In This Issue:
SPEECH TRAINING FOR THE CP CHILD IN AN INDIAN LANGUAGE CONTEXT
Shyamala Chengappa, Ph.D.
1. MAKE CP SPEECH COMPREHENSIBLE
In my earlier paper (Language in India, 1:1) I made several observations of a general nature concerning speech training for the cerebral palsied. In this paper I 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 coor-dinated 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.
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.
I 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 I have offered elsewhere (see for example, Shyamala 1991) 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
My 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.
9. 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.
10. 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.
I 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.
11. 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.
12. 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.
13. 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.
14. 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.”
15. COMMONLY USED SPEECH TRAINING ACTIVITIES
I give below a few speech training activities commonly and successfully implemented:
Settle for consistency rather than accuracy in the production of sounds normally difficult for a CP child.
Mueller suggests: “In our efforts to help the child to form concepts we should start by teaching him about his own body, the objects around him in his cot, his playpen and so on. By these means gradually widening his horizon by talking about familiar objects he knows and uses in his room. Later take him to the window and talk about the familiar scene outside
Some of the basic steps in producing speech, such as opening and closing the jaw, opening and closing the mouth, manipultion of the tongue inside the mouth, etc., are very hard to achieve for the CP child. So, initially our focus needs to be on achieving some skill in the manipulation of the mouth and the tongue. Many times the therapist may have to make the passive movements of the lips, tongue, and jaw, and opening and closing of the mouth for the child. You may place your finger on the lower teeth while your thumb is placed under the chin to make the passive movements. Therapists have suggested that we let the child see these passive movements being done to them in the mirror. While doing the passive movements, you may describe what you are doing to create a sense of association for the CP child. If the child is able to understand what you say, you can remind the child periodically to make the movements on her own. You can remind the child to make the movements properly for the production of speech.
Exercises for tongue movement should be given regularly. The child may be asked to hold a piece of paper or a tongue blade between the teeth or lips. She may be trained to hold a small object between her lips in order to strengthen the movements for opening and closing her lips. A game may be built around this exercise in which the therapist would try to pull the object out of her lips, while the child will try to hold on to it between the lips.
The coordination of non-speech activities such as the mastication process with speech needs to be emphasized.
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.
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Shyamala Chengappa, Ph.D.
All India Institute of Speech and Hearing
Mysore 570006, India