the surface phonology of the CP child. As we already pointed out, in most cases the CP child has difficulty with the production of sibilants and other fricatives. When a CP child has this difficulty in producing a fricative sound, he may substitute the fricative sound with one of the consonants readily available to him in his speech. In such substitutions, however, there does not seem to be any pattern followed.
In many languages, a few sounds, which are phonetically similar to one another in terms of place and/or manner of articulation and which do not occur in contrasting positions, are grouped under a single phoneme. The actual sounds under the phoneme are called allophones. Children have an inherent knowledge that these phonetically similar sounds which are not in contrastive position do indeed form a single unit. However, in the case of the speech of the CP child whose impairment ranges from the moderate to severe condition, it is hard to decide whether the phonetically similar sounds could be clubbed under a single phoneme.
There is a lot of inconsistency in the occurrence of the sounds, and the poor clarity of CP speech would not allow us to make a decision. Perhaps we need to treat each and every sound as an independent entity in itself. Strangely enough, however, many CP children do not also exhibit homophonous forms (same sounding forms which mean different things) in spite of sporadic inconsistencies in the use of individual sounds.
Allophones and Speech Training
When we teach a language as a second/foreign language to normal children/adults, we aim at enabling them to acquire a proper use of allophonic variations. This would help the clarity and understanding of the target language utterances produced by the second language learners. In speech therapy as well, depending upon the level of proficiency potential of the speech impaired child, the therapist may or may not focus on the mastery of the allophonic pattern as a goal for the speech impaired child. In the case of CP children, it is not necessary that he or she produce allophones in appropriate phonetic contexts. Restoring communication in some intelligible manner is what we should aim at in the case of teaching speech and language to the CP child.
What Shall Be Our Priority?
The first priority for us would be to increase the number of sounds in the inventory of the phonological system of the child. Secondly, we must aim at the use of the available phonemes in the CP child’s speech in a consistent and non-overlapping manner. In this process, the substitutions, deletions, and additions that are used by CP children (compared to the normal speech) may be reduced to the greatest extent possible. Thirdly, the restoration of the clarity of speech may be emphasized.
In all the above, it is necessary that the length of the utterances, including words, be kept to a minimum. This can be accomplished by identifying syllabic and disyllabic words in the normal language and by using them in speech training contexts. In human languages, one notices that monosyllabic and disyllabic words are often used in contexts of situations that are essential and normal for day to day activities. In case a multi-syllable word is used for an essential item of expression, our goal should be to enable the CP child to produce the multi-syllable word intact in as many of its occurrences as possible.
If the CP child is unable to produce the multi-syllabic word successfully in most of the contexts, then we should aim at enabling the child to produce one or more syllables of the multi-syllabic word in a consistent manner. This truncated reproduction would soon become a familiar utterance/token in a consistent manner both for the CP child and the caregiver so that the communication between the two is carried on with some familiarity.
While there may be substitutions, deletions, and additions in the words uttered by the CP child, which make CP speech distinctive from normal language use, the distributional characteristics of the individual sounds in CP speech, however, do not differ from those of normal language. Also the peculiar distributional patterns that we notice in the phonology of the normal language of the environment may be retained in CP speech. For example, in normal Kannada, most words end with a vowel. In the moderate to severely impaired CP child speech in Kannada, we also find that most of the words end with a vowel.
The positional occurrence of the sounds of a CP child’s speech makes it look like the normal language. However, it often happens that the pattern of distribution of sounds in CP speech is a simplified version of the normal language of the environment.
Simplifications in CP Speech
The following simplifications of patterns are noticed:
Sound Contrasts, and Homophonous Forms
If a CP child is encouraged to produce a sound in isolation with clarity, he may do so, even though such a reproduction may be accomplished only in a few cases out of many attempts at producing the sounds. However, the fact that a CP child is able to produce a sound with clarity when persuaded shows that the difficulty in production lies elsewhere.
Occasionally, one is able to identify the minimal pairs of contrasting sounds in CP speech. These contrasts in minimal pair positions between sounds noticed in the speech of some CP children, however, are functionally different from the contrasts found in the normal language of the environment.
The contrasts found in the speech of CP children are not built into a creative scheme for the coinage and use of new vocabulary. These contrasts are not used to distinguish one lexical item from another. These contrasts occur rarely and in a sporadic manner. While the child makes the contrast, such a contrast is not generalized.
The CP speech begins to exhibit a considerable increase in the occurrence of homophonous forms in some CP children when they try to form new words. In most children, however, use of homophonous forms is very rare, even when they have only a limited number of sounds in their inventory.
We recommend that whenever there is an undue increase in the coinage and use of homophonous forms, the CP children should be tested more extensively for their non-linguistic cognitive abilities as well as for their dysarthric problems. We suspect that in several of these cases the excessive occurrence of homophonous forms may be due to a greater cognitive disability, while in several others it could be due to dysarthritic problems, and in still others it could be due to a combination of these two reasons.
The differences between the distributional characteristics of the speech sounds in CP children and in the normal language of the environment are minimal. We find that in the initial and medial positions in a word, there is a lot of similarity between the speech sounds of CP children and the normal language of the environment, insofar as the distribution of the individual speech sounds are concerned. In the final position, however, there may be significant differences between the two, mainly because, more often than not, deletion takes place in the word final position in the CP child’s speech.
Distributional Characteristics
There is something peculiar about the similarity that we notice between the distributional characteristics of the individual sounds of the CP speech and those of the normal language of the environment. In the normal language of the environment it always happens that the distributional patterns found in the stop consonants may or may not be identical to the distributional characteristics of other non-stop consonants, such as nasals, semi-vowels, laterals or trills and so on. We notice in the CP child’s speech that the distributional patterns of the stop consonants may be replicated uniformly for the other types of consonants as well; for example, for the semi-vowels, trills, laterals, nasals, etc. In other words, the CP child’s speech presents a more or less homogenous or identical pattern of distribution for all the consonant sounds. This picture is different from the picture in normal spoken language in which the distributional patterns of sounds generally vary from one group of sounds to another group, stop to nasals to semi-vowels, etc. Thus the CP child’s distributional pattern for the sounds is a simplification of the normal speech patterns of distributionin. Because of this simplification, identification of a word in the CP child’s speech in relation to the normal language of the environment becomes a problem. For interpretation, we need to depend on the immediate context of situation.
The non-identical clusters such as [rk] in the normal language of the environment is converted into identical clusters [kk]. This conversion of the non-identical into the identical clusters is accomplished in several ways.
Variability
We have made a series of general statements about the changes that take place in the speech of the CP child in relation to the normal language of the environment. These observations look at the changes as additions, deletions, or substitutions, etc. We should, however, caution that not all these processes would be identified in every CP child’s speech. In other words, these statements should be considered as possibilities in the speech of a CP child. The therapist and the caregivers should not seek only these characteristics of distribution in the speech of the child they are catering to. Every CP child may exhibit his own distributional characteristics well beyond the general statements we have made. This point should always be borne in mind.
The CP children’s speech is generally marked by sporadic variations that do not fall under any pattern. Moreover, the sporadic nature of the variation differs from child to child and, as such, it is necessary for the therapists and caregivers to identify the sounds in sporadic variations in every child and to work out strategies to eliminate as many sporadic variations as possible. This has to be accomplished by intensive training. We would not, however, know for sure whether a CP child will be able to participate in any intense training program. It all depends on the severity of the disorder. It is usually found that a moderate to severely affected CP child lacks attention. As such, his participation in the training program could be ensured for only a very limited duration in a session.
More on Clarity or Intelligibilty of CP Speech
When a CP child’s speech has some clarity, there is always a greater similarity between the normal language of the environment and the CP child’s speech. Most children may have an ability to produce most of the normal speech sounds in isolation with considerable clarity. However, these children would exhibit difficulty in producing the same sounds in contiguity which is required for the production of words.
In some CP children, clarity of speech is only mildly affected, mostly as a consequence of less severity in their CP condition. The speech of such children may be quite easily understood by the listeners who are familiar with these children’s speech. However, for those who are not, the speech abounds in misarticulations, and distortion of all sounds.
Some CP children may have a fumbling behavior with syllables and words, giving the impression that they stutter. The difference between CP speech and normal speech is always maintained in the manner of clarity, quality of pauses between syllables, transitional difficulties from one sound to another, heavy distortions, substitutions of a free varying nature, and correspondences which are maintained in an irregular fashion.
When the utterances of the CP child are transcribed on paper, and this transcribed data is looked into, one does not notice much difference in the phonemic distributional patterns of some CP children and those of the normal language.
The data of a CP child would look like an utterance from a dialect of the normal language, a dialect somewhat different from the normal language, but quite similar in the underlying patterns of distribution. However, when the very same data is converted back into audio mode, the difference between normal speech and CP speech becomes more glaring.
Vowel Distortions
The distortions noticed in the use of the vowels are caused by the reduction in the time taken for their production. This results in the shortening of the length of the vowels. As a consequence, confusion between the short and long vowels is quite common. We notice also a reduction in the size of the closure of lips. A notable feature in vowel distortion is the almost equal distribution of high, mid low, front, back, and central vowels in the word final position in the CP speech in Kannada. This is somewhat different from normal speech. In Indian languages, especially those belonging to the Indo-Aryan and Dravidian families, not all the vowels are distributed with equal frequency in the word final position. Perhaps this is true also of other languages. In normal Kannada speech, for instance, the vowel /u/ is found more commonly in the word final position. In the speech of CP children, with moderate to severe symptoms, this vowel is rather reduced in its frequency in that position. The rounding of the lips required in the production of this vowel /u/ probably requires an additional effort on the part of CP children. This might have resulted in the lesser frequency of this vowel in CP speech.
In some CP children, the production of sounds is so limited and is so distorted that it is difficult to isolate speech sounds and to arrive at a distributional pattern. Some children exhibit geminations (doubling of consonants) in the word initial position which is quite contrary to what we have in normal Kannada speech. The occasional geminations in the word initial position may be a pointer towards the prolonged effort the children make in producing a particular sound. In some children there may be no non-identical clusters at all. In some CP children there may not be even a homorganic nasal-stop cluster.
Some CP children, as they grow in age, reveal an increase in the number of sounds and the variety of patterns of their use. They also reveal an increase in the number and kinds of words. However, this profile of increase and better approximation to the normal speech of the environment is upset by a regressive picture noticed in other CP children. We are thus forced to conclude that age may not be a significant factor in the improvement of the quality of speech and language in spastic children. With increase in age we do not notice a hierarchically linear or homogeneous increase in the linguistic inventories and their use.
Spastic and Athetoid Speech
In spastic children, some sort of a cardinal pattern of vowels is found. These children acquired certain vowels of a “basic or general” nature, but the finer modifications of these vowels are not easily attested in their speech. This is rather similar to the occurrence and distribution of consonants in the CP child’s speech.
The CP child is known to produce only those consonants for the production of which “finer positions and movements” are not involved. The athetoid speech is not very different from the spastic speech. However, the athetoid speech is more deviant from the normal speech of the environment. This deviance is noticed more in the distributional patterns of the speech sounds. The deviance does not fall into any pattern.
Another characteristic of the athetoid speech is that this speech may have sounds not readily found in the spastic speech. Some athetoid children of moderate severity produce the retroflex sounds, sibilants, and other fricatives in great measure. The athetoids can even produce those sounds which require a finer manipulation of the articulators.
This certainly is quite different from the spastic speech, which does not provide for such finer manipulation of the articulators. All the same, these athetoid children do not use these sounds in any regular pattern. So, while the production of the sounds with finer manipulation of articulators does not pose much problem to the athetoid, use of these sounds in consistently regular patterns poses a problem to these athetoid children.
Distorted production both in place and manner of articulation characterizes the athetoid speech. For example, some of the athetoid subjects may produce vowels with nasalization which are not nasalized in the normal language. Moreover, substitution of one vowel for another is quite common in athetoid speech. Distortion and substitution thus come to characterize the athetoid speech as well. In general, the athetoid speech may present a better picture of acquisition of sounds. The athetoid subjects may have more number of consonant sounds than the spastic subjects. However, the distributional patterns of these sounds do not follow the pattern found in the normal language.
A similar picture prevails regarding the use of vowels. Substitution of one vowel for another is quite common. There is an inconsistency in the use of the vowels. The athetoid words may not have the same vowels for the corresponding words in the normal speech of the environment.
Like spastic children, athetoid children also have difficulty in producing and using consonants other than stops. When the production of a sound involves a single and total constriction, the athetoid subjects perform better. When the production of a sound involves not a total constriction and stoppage but a narrow aperture maintenance for a longer duration, the athetoid subjects do not perform well.
Phonological disability is a stable feature in spastics even with increase in age. On the other hand, the athetoid subjects do acquire more sounds in significant number with increase in age. This does not, however, make athetoid speech look more like normal speech because the athetoid speech continues to exhibit great distortion in the distribution of the sounds used.
In spastic speech, although we get a picture of inadequacy in terms of the sounds acquired and used, what emerges is a picture of close to normal condition in the distributional patterns of these sounds. We would expect a picture of close to normal condition in athetoid speech because of the number of sounds at its disposal. But what emerges is a speech which is much further removed from the normal speech of the environment because of less cogent distribution, which is unlike the normal speech of the environment.
The speech of the CP children may vary from severely unclear speech to moderately clear speech. In some cases, the speech may be so clear that it ceases to signal the CP condition of the child. However, more often than not, an unaccustomed listener would need several repetitions to understand the CP child’s speech. The assistance of the mother and other caregivers is often required to understand the speech of the CP child.
Most mothers and caregivers take upon themselves the responsibility of interpreting the CP child’s speech to outsiders, visitors, and guests. If this is done as a routine and very often, the CP child soon comes to depend upon such crutches for communication with people outside the circle of immediate caregivers. This comes to have an adverse effect on the child’s progress towards acquisition of communication skills.
Thus, although it may be quite comforting to the CP child in the beginning to have such interpretive helps, the caregivers should generally avoid the crutches offered to the CP child and instead encourage him kindly to express and communicate himself to the visitors. A kindly touch, a kindly look, and a kindly appreciation of the child’s efforts at independent communication is absolutely essential and should be readily forthcoming from the visitors. Caregivers are required to be alert to the possibility that a well-fashioned outline of the context of situation may be either widened or narrowed so suddenly that they may not be able to immediately recognize the change; it may also be distorted.
Paralinguistic Features - Part of Natural Speech
Paralinguistic features are an essential and integral part of normal speech. They function as the launching pad for acquiring speech sounds in early infancy. However, it is difficult to teach paralinguistic features to both normal and CP children. It is hard to extract and isolate paralinguistic features from speech and focus upon only these in any speech training.
Paralinguistic features in normal speech occur as an integral part of speech utterances. Hence, in training CP children to acquire and use essential paralinguistic features, we should present these features only in association with actual utterances of speech.
Pre-vocalizations
CP children are known to emit vocal noises during speech production. These noises are not part of the words in CP and normal speech. These noises in the CP speech are pre- vocalizations—these are meaningless sounds uttered prior to the actual production of an utterance in speech. Sometimes these are noticed as unnatural gaspings only.
The pre-vocalizations preceding the production of a sound generally indicate the difficulty faced by the CP child. These indicate also that alternative strategies are being attempted by the CP child to overcome his difficulty in producing speech.
Pre-vocalizations often occur when the CP child knows that it will be difficult to produce stop and nasal sounds distinctly. This is a consequence of the problem the child has controlling the oral and nasal passage. The CP child also exhibits pre-vocalization behavior when he has to produce voiceless and voiced sounds. In this case, the child’s difficulty with the manipulation of the vocal cords is identified as the cause for pre-vocalization.
It should be noted here that pre-vocalizations occur more frequently in athetoid speakers.
Proprioceptive Feedback
We get a feedback of what we say not only in sound waves caused, but also through the physical movements of speech organs. The formation of this proprioceptive feedback is hampered by the difficulty in controlling and coordinating articulators and in making appropriate connections between the articulators and the places of articulation.
Because we hear what we say instantaneously, we are able to edit our speech and produce sounds correctly. CP children have very little proprioceptive feedback, and this adds to their difficulty in producing speech sounds correctly.It also adds to the difficulty the CP child has in recognizing correctly the speech uttered to him/her. Thus, both production and recognition of speech sounds are affected. It is important that speech training given to CP children recognize the problem and try some suitable steps to remedy this situation.
Intelligibility of CP Speech and the Extent of Neurological Damage
Aronson and Brown (1969) have detailed several articulatory inaccuracies that characterize the speech of the cerebral palsied children: imprecise consonants, irregular articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, prolonged intervals, slow rate, mono-pitch, mono-loudness, and harsh voice as well as slow rate of delivery of speech.
The paralinguistic features of speech in CP children are more affected if the children themselves are neurologically more affected. When a child is more affected neurologically, he often exhibits a greater lack of coordination of the speech organs, and consequently his speech tends to be more slow and laborious and to contain many articulatory errors. But, conversely, the severity of neurological impairment itself generally tends to be measured by the severity of speech affected in the CP children! Severity in speech impairment in CP children can be identified, but its relationship to the severity of neurological impairment should be carefully evaluated.
What strikes one most is the lack of intelligibility and distortions in CP speech. The dysarthric musculature affects the intelligibility of CP speech and, as a consequence, the communicative ability of the children is often treated as low.
CP speech may vary from a severely unclear to a moderately clear condition. In some cases, the speech may be so clear that speech and language cease to signal the condition of the CP subjects. However, in most cases, an unaccustomed listener would need several repetitions to understand the CP child’s speech.
As we pointed out in the last chapter, the assistance of the mother and other caregivers is often required to understand the speech of the CP child. Most mothers and caregivers take upon themselves the responsibility of interpreting the CP child’s speech to outsiders, visitors, and guests. If this is done as a routine and very often, the CP child soon will depend upon such crutches for communi- cation with people outside the circle of immediate caregivers, and this comes will have an adverse effect on his progress towards acquisition of communication skills.
Thus, although it may be quite comforting to the CP child in the beginning to have such interpretive help, the caregivers should generally avoid extending these crutches to the child. Instead, they should encourage the CP child kindly to express and communicate himself to the visitors. A kindly touch, a kindly look, and a kindly appreciation of the child’s efforts at independent communication is absolutely essential and should be readily forthcoming from the visitors.
Even the mothers and caregivers may have problems in understanding the CP child in spite of their familiarity with his speech. The context of situation assumed to be relevant for and understood by them may suddenly be so widened or so narrowed that the caregivers may have difficulty in closely following the intent of the CP speech addressed to them.
Apart from this, the extremely affected articulation due to dysarthria, the abnormal pauses, stress, and juncture may affect the intelligibility of the CP child’s speech.
Abnormal Pauses in CP Speech
The pauses present in the CP child’s speech are of several types. They are frequent and are longer than the pauses found in the normal language. In one type of pauses, CP children make prolonged pauses between forms/words. In such cases, each word sounds as if it were a separate sentence by itself.
It is true that CP speech abounds in single word sentences. However, on several occasions, the CP child does indeed try to put together two or three words with the intent of making a sentence, in spite of the long pauses between them. In such cases, meaning retrieval of the utterance becomes a problem. It becomes difficult to isolate groups of words as forming individual sentences.
In another type, pauses may occur between the syllables of a word uttered. The pauses noticed between syllables are much longer than those found in normal speech. Pauses also occur before the start of the utterance.
CP children have a rate of speech that is much slower than the speech rate we find in normal speech. The speech rate is affected by the difficulty faced in the production of sounds. The longer the abnormal pauses, the longer it takes to produce the response. It is also possible that inadequacies in cognitive skills needed for verbal communication contribute to this condition. All this may result in a slower speech rate. However, we should not jump to the conclusion that a slower speech rate is a sure sign of inadequate communicative or cognitive skills.
Focus of Speech Training in CP
Affected musculature does not allow the CP child to produce speech at the normal speech rate, which in turn creates disturbances in the performance of communicative behavior in the CP child. If a priority between speech rate and clarity of speech needs to be made, the priority should be in favor of developing an adequate clarity of speech rather than developing an adequate speech rate.
Since the dysarthric problems are likely to continue and thus may hamper speech rate in some form or another, speech training to CP children should focus more on bringing out the clarity of “essential” words rather than on producing a higher speech rate.
As we already pointed out, in the CP child’s speech, pauses are abundant. Pauses are heard both between syllables of a single word as well as between the occasionally heard two-word and multiple word utterances. These pauses are more prolonged than normal ones.
CP children have a speech output that is very low compared to the speech output of their normal peers. This is due to the fact that their speech is composed of single word utterances most of the time. The other reasons for this lesser quantity of speech output may be the longer response time taken by the children for each utterance, the abnormal and long pauses, and the lack of self-initiated speech.
Most of the CP child’s utterances are responses to others’ speech. The CP child’s self-initiated utterances include words calling for the attention of those around him. These words, just as the address terms, are very rare, since his needs are attended to by others often without him asking for such attention.
Asking for fulfilling certain basic personal needs such as food, water, etc., is done by using perseverative verbal forms which include repetition of the word even in the absence of the original stimulus that caused it in the first place.
Consequently, infrequent speech coupled with pauses, lack of self-initiated utterances, slow rate of speech, single word utterances, and longer response time, all characterize the quantity of speech as reduced or limited.
Intonation Patterns in CP Speech
Difficulty in controlling lips, tongue, mandible, and velum is noticed in CP children. Large ranges of jaw movement, inappropriate tongue positioning, and intermittent velopharyngeal movements are further worsened when combinations of sounds are attempted. As a result, the prosodic features (sentence melody) in the speech of CP children are heavily affected.
CP speech does not indicate the presence or the absence of any intonation pattern found in normal speech. This is so mainly because the speech of the CP child consists mostly of single word utterances. There are very few two word and multiple word utterances. In these few two or multiple word utterances also, there seems to be no or inadequate presence of the intonation patterns.
Note that in the normal language of the environment, many single word utterances have some inherent intonation such as the imperative tone. Even in the single word utterances, CP children have difficulty in using such inherent intonations. They utter these imperative forms in a non-inflected fashion. As a result of this, and because of the poor intelligibility of the utterances, it becomes extremely difficult for the listeners to decipher the CP utterances and the relevant intonation.
Because the CP child utters his words/sentences in a non-inflected fashion, it is familiarity with the context that enables one to assign an appropriate intonation meaning to his utterances. In other words, the distinction between interrogation, statement, exclamation, etc. is to be imposed on the utterances by the listeners based on the context of the situation. However, the occasions for the use of such varied meanings through intonations are few and far between. Most of the time, the utterances are interpreted as expressions of his need, thus imposing only an intonation of request on the utterances he makes in most of his self-initiated speech.
It is likely that just as the sounds that require a finer manipulation of speech organs are not produced, or are produced with difficulty and without clarity by CP children, the intonation patterns as a class, the production of which requires a finer tuning of vocal cords as well as a finer placement of melodies over the segmental utterances, are not produced.
Speech Training for Paralinguistic Features
As regards speech training, we would recommend that training be given for clarity of speech sounds and words. In fact, we suggest that training in intonations be given a low priority. It is much more important to focus on those items of speech which would improve the barest communication of the simplest content. If words are chosen and uttered appropriately, the content of the communication (even without the intonations) can be inferred by the caregivers and others acquainted with the context of interaction.
It is worth remembering the following points when we consider giving speech training for the improvement of paralinguistic performance of CP children:
Cognitive Skills Affected in CP
Often the dysarthric characteristic of cerebral palsy has led many of us to think that cerebral palsy affects only the physical abilities and not the cognitive skills. Yet the language disorder prevailing in this abnormality clearly indicates that a cerebral palsied child may be impaired in cognitive skills also.
Moreover, the progression through sensorimotor, perceptual, and conceptual levels may be delayed, distorted, retarded, or arrested in varying degrees of severity in cerebral palsy (Lencione 1968). Eisenson (1972) found that CP children were severely delayed in all aspects of language even when they were not mentally retarded.
This picture of arrested growth is also manifestly seen in the deficient acquisition and use of words and categories of words (parts of speech) in CP children. The picture that we have of the acquisition and use of sounds in the CP child’s speech is repeated in the acquisition and use of parts of speech.
The CP child does not acquire all the parts of speech and classes of words that are found in the normal language of the environment. The child masters only some of the uses and meanings of the individual words he has in his repertoire. Singer (1976) reports that CP children use fewer age-appropriate forms and more agrammatic forms than normal children. He reports also that the restricted or agrammatic forms are characteristic of CP speech. CP children fail to use the strategies of substitution and deletion for approximation towards the target language, unlike normal children.
The deletions and substitutions we notice in CP speech do not ultimately lead to mastery of the normal language, even with an increase in age. The limited nature of the number and kinds of vocabulary and their use continues to be a part of CP speech throughout childhood and beyond.
Some Tips for Collection and Analysis of Words, and Speech Training
There is a general tendency among speech therapists, parents, and caregivers to relate and describe the speech and language abilities (acquisition, discrimination, and use of words) of CP children as delayed in comparison with the children of the same age group. This approach is easier to follow and may even be useful in the preliminary stages of diagnosis and prognosis. However it would be better to work out our training programs mostly with reference to the competence and performance of each individual child based on the severity of the affliction.
It is more important for us to focus on data collection than on making assumptions as to the nature of the speech of the individual child. We should first of all record the utterances of the individual child. This data may consist of the spontaneous speech of the CP child, the speech elicited by the therapist and caregivers, the child’s own narrative speech, both self-initiated and elicited, and also the speech obtained while performing imitation tasks.
The caregivers are advised to keep a diary and record the utterances, their meanings, and the contexts in which these utterances are made, and note also whether consistency in producing and using these utterances is maintained. Consistency here means whether the CP child uses the very same form or word consistently to refer to the same event or object in subsequent use of the same form.
An atmosphere of linguistic activity around the child and for the child should be created as often as possible. While the caregivers generally tend to put the child in his most comfortable position all the time, they should invariably ensure this when deliberate linguistic activity is sought to be generated in the CP child. Verbal interactions take place in better quantity and quality when these are sought from the child in the most comfortable period of the day for him.
Positive reinforcements also contribute to the generation of sufficient quality and quantity of the utterances. The most desired incentive for the occasion on the part of the child should be identified by the caregivers. They should be able to see the likely changes in the incentives that the CP child desires from one occasion to another. The caregivers thus should be prepared to rotate and/or change the incentives to suit the “moods” of the CP child. Incentives may be required both at the beginning and at the conclusion of these deliberate linguistic activities.
Caregivers tend to notice and assess the impact every participant in an interaction has on the linguistic productivity and comprehension ability of the CP child. They tend to notice that some are better capable of inducing the CP child to indulge in speech activity than others. They tend to notice the context and period of conversation which generally result in better linguistic activity on the part of the CP child. The purpose of the conversation, the antecedents to the present conversation, the mood of the participants, and the locale of the conversation all have an impact on the quantity and quality of speech produced. For this reason, these factors need to be assessed and used properly.
The interpretations offered by the caregivers for the forms uttered by the CP child should be carefully evaluated when we wish to identify the growth rate and quality. Recognition of the normal language forms in the speech of the CP child helps us to identify whether there is any progressive increment to the CP child’s lexicon.
It is possible that the CP child’s approximations towards the forms of the language of the environment may not be impressive. But the child may progress in small steps towards consistency in using his own forms. When correspondence between the forms used by the CP child and the linguistic forms used in the normal language of the environment is regular and consistent, communication between the CP child and the caregivers becomes easier.
The Word Profile in CP Speech
When a CP child is severely afflicted, he/she does not exhibit any affixation process essential enough to express grammatical functions. One may notice affixes only in some utterances. Where there are affixes in the utterances, these are treated by the CP child as an integral part of his word. In other words, the CP child does not separate a word and its affixes. The child treats the whole form as a root word or an independent word.
Since the CP child does not acquire and use affixes, there is no overt marking for case relations, tense, gender, and number unlike in the normal language of the environment. Thus, these semantic notions are not explicitly stated in the CP child’s speech. The inference of such notions is left to the imagination of the listener based on the context of situation and familiarity of the target word. In the rarely occurring multiple word utterances, the order of placement of words would have to be figured out by the listener based on his understanding of the context and the general order of words followed in the normal language sentences.
The question of teaching the CP child the formal devices for these notions does not arise. As we pointed out earlier, the CP child’s speech consists mostly of single word utterances. Only if our speech training can focus on changing this pattern into one of using sentences/phrases of two or more multiple word utterances, would the need for the formal devices for expressing these relations arise. Even then we should focus more on teaching the appropriate order of words in an utterance than on teaching the use of affixes. We must recognize the distinct inclination and restricted ability in the CP child to produce only single word utterances.
The CP child’s speech is full of nouns, that is, it has more nouns than verbs. The verbs are also used as single word utterances. When they are used as single word utterances, the normal verb endings are generally absent, unlike in the normal language.
The CP child arrives at his own verb root/verb stem. He deletes, or better still, he does not produce the affixes that are generally attached to the verb root/verb stem to qualify the action indicated by the verb in terms of the number of persons who perform the action referred to by the verb, the first or second or third person status of the performer of the action, as well as the gender of the performer of the action. These provisions are required in the major Indian languages, including Kannada which was the language of the environment in our study. However, the CP child may retain or attempt to retain some or all of the affixes which qualify the action indicated by the verb form, when he is given a repetition/imitation task. Thus, the CP child does recognize the affixes, but finds it difficult to use these affixes on his own.
Significant Features of Word in CP Speech
We give below some of the significant features of words as noticed in the CP child’s speech.
Lack of Affixation Process - Consequences
The statement that there is no worthwhile affixation process in the CP child’s speech is a simple statement and it does not fully reveal the significance of the absence of an affixation process. When affixation is absent in the CP child’s speech, it means that there may be no overtly marked case relations, no indication of the tense involved in the utterances, no indication of the gender and number, no indication of time, manner, and location of the action performed, and no indication of various other qualitative characteristics that are routinely expressed in normal language.
In essence, the speech becomes totally inadequate to carry out day to day language functions which a normal individual does with ease. Conveying notions of time, quality, gender, number, etc., is not explicit in the speech of the CP child. Inference of such notions is left to the context of situation in the real world around the child. Inference depends heavily also on assuming what the utterance could or would be in that context, and its frequency of occurrence.
On the other hand, some mild to moderately affected CP children do make use of the affixation processes partially. The affixes are not fully attached to the head words, and the affixes themselves sound like independent words. Moreover, affixation is not consistently used in all the words which must have affixes in the normal language. The presence and partial use of affixation in these children must be viewed as an indication of the child’s effort towards approximation to the normal utterances. However, even in such children, semantic notions of quality, case, gender, number, etc., are not explicit to the degree we find in the normal language.
The CP child does not distinguish between masculine and feminine names. This is in contrast to the child’s ability to maintain the sex difference while using kinship terms. However, note that the CP child does not correctly use specific terms such as cow and bull in which sex difference is inherent.
Some CP children are able to indicate a few case relations in their multiple word utterances through word order. However, they do not use explicit case markers. It is difficult to explain why the CP child chooses to express covertly some of the case relations but not others. And yet the use of some case relations gives some hope that through further exposure and training more case relations could be taught.
In some multiple word utterances, adverb of location is also expressed through word order by some CP children.
Some CP children do use interrogation in their speech. However, the interrogation they use is restricted generally to the use of what (kya in Hindi, or e:nu in Kannada, enna in Tamil). This is done without any appropriate intonation. We notice that not all the functions of what (Wh-question) are acquired. Use of what as a self-initiated explorative question is commonly found in normal children and this leads to acquisition of information as well as other linguistic items.
What is used both for event and object identification in normal children’s language acquisition process. CP children use what more for object identification. Moreover, the child does not use the interrogative intonation at all. As a result, interrogative and declarative/ordinary statements are not distinguished clearly.
Some CP children use some color terms but not all. In general, the adjective category is not used much in the CP child’s speech. However, we noticed in a CP child that his speech, although much distorted, contained several color terms. The child was five years old at the time of observation. The child was also able to discern the use of these color terms. This was surprising to us since even normal children of his age would have problems with these terms. When the parents were questioned about it, we learned that this child had been taught these terms since the lack of the ability to use color terms was strikingly obvious in comparison to a cousin of his. Otherwise, the parents said, the child would not have been well versed with the color terms.
The generally longer expressions (words or phrases) in normal language are shortened in CP speech by way of simplifications. There may be deletion (non-use) of affixes. Even some sound segments of the root word may be deleted. The child may retain the meaning of the utterance, but he reduces the length of the word/phrase/utterance in conformity with the constraints of his phonology.
Peculiarity of Language Acquisition in CP Children
The CP child’s speech is rather different from normal speech in a peculiar manner. While a CP child may exhibit a knowledge of many parts of speech and may even use these in his utterances, he may not acquire in full all the major characteristics of these parts of speech. For example, some CP children do exhibit a knowledge and use of personal pronouns as a category, as a part of speech. But these very same children may not have acquired all the three persons (first, second and third), with their subcategories (such as my, your, his, her, their, etc.).
This difference in the scope of acquisition is seen in all the parts of speech acquired by CP children. A CP child acquires one or a few of the features of a part of speech but not all the characteristics of that part of speech. And this picture of “reluctance” is seen in all aspects of language acquisition by CP children.
In addition to this difference in the scope of acquisition, there is also some confusion in the use of the features acquired. In all these instances, we should try to identify the relative frequency of occurrence of each of the items and their characteristic features of use in order to work out a hierarchy of usage. This will help us to identify not only those features which do not occur in CP speech of individual children, but also those features which are differently and sporadically used.
Some CP children may use affixation processes when compared with other CP children. A CP child with moderate spastic quadriplegia whom we observed did not always use the overt affixes, but he did use some of the case suffixes sometimes in Kannada. He did use the affixes for time, manner, and location. And yet it was not possible for the listeners to distinguish clearly these notions in his speech.
Some CP children did not use some of the pronouns but they comprehended even the meaning of those pronouns they did not use. Some CP children have no difficulty at all in distinguishing pictures of males and females, but feminine and masculine names are not distinguished correctly all the time.
Some CP children may not use most of the pronouns, but their speech may covertly indicate the knowledge of pronouns through the rare use of personal endings in verbs. These children may not exhibit any consistency of function for some of the pronoun forms they have acquired. When asked to identify, some CP children may distinguish correctly the pictures showing single and multiple objects. Only a few verbs are used by CP children. These relate to immediate personal acts or for describing pictures shown. Even among the few verbs, the transitives are used more often than the intransitives. Other subcategories of verbs are rarely used.
CP children do not normally inflect their verbs for tense. However they understand the past and non-past distinction in a comprehension task.
Some CP children with moderate affliction may imply dative, locative, nominative, and accusative cases in their utterances; sometimes these children may even use some appropriate affixes explicitly. However, the very same children exhibit difficulty in using or demonstrating the use of genitive, instrumental, and ablative case relations.
While tense is not distinguished clearly in the CP child’s utterances, some CP children may use the present tense markers in place of past tense markers. We noticed that CP children had difficulty correctly using words for today, tomorrow, and yesterday, thus showing their difficulty with time expressions.
Verbs occur both as single word utterances as well as the second item in a two word utterance. The single word verb utterances are more numerous. The item that precedes the verb in two word verb utterances is usually a subject or an object noun.
CP children acquire the kinship terms to address those who attend to them frequently. These terms are used only as address terms and not as reference terms. The immediate presence of these persons appears to have helped the acquisition of these terms, and these terms are used only when the person is immediately present.
In some CP children, we find overt and covert markers of case relations, tense, gender, number, and various other qualitative characteristics. These explicitly bring out the meanings of time, gender, etc. With contextual information, CP children’s utterances are fairly understood by the listeners. In spite of all these characteristics, the affixation process in these children is not regular in the sense that the affixes are not invariably used wherever necessary in an utterance.
In the speech of the CP child, there are two types of distortions. The individual sounds may be distorted, but this distortion acts as a trace for a sound or sounds that are not clearly produced in the speech of the CP child but are found in the normal language of the environment. The distortions caused at the word level are mostly a function of the dysarthric and/or cognitive inadequacies which result in shortening the words uttered.
Some CP children with moderate affliction are known to use the gender system correctly in verb endings. Likewise, some CP children with moderate affliction may show difficulty in producing forms with plural affixes, but no difficulty in comprehending the meaning of such expressions. Some CP children do not use plural affixes in the nouns, but they do use them correctly in the verbal endings. In the latter case, these children appear to have acquired the word along with the plural affix as its integral part.
Whenever CP children have demonstrated a capacity for using numerals, their comprehension of numerals was far better than the actual use of numerals.
Some CP children make an occasional use of manner adverbs in addition to place adverbs. But these children do have difficulty with regard to the use of time adverbs. CP children shake their heads to refuse things offered to them. Some use simple negative elements to express “no.” These children have difficulty in using modal negatives.
The modal negatives are not as frequent as the simple and ordinary “no” expression in the normal language of the environment (Kannada). However, prohibitive negatives, (such as gu:Dadu, ba:radu “shall not”) which constitute an important part of the process of expressing negation, are not used by these children, perhaps because these prohibitive negatives are used only in syntactic construction. Since CP children have difficulty with multiple word utterances, the acquisition and use of prohibitive negatives in Kannada appear to be beyond the reach of these children.
A chief characteristic of spastic speech is the lack of affixation process. No CP child presents a complete picture of affixation. However, they all show traces of partial attempts at affixation in their speech. Even on imitation tasks, there are only poor attempts which retain some semblance of affixation in some of the items.
Note also that not all the morphological characteristics found in the normal language of the environment are used in spastic speech. While this is expected in any disorder, what is significant here is that the spastic does not present mastery of any of the grammatical categories in any comprehensive manner.
In the data we collected, the following parts of speech were traced in spastic speech:
Noun, Adjective, Pronouns, Numeral, Gender, Adverb, Number, Interrogation, Cases, Negation, Conjunction, Kinship terms, Verb and Tense, and Reduplication
It is possible that there are some more categories used in the speech of CP children. However, all these categories of speech are represented only deficiently as explained above. Note also that not all these categories may be found in the speech of all CP children. Generally speaking, CP children show an inadequate mastery of any grammatical category they have in their speech.
The morphological categories used by the CP child are often used incorrectly. For example, some nouns are correctly used and some are not. Some pronouns are correct, but some are not. In essence, even though some CP children may show a much greater mastery of the grammatical parts of speech in terms of form and function, there always remains some feature or another which is inadequate in every part of speech they have acquired.
Two Broad Types of Language Use
There are two broad types of language use in CP children. In one type, CP children are not able to acquire grammatical categories of various sorts, and in the other type we have children who can acquire or have acquired a mastery of almost all the grammatical categories. However, in both types, what is acquired is inadequate or deficient in terms of form and content/function when compared with normal children.
It so happens that a CP child who has acquired and who uses a greater number of grammatical categories explicitly in his speech makes a less deficient use of these categories. Deficiency or inadequate mastery of the features of all the categories is a general characteristic. Every category is affected in one manner or another.
Word Derivation Processes
The spastic child uses a blend of various strategies to derive words. The major effort is in the direction of retaining at least partial similarity between his utterances and the corresponding normal language utterances. He may retain the initial syllables of the normal language utterances. He may maintain some correspondence between his utterances and the normal language utterances through substitution, or he may produce neologisms which may be quite different from the normal language utterances. Sometimes these neologisms could be produced with some consistency.
These strategies are not different from those adopted by normal children in their language acquisition process. However, in normal children they are a passing phase while acquiring their first language. On the other hand, these strategies become a part of the language use in CP children. Because of these deficiencies, mothers and other caregivers would, on their own, work out correspondences, taking into account the context of situation. For the uninitiated listener, most of the utterances may appear to be neologisms or alien utterances because of abundant sound distortions and pronunciation deficiencies.
Pronouns
CP children exhibit difficulty in acquiring and using the pronouns. Some CP children may use only some of the pronouns and may not use other pronouns at all. These children tend to use the pronoun form they have mastered to refer to all the other pronouns as well.
Mothers and caregivers find out very early that their CP children confuse the use of one pronoun for another. Initially, they notice the lack of pronoun forms in their children. Soon, they notice that their children not only confuse pronoun forms, but they do not acquire all the pronouns of the normal language.
The caregivers may also notice a reversal between two pronouns in a regular fashion. For example, a CP child may use I for you and you for I. Note, however, that a consistent reversal between pronoun forms is hard to establish.
As regards the use of pronouns, the following may be stated as a summary:
Gender
Regarding the use of gender, the following general observations may be made. Most CP children may not distinguish between genders when they use words that demand such a distinction. This is directly related to a lack of appropriate affixation in nominal forms, verbal forms, or both in their speech.
In some languages, gender distinction is inherently noted in the words. For example, the words he and she carry an inherent feature of gender distinction.
These words are acquired as such, and hence the listeners assume that the CP child has made a gender distinction in his/her use of these words. On the other hand, in some languages gender distinction of the objects or animate beings is made overtly in the words through the affixation processes.
Since the CP child does not use the affixation process, gender distinction in the words which demand affixation is not mastered by him/her. In addition, we found that some of the severely disordered CP children had difficulty in distinguishing the male and female pictures correctly.
Gender is distinguished in some CP children’s speech only when they used kinship terms like appa ‘father’ and amma ‘mother.’ Maintaining such a distinction in gender may be due to the habitual exposure which makes the acquisition of these words more like mnemonic terms.
Generally speaking, CP children exhibit difficulty in mastering the words which distinguish the sex of the members of the same species.
Number
In languages which make a distinction between singular and plural through affixation, the CP child does not discriminate between singular and plural in his/her utterances. Some of these children do not discriminate between single and multiple objects even in comprehension tasks.
In most Indian languages, the verb form is inflected to show whether the performer(s) of the action indicated by the verb is singular or plural. The speech of the CP child, in these languages, does not indicate the number of the subject (singular, dual, or plural).
Concerning the use of number, the following general observations may be made:
Most of the inadequacy may be linked to the absence of affixation process, which, in its turn, may be caused by the difficulties of production of speech. However, the failure to recognize plural number in comprehension tasks cannot be assigned to dysarthric difficulties of production and the lack of affixation processes. This failure must have something to do with some cognitive problem.
Case Relations
The CP child’s speech does not use case markers/affixes. There are several ways in which the relationship between the action, the performer of the action, and the recipient of the action are indicated in linguistic utterances, the chief among them being the affixation processes and the order in which words occur in the utterances. However, the CP child does not use any case markers. This is due to his general tendency to avoid and not to use any affixation process.
In some words we may be able to recognize some affixes, but these are used as an integral part of these words. The normal young child may acquire a word along with the affixes. In due course, the child comes to recognize that the word he has been using all along does contain a root/base and one or more affixes. Then the normal child begins to use the affixes with other words in a regular pattern. The affixes are recognized as a class by themselves. The CP child, however, does not begin to acquire and use the affixes as a separate class by themselves.
The moderate to severely affected CP child does not use any case markers. Even the case relations are difficult to trace in his speech because two word utterances are very rarely found. That is, there is not much of an opportunity for us to work out word orders in the utterances, since two and multiple word utterances are seldom used in the CP child’s speech.
In the single word utterances, the listener is forced to imagine the case relations based on the context of situation. Thus the absence of case affixes in the nouns is a regular pattern of the CP child’s speech.
A summary of our findings regarding the case relations and their forms in CP speech is presented below:
Conjunction
Conjunction is generally used in normal language in two and/or multiple word utterances. Conjunction, by its very nature, is a process connecting two or more items. Overt use of conjunction is not found generally in the CP child’s speech. The listeners have to place the words uttered by the CP child in the appropriate adjacent positions to arrive at the conjunctive sense.
Some CP children do comprehend the conjunctive sense while others do not.
Iterative conjunction is more commonly used among CP children who show an ability to use and comprehend conjunction.
The severely affected CP children do not have conjunctive process in general, whereas the moderately affected CP children may have implied the conjunctive but no overt markers of conjunction. The absence of overt conjunctive markers may be related to difficulties with affixation process and production, whereas the inadequate and implied conjunctive relations may be related to cognitive deficits.
Syntactically, conjunction may be viewed as a syntagmatic process, a chain of linear contiguity, whereas semantically the items that are linked with conjunction form a paradigmatic class, a class formed by a process of substitutability. The absence of overt conjunctive markers indicates the break in linear continuity. But the possibility of implied conjunctive relations based on adjacent relationship in two/multiple word utterances indicates that this linear chain of contiguity is rather retained through a paradigmatic process.
In any case, the presence of implied conjunctive relations shows the availability of the concept in the spastic speech. Its limited application shows that the concept is inadequately acquired.
Non-use of affixation as a regular process results in the non-use of conjunctive markers in the CP child’s speech in Indian languages. In most of the major languages of India, conjunction is expressed by a process of affixation and through the use of independent words such as aur in Hindi, or mattu in Kannada, which is similar to and. Although these languages may have some independent words to express and, those words express only a function (conjunction). Their use in a phrase or sentence is dependent upon the use of other words. In their very nature, these are link words which depend upon the occurrence of other words. In a way, these are a form of affixes, if we consider the dependency status of the words. The CP child does appear to have difficulties with all words/forms which depend upon other words/forms. For this reason, the CP child’s speech does not have any provision for both conjunction types.
The Verb in CP Child’s Speech
The CP child may use verbs or nominalized verbal nouns ([bandavanu], ‘the one who came (masculine))’. However, these are not retained in full form in either single or two word utterances. In most instances, verbs have only root forms with no inflections.
In the moderate to severely affected condition, the CP child uses fewer verbs than nouns. These are used mostly as single word utterances. When the verbs are used, they are in root form without any affix. There may be other simplifications of the verb forms. The word may be further abbreviated or there may be deletion or substitution of some of the sounds of the word.
Inflections of the verb form for tense, number, and gender are common in the major Indian languages, but the speech of the CP children generally ignores such inflections.
The intransitive forms are least used.
Verb forms are usually devoid of any inflection for tense. On the imitation tasks also, the CP child is not successful at tense affixation process. In most Indian languages, the verb is inflected to show the person, number, and gender of the performer of the action indicated by the verb form.
The CP child leaves out this information and presents more or less only the verb root. Difficulties with the affixation process have led to this characteristic of the CP child’s speech. We noticed the following characteristics:
This indicates that the child has difficulty with the instant retrieval of the relevant word in the immediate context. Even if a term is available to him in his repertory, he needs to be trained in the processes of instant retrieval.
Tense and Time in CP Speech
Tense distinction in most CP children is not explicitly stated. It is doubtful whether the tense distinction is even implicitly understood.
Numerals in CP Speech
Regarding the numerals, the CP child uses only some of the numerals but not all. There are very few cardinal numbers in his speech. Also the child does not match the number he utters with the actual number of objects shown to him. Some CP children may know a few of the numerals mnemonically.
Most children do not show a distinction between ordinal and cardinal numerals. The singular-plural distinction is also not maintained. In essence, CP children do not master the numeral system. They give a semblance of mastery of the production and use of some numbers, but the system itself is not mastered/acquired in any significant manner. Here also we see the very same pattern repeated—the CP child exhibits a knowledge of a category, but he does not acquire the category in any complete manner.
Adverbs in CP Speech
The CP child’s speech does not show the use of adverbs of location, manner, or time except on imitation task. Nor does the child use adjectives of quality or quantity. However, some basic color terms are used. Again, use of these terms is no guarantee that the children have comprehended their meanings. These terms are not matched with the corresponding actual colors in tasks given to the children.
Interrogation in CP Speech
CP children do not use interrogative markers, nor do they use the interrogative intonation. Hence questions such as “What is that?,” “Where is that?,” “When?,” “How?,” and “Why?,” which are directly relevant for cognitive development and vocabulary acquisition, are never raised.
Negation in CP Speech
CP children do indicate negation in a variety of ways. They may shake their heads to express negation. They may use some or all the independent negative forms used in the normal language of the environment. Or they may devise their own utterance and/or strategy to express negation. What is significant is the fact that the negation affixes are not used by CP children. Syntactic negation (use of negation as part of a sentence, using forms such as not, n’t) is not used.
The spastic exhibits a knowledge of an ability to use a grammatical category, but in doing so, he simplifies the category or selects and uses probably the simplest characteristic of the category. Again and again, we notice this pattern. And this certainly is a great challenge to the therapist. We need to devise a strategy which, while introducing items one by one, will help strengthen the process of generalization.
Adjectives in CP Speech
Kinship Terms in CP Speech
Some kinship terms are used by CP children. However, these terms are used as address terms, and only very infrequently for reference. The children use these terms to refer to kinsfolk in the immediate environment. Note also that familiar kinship terms such as the ones for mother, father, grandmother, grandfather, and aunt are used correctly. Perhaps continuous exposure to both the terms and persons may have helped the use and retention of these terms in CP children’s speech.
Reduplication and Onomatopoeia in CP Speech
Reduplication (repeating a word or part of a word more than once) is found commonly in Indian languages to express meanings of intensification, emphasis, addition, distribution, enumeration, etc. CP children indulge themselves very frequently in the reduplication of words. However, the reduplicative process indulged in by these children is somewhat different from the form and function of reduplication in the normal language. In the normal language, as stated earlier, reduplication is used for intensification, emphasis, distribution, enumeration with numerals, and for echo. In contrast, the CP children reduplicate part of the actual normal word in their effort to produce the normal word. For example, the CP child produces ga ga ga for gaDya:ra meaning ‘clock’ in Kannada, which makes it sound as if the child is stuttering.
CP children do use onomatopoeic forms. These forms are used as independent words. The action performed by the animals come to refer to the animals themselves. For example, some of our subjects used bau bau to refer to dogs, miyya to refer to cats, poypoy to refer to cars, etc. Some of our other subjects, however, did not use onomatopoeic words to label the objects. These children preferred to use the actual word in Kannada for dog rather than a corresponding onomatopoeic label.
In normal children, there is a stage of non-fluency around two years of age, due to inadequate language acquisition (Berry and Eisenson 1962). In the case of CP children, this state of non-fluency is also related to the problems of musculature.
We notice that the reduplication process found in CP children is unlike the reduplicative process found in autistic children, another group of developmental language disorders. The reduplicative processes of CP children are made generally as responses to elicited speech. These are not self-emitted responses as found in autistic children, nor can these be categorized as babbling or self-talk. These reduplications are responses which occur more on initial syllables.
However, some CP children may use the reduplicative processes for emphasis and to convey a sense of completion. In some CP children, reduplication may even perform the function of babbling and self-talk. It may also indicate that the child is currently in the stage of non-fluency in speech, a sign of inadequate language acquisition in children. In some CP children, reduplication may indicate the on-coming processes of stuttering.
Onomatopoeia is found in some spastic children as a strategy for acquiring new words. Some CP children may not use onomatopoeia at all. Where onomatopoeia is used, it is used for labeling an object which is usually animate. In normal language acquisition, children will use onomatopoeia in the beginning stage, but they soon cease to use it as a means for language acquisition.
The way spastic children make use of onomatopoeia is no different from the way they make use of other parts of speech. The spastic child makes use of the onomatopoeia only partially as an alternative to overcome the constraints imposed on him by dysarthria. He does not even utilize 50% of the processes of reduplication and onomatopoeia. Perhaps this is because onomatopoeia involves some measures of cognition apart from the need to produce multiple syllable utterances. The picture is the same as we find in the use of other grammatical categories in which a spastic child makes a beginning with the acquisition of a category, but does not fully master the use of that category.
Make CP Speech Comprehensible
In the earlier chapters we made several observations of a general nature concerning speech training for the cerebral palsied. In this chapter we focus on a few problems that may be tackled through proper speech training.
Communication with CP children is heavily hampered by the difficulty in understanding their speech. So, one of the earliest things we should consider is how to make the CP speech comprehensible to the greatest extent possible.
The CP children’s speech is difficult to understand because these children not only lack the sounds and sound units commonly found in normal speech, but also because these children are unable to manipulate the articulators and the manner and places of articulation.
In addition, because of dysarthria, these children repeat the same sound, syllable, word, or phrase over and over again. Their speech movements are slow, labored, and repetitive. In effect, their tongue and the other parts involved in speech production do not cooperate, and are not co-ordinated properly. The tongue and/or jaw muscles may be weak.
While this is the case with spastic children, the athetoid children suffer from involuntary movements of muscles. This could result in extra sounds, noises, and clicks. Moreover, the ataxic child has disordered feedback mechanisms, apart from his difficulty with the muscles.
All these need to be overcome through patient training. Even if these are not overcome fully, some reduction in these characteristics which hamper appropriate speech production needs to be achieved. The use of a variety of articulation exercises helps accomplish this and improve speech production.
Preparations
Teach the child first to produce those sounds he is most comfortable with. Every CP child has his own distinctive profile of the mastery and use of sounds. And this profile often depends upon the condition of his muscular movement and other motor capabilities. The CP child has a lot of difficulty producing sounds and their combinations if these require tongue-tip and fine movements, and fine closure and opening of the vocal tract. On the other hand, the primary bilabial sounds p, b, and m are more easily produced.
It is important that the CP child is trained in auditory recognition and discrimination of speech sounds before he is trained to produce the sounds and their combinations.
Success with auditory recognition and discrimination helps a lot in the production of speech sounds. The CP child may be asked to listen and guess the objects/animals which produce distinctive sounds such as bells, whistles, animal sounds, people’s voices, etc. These exercises/games help the child to develop the identification, and discrimination of familiar objects around him. These help the child to develop deliberate listening skills. The sound emanating from objects, animals, and persons around him will come to signify something to him. The child will get interested and involved in what is happening around him. This listening awareness is a significant step towards inter-personal communication.
If we have a brief profile of the consonants and vowels found in the child’s speech, we can identify which sounds are not found in his speech. Some or most of these sounds may be produced by the child in isolation, but not in combination, or in words and phrases. Articulation practice is usually given for those sounds which are difficult for the child to produce. Practice is also given for the sounds which are important for meaning contrasts, but not found in the speech of the child.
Prepare a list of monosyllabic, disyllabic, trisyllabic, and multisyllabic words in the normal language. Have the sounds under focus in the initial, medial, and/or final positions in these words. Model their pronunciation before the child. Encourage him to imitate you. Repetition of this procedure is difficult, to begin with, but could be established with appropriate rewards including smiles, endearments, physical touch, and so on.
If the child shows inclination to enter into this game and is seen to succeed, the prognosis will be good. On the other hand, when the child is reluctant because of severe dysarthria and cognitive impairments, the prognosis will not be very impressive.
Under latter circumstances, the alternative is to establish some consistency in association between the syllables/words the child produces and the reference that he intends for these. Picture association practice is highly recommended here. Articulation of sounds associated with the picture presented is always more effective than mere presentation of syllables and words.
We suggest that a list of words, which would represent the child’s needs and the environment around him fairly well, be prepared for speech training purposes. If the child is more severely affected, the list would be a very short one; and if the child is moderately affected, the list would be a little longer. In any case, the list is to be treated as an open-ended one, which we would enlarge or shorten depending upon the progress the child is making. Practice with these “essential” words one by one will help create a linguistic environment for the child.
The profile of speech we have offered for CP children in the Kannada environment could also be used as a tentative profile for other Indian languages. We have focused not only upon the sounds and their combinations, but also upon the grammatical and semantic-lexical categories. Most of these may be used in the form of articulation training. In our opinion, articulation would be the major form of speech training through which training in other functions and forms of language would be carried out.
Continuous Speech Training Is Needed
A gentle, but consistent and continuous, speech training is a must for the CP child. If the child is not inherently mentally retarded, even the smallest improvement noticed in articulating a few words should be an occasion for joy and hope.
It is important to recognize that early intervention is highly useful, necessary, and relevant for the speech training of the cerebral palsied children. From birth to three years is the period for all children (including CP children) during which important cognitive and symbolic processes develop.
Speech Related Physical Training
Relaxation of the child plays a very crucial role for the success of speech training to the CP child. Stabilization of the muscles of the neck, shoulders, and trunk is also very important. Various types of stabilization techniques have been tried. These include a chin strap for the control of the lower jaw, use of sandbags to stabilize the shoulders, and holding the arm of the child to keep it steady while he concentrates on speech production.
The caregivers should position themselves in such a way that the child is able to see their lip movements. They should be in front of the child and in a convenient eye level for the child so that he need not make any extra effort to look up to the caregivers.
Chewing, sucking, and swallowing are the processes in which the CP child needs to be trained. This feeding training is usually given by the occupational therapist. So, the speech therapist or the caregiver who is involved in giving speech training should establish a close coordination with the occupational therapist.
There are several simple practical steps that the caregiver could adopt in getting a steady prolongation of the exhaled breath from the CP child. The child may be encouraged to keep the flame of a candle bent for a while. A few times, the candle will be blown out! But soon the child will be able to prolong his exhalation. Perhaps, in the initial steps, a funnel could be given to the child to blow the air through. Similar blowing activities are suggested in the literature which include blowing a ping-pong ball up an inclined plane, blowing plastic bubbles, and blowing toy wind instruments.
To increase the participation and motivation of the child, the caregiver may pretend to have a contest between the child and herself in bending the flame of the candle. Praise and recognition help the child to try her best to perform the task. The caregiver touches the nose, or strokes the throat, tongue, and lips gently to make the child feel and recognize the direction in which the air is blown.
Social and Vocal Stimulation
Continued social and vocal stimulation leads to an increase in the frequency of emission of the sounds even in CP children. The improvement is slow in coming, but it is noticeable. It is suggested that group activities with other CP children be planned. When group activities are performed, there will be greater mutual social stimulation among the children, and a sense of competitive achievement is instilled in them.
Breathing and Speech
The CP child is able to breathe better silently. His breathing during speech is more labored. The diaphragmatic pattern of breathing is not replaced completely by the thoracic pattern of breathing as in normal children. The child is not able to take deep inhalation and to prolong exhalation necessary for articulation of multisyllabic words.
For this reason, our speech training should focus on teaching single syllable normal words (not single sounds in isolation) in the early intervention stages. Continued practice of these words would establish some control of breathing patterns associated with speech production. Note, however, that sustaining this practice requires social stimulation. While imitation is important in speech training sessions, social stimulation elicits imitation indirectly in normal conversations, as well as in other types of interactions between the caregiver and the child.
The tension in the laryngeal and pharyngeal regions needs to be controlled or modified. This is an important goal in the speech training of the cerebral palsied. Once again, we do not have many effective ways of accomplishing this. However, practice and play with single syllabic words which have velar and post-velar sounds in the initial position, along with picture stimulation, is helpful.
Omissions and Substitutions
In the speech of the cerebral palsied there are more omissions than substitutions. So, it is important for us to decide whether the particular word uttered by the CP child has undergone omission or substitution.
If there is omission, our focus should be to build on what the child already has. Adding syllables one by one to the word would be a good strategy.
Substitutions, however, would require a different strategy. Where these substitutions fall under specific patterns, we may be able to identify the frequently occurring words and devise an articulation exercise for them in the case of the child who is mildly or moderately affected. In the case of a CP child who has a moderate to severe palsy condition, the focus need not be on the modifications of substitutions which are consistently made. The focus should be on those types of substitutions which are sporadic and inconsistent.
Partial Similarity and Approximations
Since voiceless sounds are more difficult than the voiced sounds for the CP child to produce, therapy programs in Indian languages may have to focus on the child’s production and use of voiced sounds in place of voiceless sounds. Again, such a drastic limitation in the goal of speech therapy is suggested only in the case of the severely affected CP child.
Our general recommendation is that, based on the speech profile of a CP child, we should make a tentative distinction between sounds, the pronunciation of which may be achieved in isolation and in combination with other sounds in words, and sounds whose pronunciation may not be achieved at all in these contexts by the child. Under the latter category are sounds that require finer positioning of the articulators. Information on the severity of the disorder will give us some help in this process of classification.
Words for Speech Training
One of the most important decisions we need to make is the number and kinds of vocabulary we wish to teach the child through speech training. Another important decision to make is the extent to which the child’s utterances must match the words in normal language. Partial similarity in form with a steady consistency in its usage and reference should be more than adequate as the goals of speech training for the moderate to severely affected CP child.
Goal of Speech Training
An analysis of the environment of the child, and the identification of the words that are needed and frequently used to meet his needs and to communicate with him, are the next two important steps. Matching this information with what is presumed to be possible for the child to produce and what is not, and linking the same with any consistent patterns noticed in the production of the utterances will help us fix a linguistic domain of sounds, words, phrases, and sentences which should be the focus of speech training.
The goal of speech training for the cerebral palsied child will vary from child to child. In most cases, approximating to the normal language use including pronunciation and clarity, is not the goal. For example, it is commonly found that the CP child is able to produce and retain the initial syllable better than the middle syllable, and the middle syllable better than the final syllable in a word. Few sounds in the final position are mastered. If consistency of patterns could be maintained, we may not insist on the mastery of the full forms of words.
We feel that the current therapies and training offered to CP children in India do not focus their attention adequately on the need to develop speech and language capabilities in these children. It is important to recognize that communication via language and nonverbal means are basic to the development of other cognitive and social skills.
Role of the Parents
Often the families, especially those of the lower socio-economic classes, do not realize the importance of continued parental discourse to these children, even when the children do not talk to them. We have seen many parents who really love their CP children, but when it comes to having a conversation with them, they are not very enthusiastic about it.
Encourage the parents and siblings to talk to the CP child in a normal way, and let there be a lot of such conversations.
Thus, a major responsibility of the speech and hearing caregiver is to train the parents concerning how to talk to the CP child, and to tell them what they should and should not expect from the child. The parents have God-given instincts to understand and communicate with their children, but such instincts are dimmed because of the traumatic context in which they are placed now.
Note that parental training assumes greater importance in Indian contexts in which most women continue to be illiterate or are insufficiently educated to be able to seek on their own access to information and self-training. In the early years, mothers become the primary source of oral and physical training. Hence, it may be advisable to impart training to the mothers regarding all aspects of cerebral palsy.
The parents and caregivers should provide verbal and motor models to the child through play-like situations. The caregiver lifts her hand, for example, and while doing so she says a word selected from the list of words the child is ultimately expected to master. Oral production and manual manipulation of limbs should go together or follow in quick succession. Mothers need to be educated about the importance of early interaction between them and their children.
Sensory Story Method
It is important for the mothers to get their CP children involved in conversation with them, whether the child responds orally or not. Often mothers tell stories to their infants while feeding them. In many of these stories, the infant is the hero. The child may not fully understand the story, but he or she enjoys being the central part of the story. The child begins to associate himself or herself with the characters in the story, and begins to develop an empathy and an emotional bonding. This technique, used by all mothers, has been developed into a method, called the Sensory Story method. This has been effectively used to involve the CP child in a communication process.
Use of Confined Space
Another important method is the use of confined space. This may be a little playhouse in which the children are allowed complete freedom. When a CP child comes into contact with other CP children in this confined space, they develop some identity among themselves, and a fused communication process involving both oral and non-oral social activity results. The CP children are exposed to a variety of sensory experience in the confined space. This helps improve their readiness to use language and other communicative tools. In addition, confined space experience helps the children to develop an awareness of the environment, encourages them to do some goal-oriented activity, and helps develop peer relationships.
More on Mother’s Role
As already pointed out, mothers tend to talk less to their handicapped children. With so much to do to take care of the infant, it is quite natural that the mother feels put out when her disabled child does not respond to her initiative to talk and play with him. This unfortunately forces the mother to decrease her vocal play with the child. Sometimes, the vocal spasms of the disabled child may sound so violent that they frighten the mother and she starts feeling that vocal play causes pain to her child. This, in turn, forces the mother to further reduce her own vocal play with the child.
As Lencione pointed out, there is a great need “to show the mother in the home how to become the mother of a deviant child. This includes helping her to learn how to bathe, feed, dress, and play with the child; how to work through her own feelings of depression, and in some cases guilt, concerning her handicapped baby; how to cope with her child’s often bizarre responses, or lack of response; how to learn to talk to her child, and to pick up cues which will help her recognize the baby’s vocalizations and gurglings, even though they are infrequent or different from those of other children of the same age” (Lencione, “The Development of Communication Skills” in Cruickshank 1976:215).
Another recommendation given by the experienced speech therapists is that the mothers keep a record of the child’s vocalizations to find out the times during which most verbal activities (such as cooing, babbling, singing, and talking) take place. This may take place in the morning after awakening for some children, during or after bathing, or during feeding.
“Even minimal amounts of vocalization by the baby spur most mothers, without any training on the part of the facilitator, to begin to respond to their baby’s babblings by more frequent eye contact and play activities” (Lencione, “The Development of Communication Skills,” in Cruickshank 1976:216).
Lencione and others have recommended that the mothers learn to position their children “for head and sitting control during feeding, which also facilitates more frequent vocalizations; and how to use toys and other common objects in the home in meaningful play activities” (Lencione, “The Development of Communication Skills,” in Cruickshank 1976:216).
Finnie (1974:138) states that “a baby learns and forms concepts by mouthing, handling, manipulating, playing and listening to your talking about the objects you are showing him. Use the parts of his body, simple elementary toys, the things that you use when feeding, bathing, dressing him and so on. Do not expect the young child to maintain his interest and to want to take part in such play for more than a short time, nor expect any immediate verbal reaction from him, let alone imitation of your talking - stop while he still has fun and he will be eager to go to on the next time.”
We give below a few speech training activities commonly and successfully implemented:
Several suggestions have been made in the earlier chapters concerning the coordination of non-speech activities such as the mastication process with speech.
Remember that general tongue activity and other muscular coordination helps the CP child in her speech production. The specific movements required for speech production may or may not be derived from the other basic tongue, lip, or jaw movements. But the problem of the CP child is getting her to produce the movements in general. Transfer from the general movements to the movements specific to speech production is recommended by many speech therapists. The child demonstrates many random movements when she is under pain or stress. She demonstrates many random movements when something tasty is placed on her tongue. Such random movements may be observed and recorded so that the same could be used for deliberate speech production through the training process.
Speech training of the CP child is a specialized task which is more effectively carried on with the help of a speech therapist. The speech therapist may use several methods such as the stimulus-response method, the phonetic-placement method, etc. Often she combines aspects of different methods to work out a strategy of speech training suitable to the particular CP child, taking into account the existing speech capabilities of the child. The parents would do well to have the guidance of a speech therapist for a suitable follow up at home. Needless to say, the parents/caregivers who spend more time with the child than the therapist need to be imaginative in carrying out the suggestions of the therapist. Often the experience of the parents and the information the parents provide to the therapist would guide and modify the therapy program itself.
Problems of Belief Systems
Parents often blame themselves for the birth of their CP children. They argue within themselves and with others that if only they had handled this or that more carefully their child would be in perfect, normal condition. As Burke (1991:36) states, “....in many cases it is virtually impossible to pinpoint the exact moment when the brain damage occurred.” While adequate precautions during pregnancy, birth, and immediately after birth would help reduce the occurrence of cerebral palsy, worry and blaming oneself does not help the parents or the CP children. More often than not, the continued sense of guilt results in negligence of the child, which is more damaging than the damage already caused to the child.
Parents often wonder and ask why this happened to them and not others. They begin to think that perhaps what they did in their previous birth has resulted in this present suffering for them. Sometimes they may even wonder if the child has such a disorder because in his previous birth he did something wrong.
Parents may consider that it is their fate that has led them to their present suffering. They may even wonder if it might have been a curse on their family caused by their failure to propitiate a divine or a spirit or a supernatural power or an ancestor. It could be a curse or an evil eye even from the jealous neighbor, they may think. It may have been caused by sorcery and witchcraft, which should be countered through proper consultation with a shaman or some such person endowed with supernatural powers, someone may advise them. Sometimes they may seek “scientific” answers to the question “Why me? Why my child?”
The problem of pain and suffering is an age-old riddle. Physical and biological sciences may offer etiological reasons, but they cannot answer the ultimate question “Why me? Why my child?”
Biological facts may explain and describe a condition, or how it came about, but these would not fully satisfy the troubled parents. They need a theology of hope, and a theology of patience, fortitude and prayer which would enable them to accept the condition as it is and serve their child with some reconciliation.
The sense of hopelessness leads to the cancerous growth of bitterness and scepticism. Faith in God who is loving, merciful and compassionate, who is the source of all good and no evil, who is ever-gracious and involved in our daily life, will help the parents to face the reality with confidence. This faith in God will help them to see the beauty of their child even in his so-called deficient status and come to admire and love his soul, spirit, and body as a whole. It is important to recognize the fact that a weak or deformed body has nothing to do with the beauty of the soul and spirit of the same person.
A religious teaching or a theology which claims that since the body is deformed, the soul also must be deformed or deficient in some manner because of the presumed sins of the past does not help the parents to attain a balanced attitude and right disposition towards the cerebral palsied child. A mother intuitively possesses the truth that although her child is deformed, he has a beauty of his own and this beauty comes not from his body but from his soul. Yet often she is forced into questioning her own intuitive understanding. On such occasions a theology of hope and love will certainly help her to regain her balance.
We must recognize that it is imposssible to find complete answers to the questions which rage in the minds of the parents. The Gospel of John presents an interesting episode in the ministry of Jesus Christ. It reports that when Jesus passed by, he saw a man blind from birth. The disciples of Jesus asked him, saying “Teacher, who sinned, this man or his parents, that he should be born blind?” The disciples were more interested in knowing and pinpointing the cause for the present condition than in showing a real concern and love for the blind person they encountered. The blind man became a central point in a theological debate or issue for them. On the other hand, Jesus saw it entirely from a different angle. He answered, “It was neither that this man sinned, nor his parents.” Jesus also added, “but it was in order that the works of God might be displayed in him” (John 9:1-3) meaning thereby that what has happened has become an instrument of salvation for all, if only we love, serve, and cherish this person with disability as we would any other person. The implication is that we love all without any reservation. Handicaps do not make a human being a lesser person.
Problems of Personal Psychology
Parents are shocked beyond belief when it is confirmed that their child is indeed a cerebral palsied child. There is sudden rage, grief, shock, guilt, resentment, anger, and denial in them. It is like someone dear to them has died, and they are forced into a state of mourning, from which they can never hope to free themselves.
At this moment, the parents need all the support they can get from the family, friends, and neighbors. They need the support of the medical and relief agencies, and the society at large.
The parents should be encouraged to address their emotions. They should be told that their life does not end when they discover that their child is a cerebral palsied child. Over the years they would realize that they would serve their child better if they accept the child as any other person of the family, however with some special needs. The parents should get the basic information about cerebral palsy and understand the ways and means by which they can help their CP child in the rehabilitation process. Information is absolutely important. Often lack of appropriate and correct information leads to injurious practices. They need to be introduced to the methods of handling CP children.
The members of the family, including the siblings and grandparents or other elders staying with the family, need to be educated as to their responsibilities and behavior towards the CP child. Friends and visitors need to be gently reminded of what is expected of them.
Indeed, a lot of responsibility is upon the shoulders of the parents. They need to talk to the child and encourage the child to talk. Let there be great joy when the child speaks. Let us not avoid talking to the child because he is not able to talk well or talk frequently like other children. Get yourself involved with the child.
Social Problems
Unfortunately, Indian social and economic conditions in rural areas are not congenial for the families with a cerebral palsied child. Caregiving is left entirely to the imagination of the parents. It is important that the adult education programs for the rural areas have some focus on the disordered population and how to care for them. The primary health centers in rural areas should have some provision for training the mothers of cerebral palsied children in feeding, and other child care activities.
Parents need to be treated with respect, and not pity. The parents and their CP children have a right to expect the best from the society and public agencies. And it is our responsibility to serve them with patience. This needs to be taught to young students in our classrooms, and the adults through the media.
Unfortunately, ethnic, religious, linguistic, and caste considerations still continue to cloud our thinking and our attitudes toward one another. The disabled are not only ignored, but they become the subject matter of ridicule and pointless jokes. It is important for our society to begin to assume responsibilities to take care of the diabled. Among other things, how we care for our orphans and the disabled will reveal what kind of a nation are we.
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Shyamala Chengappa, Ph. D.