Adults and Children with Cerebral Palsy

Place of work

Speech and language therapists work in community health centres, hospital wards and outpatient departments, mainstream and special schools, further education colleges, day centers and in their clients' homes. Some now work in courtrooms, prisons and young offenders' institutions.

Some speech and language therapists who work independently will see children and adults in their own homes.

Stuttering

Stuttering (alalia syllabaris), also known as stammering (alalia literalis or anarthria literalis), is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases, and involuntary silent pauses or blocks in which the stutterer is unable to produce sounds. 'Verbal non-fluency' is the accepted umbrella term for such speech impediments. The term stuttering is most commonly associated with involuntary sound repetition, but it also encompasses the abnormal hesitation or pausing before speech, referred to by stutterers as blocks, and the prolongation of certain sounds, usually vowels and semi-vowels. The term stuttering, as popularly used, covers a wide spectrum of severity: it may encompass individuals with barely perceptible impediments, for whom the disorder is largely cosmetic, as well as others with extremely severe symptoms, for whom the problem can effectively prevent most oral communication. The impact of stuttering on a person's functioning and emotional state can be severe. Much of this goes unnoticed by the listener, and may include fears of having to enunciate specific vowels or consonants, fears of being caught stuttering in social situations, self-imposed isolation, anxiety, stress, shame, or a feeling of «loss of control» during speech. Stuttering is sometimes popularly associated with anxiety or low intelligence, but there is actually no such correlation (though as mentioned social anxiety may actually result in individuals as a result of their stuttering). Despite popular perceptions to the contrary, stuttering does not affect and has no bearing on intelligence.

Stuttering is generally not a problem with the physical production of speech sounds or putting thoughts into words. Apart from their speech impediment, people who stutter may well be 'normal' in the clinical sense of the term. Anxiety, low self-esteem, nervousness, and stress therefore do not cause stuttering per se, although they are very often the result of living with a highly stigmatized disability and, in turn, exacerbate the problem in the manner of a positive feedback system.

The disorder is also variable, which means that in certain situations, such as talking on the telephone, the stuttering might be more severe or less, depending on the anxiety level connected with that activity.

Stuttering is a disorder of childhood. The incidence of stuttering is highest from the age of six to ten: as the age of puberty is approached, the number of cases of stuttering decreases markedly. More boys than girls stutter.

This fact is certainly significant. This is because boys learn speech more slowly and are more apt to have speech defects of all kinds than girls.

Stuttering has certain hereditary aspects. The persistent recurrence of this disorder in certain families is difficult to explain merely on the basis of imitation. The fact that many of stutterers in those families had little or no contact with stuttering relatives indicated the presence of some biological transmittable factor. Twinning, lefthandedness and stuttering are often associated as hereditary factors.

The so-called speech organs of stutterers are structurally normal as in nonstutterers.

The stutterer's articulatory muscles show some slowness. He cannot move his muscles as fact, as continuously, or as independently as a non-stutterer can. During a stuttering block, a serious disorganization of the integrating centers of the central nervous system takes place. An asymmetrical action of paired muscles on the two sides of the face appears. Lack of соordination of the limbs or eyes occurs.

Characteristics

Primary behaviors

Primary stuttering behaviors are the overt, observable signs of speech fluency breakdown, including repeating sounds, syllables, words or phrases, silent blocks and prolongation of sounds. These differ in from the normal disfluencies found in all speakers in that stuttering disfluencies may last longer, occur more frequently, and are produced with more effort and strain. Stuttering disfluencies also vary in quality: normal disfluencies tend to be a repetition of words, phrases or parts of phrases, while stuttering is characterized by prolongations, blocks and part-word repetitions.

• Repetition occurs when a unit of speech, such as a sound, syllable, word, or phrase is repeated and are typical in children who are beginning to stutter. For example, to-to-to-tomorrow.

• Prolongations are the unnatural lengthening of continuant sounds, for example, mmmmmmmmmilk. Prolongations are also common in children beginning to stutter.

• Blocks are inappropriate cessation of sound and air, often associated with freezing of the movement of the tongue, lips and/or vocal folds. Blocks often develop later, and can be associated with muscle tension and effort.

Secondary behaviors

Secondary stuttering behaviors are unrelated to speech production and are learned behaviors which become linked to the primary behaviors.

Secondary behaviors include escape behaviors, in which a stutterer attempts to terminate a moment of stuttering. Examples might be physical movements such as sudden loss of eye contact, eye-blinking, head jerks, hand tapping, interjected «starter» sounds and words, such as um, ah, you know. In many cases, these devices work at first, and are therefore reinforced, becoming a habit that is subsequently difficult to break.

Secondary behaviors also refer to the use of avoidance strategies such as avoiding specific words, people or situations that the person finds difficult. Some stutterers successfully use extensive avoidance of situations and words to maintain fluency and may have little or no evidence of primary stuttering behaviors. Such covert stutterers may have high levels of anxiety, and extreme fear of even the most mild disfluency.

Variability

The severity of a stutter is often not constant even for severe stutterers. Stutterers commonly report dramatically increased fluency when talking in unison with another speaker, copying another's speech, whispering, singing, and acting or when talking to pets, young children, or themselves. Other situations, such as public speaking and speaking on the telephone are often greatly feared by stutterers, and increased stuttering is reported.

Feelings and attitudes

Stuttering may have a significant negative cognitive and affective impact on the stutterer. In a famous analogy, Joseph Sheehan, a prominent researcher in the field, compared stuttering to an iceberg, with the overt aspects of stuttering above the waterline, and the larger mass of negative emotions invisible below the surface. Feelings of embarrassment, shame, frustration, fear, anger, and guilt are frequent in stutterers, and may actually increase tension and effort, leading to increased stuttering. With time, continued exposure to difficult speaking experiences may crystallize into a negative self-concept and self-image. A stutterer may project his or her attitudes onto others, believing that they think he or she is nervous or stupid. Such negative feelings and attitudes may need to be a major focus of a treatment program.

Sub-types

Developmental

Stuttering is typically a developmental disorder beginning in early childhood and continuing into adulthood in at least 20% of affected children. The mean onset of stuttering is 30 months. Although there is variability, early stuttering behaviours usually consist of word or syllable repetitions, and secondary behaviours such as tension, avoidance or escape behaviours are absent. Most young children are unaware of the interruptions in their speech. With early stutterers, disfluency may be episodic, and periods of stuttering are followed by periods of relative fluency. Though the rate of early recovery is very high, with time a young stutterer may transition from easy, relaxed repetition to more tense and effortful stuttering, including blocks and prolongations. Some propose that parental reaction may affect the development of chronic stutter. Recommendations to slow down, take a breath, say it again, etc may increase the child’s anxiety and fear, leading to more difficulties with speaking and, in the “cycle of stuttering” to ever yet more fear, anxiety and expectation of stuttering. With time secondary stuttering including escape behaviours such eye blinking, lip movements, etc. may be used, as well as fear and avoidance of sounds, words, people, or speaking situations. Eventually, many become fully aware of their disorder and begin to identify themselves as «stutterers.» With this may come deeper frustration, embarrassment and shame. Other, rarer, patterns of stuttering development have been described, including sudden onset with the child being unable to speak, despite attempts to do so. The child usually blocks silently of the first sound of a sentence, and shows high levels of awareness and frustration. Another variety also begins suddenly with frequent word and phrase repetition, and do not develop secondary stuttering behaviours.

Acquired

In rare cases, stuttering may be acquired in adulthood as the result of a neurological event such as a head injury, tumour, stroke or drug abuse/misuse. The stuttering has different characteristics from its developmental equivalent: it tends to be limited to part-word or sound repetitions, and is associated with a relative lack of anxiety and secondary stuttering behaviors. Techniques such as altered auditory feedback (see below) which may promote fluency in stutterers with the developmental condition, are not effective with the acquired type.

Psychogenic stuttering may also arise after a traumatic experience such as a bereavement, the breakup of a relationship or as the psychological reaction to physical trauma. Its symptoms tend to be homogeneous: the stuttering is of sudden onset and associated with a significant event, it is constant and uninfluenced by different speaking situations, and there is little awareness or concern shown by the speaker.

Although the exact etiology of stuttering is unknown, both genetics and neurophysiology are thought to contribute. There are many treatments and speech therapy techniques available that may help increase fluency in some stutterers to the point where an untrained ear can not identify a problem; however, there is essentially no «cure» for the disorder at present.

Causes of Developmental Stuttering

No single, exclusive cause of developmental stuttering is known. A variety of hypotheses and theories suggest multiple factors contributing to stuttering. Among these is the strong evidence that stuttering has a genetic basis. Children who have first-degree relatives who stutter are three times as likely to develop a stutter. However, twin and adoption studies suggest that genetic factors interact with environmental factors for stuttering to occur, and forty to seventy percent of stutterers have no family history of the disorder. There is evidence that stuttering is more common in children who also have concomitant speech, language, learning or motor difficulties.

In some stutterers, congenital factors may play a role. These may include physical trauma at or around birth, including cerebral palsy, retardation, or stressful situations, such as the birth of a sibling, moving, or a sudden growth in linguistic ability.

There is clear empirical evidence for structural and functional differences in the brains of stutterers. Research is complicated somewhat by the possibility that such differences could be the consequences of stuttering rather than a cause, but recent research on older children confirm structural differences thereby giving strength to the argument that at least some of the differences are not a consequence of stuttering.

Auditory processing deficits have also been proposed as a cause of stuttering. Stuttering is less prevalent in deaf and hard of hearing individuals, and stuttering may be improved when auditory feedback is altered, such as masking, delayed auditory feedback (DAF), or frequency altered feedback. There is some evidence that the functional organization of the auditory cortex may be different in stutterers.

There is evidence of differences in linguistic processing between stutterers and non-stutterers. Brain scans of adult stutterers have found increased activation of the right hemisphere, which is associated with emotions, than in the left hemisphere, which is associated with speech. In addition reduced activation in the left auditory cortex has been observed.

The capacities and demands model has been proposed to account for the heterogeneity of the disorder. In this approach, speech performance varies depending on the capacity that the individual has for producing fluent speech, and the demands placed upon the person by the speaking situation. Capacity for fluent speech, which may be affected by a predisposition to the disorder, auditory processing or motor speech deficits, and cognitive or affective issues. Demands may be increased by internal factors such as lack of confidence or self esteem or inadequate language skills or external factors such as peer pressure, time pressure, stressful speaking situations, insistence on perfect speech, and the like. In stuttering, the severity of the disorder is seen as likely to increase when demands placed on the person's speech and language system is exceeded by their capacity to deal with these pressures.

The Treatment of Stuttering

It is necessary for parents and teachers to соoperate with the specialist (speech therapist) in the treatment or stuttering. Imitating factors in the environment should be removed. We have a problem of preventing the development of fears and anxiety. The stuttering spasms usually produce fear and anxiety; they, in turn, result in more serious and complex speech blocks. The speech -therapist who examines the cases of stuttering will indicate, of course, the specific measures for the treatment of each case. These specific measures are different. There is no sudden cure, but there is every reason to hope for improvement.

First of all the specialist should persuade the patient that the first thing which he must understand is he must learn to live with the stuttering. Of course he does not want to stutter, he would prefer not to stutter. However the more he tries to avoid stuttering the more he stutters. When he acquires the objective attitude to his stuttering, the second phase of therapy may be begun, namely, the process of eliminating the habit of substituting other words for words upon which the stutterer fears he will block. As the speech of the stutterer is rapid, stirred, indistinct, it is desirable to give the stutterer the opportunity to participate in choral reading and singing. A very important aspect in speech training for the stutterer is the acquisition of slow speech of a normal rhythm.

The general principle for speech therapy is this: a) seek to discover and remove all the possible irritating factors in the child's environment, b) prevent the development of fear and anxiety about his speech, c) promote the growth of personality and social adjustment. Since stuttering is a disorder of childhood, it is more than probable that as the processes of normal maturation take place the symptoms of stuttering will gradually disappear, if a good therapy is applied in treatment of such stuttering children. There is not one simple procedure for treatment, they are many. The speech therapist must have some information about the child: 1) Does he stutter every time he talks or is it spasmodic? 2) Is it getting worse? 3) Does it appear in his speech when he is on the playground, as well as in the classroom? 4) Is there any relationship between appearance of the stuttering and his apparent physical condition, emotional state, persons with whom he talks, topics of conversation, time of day, attitude of the teacher?

This information is important to choose the most effective procedures for the treatment of stuttering.

Fluency shaping therapy

Fluency shaping therapy, also known as «speak more fluently», «prolonged speech» or «connected speech», trains stutterers to speak fluently by controlling their breathing, phonation, and articulation (lips, jaw, and tongue). It is based on operant conditioning techniques.

Stutterers are trained to reduce their speaking rate by stretching vowels and consonants, and using other fluency techniques such as continuous airflow and soft speech contacts. The result is very slow, monotonic, but fluent speech used only in the speech clinic. After the stutterer masters these fluency skills, the speaking rate and intonation are increased gradually. This more normal-sounding, fluent speech is then transferred to daily life outside the speech clinic, though lack of speech naturalness at the end of treatment remains a frequent criticism. Fluency shaping approaches are often taught in intensive group therapy programs, which may take two to three weeks to complete, but more recently the Camperdown program, using a much shorter schedule, has been shown to be effective.

Stuttering modification therapy

The goal of stuttering modification therapy is not to eliminate stuttering but to modify it so that stuttering is easier and less effortful. The rationale is that since fear and anxiety causes increased stuttering, using easier stuttering and with less fear and avoidance, stuttering will decrease. The most widely known approach was published by Charles Van Riper in 1973 and is also known as block modification therapy.

As proposed by Van Riper, stuttering modification therapy has four overlapping stages:

• In the first stage, called identification, the stutterer and clinician identify the core behaviors, secondary behaviors, and feelings and attitudes that characterize the stuttering.

• In the second stage, called desensitization, the stutterer works to reduce fear and anxiety by freezing stuttering behaviors, confronting difficult sounds, words and situations, and intentionally stuttering («voluntary stuttering»).

• In the third stage, called modification, the stutterer learns «easy stuttering.» This is done by «cancellations» (stopping in a dysfluency, pausing a few moments, and saying the word again); «pull-outs,» or pulling out of a dysfluency into fluent speech; and «preparatory sets,» or looking ahead for words one may stutter on, and using «easy stuttering» on those words.

• In the fourth stage, called stabilization, the stutterer prepares practice assignments, makes preparatory sets and pull-outs automatic, and changes their self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly.

Electronic fluency devices

Altered auditory feedback, so that stutterers hear their voice differently, have been used for over 50 years in the treatment of stuttering. Altered auditory feedback effect can be produced by speaking in chorus with another person, by blocking out the stutterer's voice while talking (masking), by delaying the stutterer's voice slightly (delayed auditory feedback) and/or by altering the frequency of the feedback (frequency altered feedback). Studies of these techniques have had mixed results, with some stutterers showing substantial reductions in stuttering, while others improved only slightly or not at all. In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups.

Prognosis

Among preschoolers, the prognosis for recovery is good. Based on research, about 65% of preschoolers who stutter recover spontaneously in the first two years of stuttering, and about 74% recover by their early teens. In particular, girls seem to recover well. For others, early intervention is effective in helping the child achieve normal fluency.

Once stuttering has become established, and the child has developed secondary behaviors, the prognosis is more guarded, and only 18% of children who stutter after five years recover spontaneously. However, with treatment young children may be left with little evidence of stuttering.

With adult stutterers, there is no known cure, though they may make partial recovery with intervention. Stutterers often learn to stutter less severely and be less affected emotionally, though others may make no progress with therapy.

Epidemiology

The lifetime prevalence, or the proportion of individuals expected to stutter at one time in their lives, is about 5%, and overall males are affected two to five times more often than females. Most stuttering begins in early childhood and according studies suggest 2.5% of children under the age of 5 stutter. The sex ratio appears to widen as children grow: among preschoolers, boys who stutter outnumber girls who stutter about two to one, or less, but widens to three to one at first grade and five to one at fifth grade, due to higher recovery rates in girls. Due to high (approximately 65–75%) rates of early recovery, the overall prevalence of stuttering is generally considered to be approximately 1%.

What is Apraxia?

Developmental Verbal Dyspraxia or Developmental Apraxia of Speech?

These two terms are generally synonymous. Developmental verbal dyspraxia is often shortened to «DVD» and developmental apraxia of speech to «DAS». The «a» in «apraxia» stands for absence and «dys» in dyspraxia stands for partial. Thus, apraxia is absence of speech and dyspraxia is used by some to indicate some speech ability. «Praxis» indicates difficulty executing skilled movements. However, more recently Childhood Apraxia of Speech is the preferred term for describing apraxia of speech in children.

Oral Apraxia and/or Verbal Apraxia?

Oral apraxia indicates that the child has difficulty with volitional control of nonspeech movement. For instance, perhaps the child will have difficulty sticking out and wagging their tongue when requested to do so. Or the child may have difficulty sequencing movements for the command, «Show me how you kiss, now smile, now blow». Verbal apraxia indicates that the child has difficulty with volitional movement for the production of speech. This can be at the level of sounds, syllables, words, or even phrases (connected speech). The motor struggle is most typically seen with sounds sequencing.

Often oral apraxia accompanies verbal apraxia, but that is not always the case. Speech and language pathologists have mentioned that it is very rare and fairly unheard of for a child to have oral apraxia without verbal apraxia/dyspraxia.

Volitional -- What does it Mean?

In the course of discussing apraxia, as we have above, you will note the use of the word «volitional». The meaning of this word in relationship to apraxia/dyspraxia of speech means that the child is experiencing the difficulty in nonspeech and speech movement when they are very consciously aware of trying to make movements or they are attempting movements when requested by others. Those same movements, sounds, etc. may be heard while the child is busy playing or he/she just seems to blurt out when no one is really paying attention or trying too hard. As an example, the child may be playing happily and parents may hear sounds being made - almost without thought - «ma, ma, ba, ma,da». However, when the parents attempt to get the child to use those sounds - «Say Mama!»- the child is unable to do so. In many cases one can see the struggle on the child's face. They may grope with their lips or silently posture their lips as if searching for the position they need. One minute they could do it (when not thinking about it or attempting the task) and the next minute it is an intense struggle (they are now aware of the request and are trying to will their mouths to make those movements - volitional control).

«Pure» Apraxia of Speech:

What is meant by «pure» apraxia of speech is that no other speech, language, cognitive, or sensory issues coexist with the deficit of impaired sequencing for volitional speech (apraxia). The professional literature tells us that «pure» apraxia of speech in children is rare, that most often apraxia is associated with other speech, language, cognitive, and/or sensory issues. Paula Square states that,

«In its purest form, acquired apraxia of speech does not coexist with language impairments, auditory processing deficits, or cognitive deficits. Nonetheless, 'pure' apraxia of speech rarely occurs. Coexisting deficits for expressive language, psychoacoustic processing, and motor execution are likely to occur in both acquired apraxia of speech and DAS (developmental apraxia of speech) because of the proximity of the neural structures underlying each of these processes to those that generate programs for praxis. A review of the literature suggests that co-occurence of language impairment with both acquired apraxia of speech and DAS is frequent...»

Associated issues might not be apparent in a young child. This is especially true in children who are young preschoolers. For instance, these children may not have any apparent problem with receptive language according to traditional and typical assessment. However, the child may begin to experience difficulty when entering kindergarten, when the language processing demands of the setting are heightened. It would not be unusual to then identify higher level language processing problems. Parents and professionals will do well to be vigilant about the child's total development to insure that, should an associated area of difficulty arise, help for the child will be readily available.

A Case Study of Childhood Apraxia of Speech

by Patti Hamaguchi, M.A., CCC-SLP

Jamie, a six year-old boy, moved into town and entered first grade. He was very unintelligible (hard to understand), but seemed to have a lot to say.

His teacher said he did well on many of the math papers, but struggled with letters and sounds. Jamie had been receiving speech therapy for the past year and a half in his previous school, but his mother reported little noticeable progress.

We did a more complete educational evaluation, including a speech-language assessment. We found that Jamie had some fine-motor weaknesses and sensory integration delays, which were identified by the occupational therapist. The fine-motor weaknesses explain why he had such difficulty with such things as gripping his pencil and writing his letters on the line in an appropriate way. The sensory integration difficulties also explained why he was resistant to wearing clothes of different textures, was knocking into walls as he walked, and didn't seem to sense when crumbs were left on his mouth after snack. The occupational therapist («OT») began therapy once a week in a small group in the therapy room. Later in the year, much of the therapy was done in the class.

The special education teacher did a learning disabilities assessment and found there was difficulty in most areas related to sequencing. Jamie could not put pictures of a story sequence in order, repeat words in order, or copy letters in order. His letter-sound understanding («S» says «sss») was adequate. He could read some memorized words, but could not sound out a new word, even when he knew each sound in the word. His math skills seemed to be age appropriate and his attention span was good. Special education help was initiated, with the special education teacher going into the first grade class to help Jamie during Language Arts.

In terms of the speech-language assessment, I found that Jamie's difficulties were a pretty classic case of «dyspraxia», also known as «Developmental Dyspraxia of Speech» or apraxia. While he had been previously identified as having a severe articulation disorder, the word dyspraxia never appeared in any of his previous evaluation reports. How did I know? Jamie was able to produce nearly all the vowel and consonant sounds in isolation. If I said, «Jamie, say 'ah' (as in *apple*), he could do it. He could say «apple» if he concentrated. He could say «pie». But if I asked him to say «apple pie», this is what I heard: «paboo bie». If I asked him to say it three times, I would get three answers. Another attempt might sound like «pappie bah». There was no consistency. He often produced single words clearly, but fell apart in phrases and conversation. Words with more than one syllable were also much more difficult for him to pronounce. Sounds that were produced in one word (the «s» in «bu*s*») were left off in other places («s» in the phrase «I *s*ee»). Moreover, his global difficulty with sequencing, fine-motor, and sensory integration was typical for children with dyspraxia. He could tell what he said wasn't sounding right, and was visibly frustrated, but couldn't sequence the sounds and syllables to match what I said.

This might explain why his previous therapy, which consisted of ear training and traditional articulation therapy (where he worked on one sound at a time in single words) wasn't producing any significant change. He was also getting oral-motor therapy designed to strengthen his muscles. I'm guessing the previous therapist knew his mouth wasn't doing something right. However, when I saw Jamie, his tongue, lips, and other muscles were not weak or lacking control during nonspeech tasks. Perhaps the therapy had done its job, I couldn't tell. While some children with dyspraxia have difficulty with verbal as well as nonverbal oral movements, Jamie did not. He was able to open his mouth, stick out his tongue, and perform a variety of other commands with normal timing and precision. His chewing, drinking and swallowing were normal. His tongue did not protrude at rest, his jaw did not slide during speech tasks, and he did not drool.

Lastly, Jamie's sentence structure (syntax) was fragmented. He said things such as Morrow I bay di my dend (Tomorrow I play with my friend) and I noticed some word-retrieval difficulties in conversation and on picture-naming tests. That is, he recognized a word's meaning when he heard it, but could not remember it when asked to name a picture. This too, is not uncommon with dyspraxic children.

In terms of therapy, I began a very structured, systematic approach. I incorporated a variety of methods, such as the PROMPT technique (The PROMPT approach (Prompts for Restructuring Oral Muscular Phonetic Targets) was first developed by Deborah Hayden in the 1970s) and drills which work at the syllable level, then are incorporated into phrases and conversation. Words that were too difficult for Jamie to produce but of high interest, were broken down into easier «versions» so he could at least approximate a consistent way of saying what he wanted. I also began using the Phonemic Synthesis program, which helps children auditorily learn to blend sounds and sequence them. This helps their speech, decoding, spelling, and word retrieval. Initially, individual sounds within a syllable or word were cued with gestures to help Jamie sequence them. As he improved, each word in a phrase was cued. Without a great deal of home practicing, all of my efforts would have been of little benefit. However, Jamie and his mother were diligent and it paid off.

By the middle of second grade (a year and a half later), Jamie's speech was significantly improved. By the beginning of fourth grade, he was done with articulation therapy and occupational therapy. However, Jamie still needed some special education support in Language Arts and work on developing his expressive language. As is sometimes the case, Jamie will most likely need some kind of speech and/or special education assistance for awhile. But he is a «normal» boy and looks and sounds like the rest of his friends at this writing.

Apraxia? Dyspraxia? Articulation? Phonology? What Does It All Mean?

By Nancy Lucker-Lazerson, M.A., CCC-SLP

Your two-year-old says no words, makes some sounds, yet he understands everything you say. Your five-year-old speaks in what appear to be sentences, but all you hear are vowel sounds. Your seven-year-old lisps, and says wabbit instead of rabbit. And your three-year-old talks non-stop, but no one can understand a word that he says. So what do you do? If you bring your child to a speech-language pathologist (SLP), the first two children would probably be diagnosed as having oral-motor planning deficits, or Childhood Apraxia of Speech (CAS). The third child has an Articulation disorder, and the fourth child has a Phonology disorder. Now that you know that, what does it all mean?

Oral-Motor Speech Disorders

Childhood Apraxia of Speech is a deficit in the ability to plan the motor movements for speech and is considered an oral motor planning disorder. Children with CAS have difficulties transmitting the speech message from their brain to their mouths. Children with significant weakness of the lips, tongue, and jaw may be diagnosed by a neurologist as having Dysarthria. Many children with cerebral palsy and multiple sclerosis have Dysarthria. CAS is usually of unknown origin. Whether or not we know the cause, SLPs can treat the disorder.

Oral-motor disorders are diagnosed by the SLP directly observing the child and completing an examination of both the childs speech and oral mechanism. The oral mechanism exam involves the SLP asking the child to do a variety of tasks (such as pursing lips, blowing, licking lips, elevating tongue, etc.), looks inside the child's mouth, observes the child eating, and listens to the child talk. The therapist will also listen for the child's ability to produce rapid oral movements. A diagnosis of CAS involves consonant and vowel distortions, distorted sound substitutions, errors consistent in type and place, and prosodic errors (prosody refers to pitch, rate, and rhythmic features of speech). Some other behaviors seen in CAS include groping, perseverative errors, and increasing errors as the length of utterance increases. The SLP will determine how «intelligible» the child is (how much of what the child says can other people understand?), and may complete a formal test (like the Kaufman Speech Praxis Test). Like a detective, a good diagnostician looks at many variables before making a diagnosis.

For children who have CAS, therapy should address the movement patterns in syllables, progressing from the simple (one-syllable words with similar sounds at the beginning and end, like «pop» «mom» and «cake») to the complex (multi-syllabic words with many different sounds). There may also be a need to teach more functional responses (e.g. yes, no, I want, I dont want, I need, etc.). In more severe cases of CAS, a child may require an alternative/augmentative form of communication, such as sign language, a communication board, or an AAC (Augmentative/Alternative Communication) device. These are not intended to replace oral speech, but in fact, to facilitate it and to provide the child with a means of communicating with others. Therapy also needs to address prosody. Frequent drill and repetition is required for therapy to be successful. Intense, individual therapy is ideal for CAS. Group therapy is not recommended for CAS, and children with moderate to more severe deficits will require therapy for a number of years.

Articulation Disorders

When a child has a simple lisp (producing [th] instead of [s], like thing instead of sing or yeth instead of yes), substitutes [w] for [l] or [r], or other similar errors, they are demonstrating an articulation disorder. Articulation refers to the manner in which a child produces a sound and the placement of the tongue, lips, and teeth. Common articulation errors are those listed above, in addition to [f] for [th] (fum for thumb), [l] for [y] (lelo for yellow). Traditional thinking has been that some articulation errors are developmental in nature (e.g. s, l, r) and that children may not be ready to address them in therapy until a specific age (typically 7 or 8). However, however, current research has disproved the idea of developmental norms for articulation, and in fact, current best practice involves starting treatment with the more difficult sounds. In addition, the earlier therapy begins, the more successful it will be. Articulation errors may not significantly reduce the child's ability to be understood.

Articulation therapy consists of drill exercises and various cues to help the child correct their sound productions. These cues may be verbal (e.g. tell the child where to place his tongue) or visual (having the child look at the therapist's mouth or in a mirror) or tactile (i.e. touch; e.g. having the child slide their finger down their arm when making the [s] sound). Frequent practice is essential for articulation therapy to be successful.

Phonological Disorders

Phonology is the sound system of language. The phonology of language tells us how sounds fit together in words. Children who have phonology disorders have not learned the rules for how sounds fit together to make words, and use certain processes to simplify words. Phonology disorders are related to language and reading and are now seen as a language-based disorder. Children with phonology disorders are frequently unintelligible; often, their parents are the only ones who can understand them, and even they have difficulties. Children with these disorders are at a very high risk for later reading and learning disabilities, and should be treated with intensive speech therapy as soon as they are diagnosed, as early as age 3.

A phonology disorder is most commonly diagnosed using the Assessment of Phonological Processes by Barbara Hodson. This test analyzes (by hand, or through a computer program) the patterns that a child is producing as they say 50 words. A phonological analysis can also be completed informally. There are other tests for phonology available, but the Hodson is the most widely used.

There are many different phonological processes which SLP's see and treat. One of the most common is called «cluster reduction». Children who use this process will take a sound blend (like [bl] [sp] or [tr]) and omit one of the sounds: blue becomes boo, spoon becomes poon, and tree becomes ti. Another common process is called «velar fronting». Children who use this process substitute sounds produced in the front of the mouth (t, d, n) for sounds produced in the back of the throat (k, g). In this instance, duck becomes guk, car becomes tar, go becomes do and can becomes tan.

Therapy for phonological processes involves making the child more aware of the correct sound patterns (rules) and drilling the new patterns. Awareness is frequently achieved through what is referred to as «auditory bombardment»; using an amplifier and headphones, the therapist will repeatedly say words using the correct patterns. One popular therapy technique for remediating phonology disorders is called «cycling», developed by Barbara Hodson. In this approach, auditory bombardment is used, and children work on a specific process for a period of time, then move onto the next process, and so on. Once through all of the processes that need remediating, the cycles are repeated again and again. Another very effective technique is called «minimal pairs». In this technique, the therapist will present a pair of words to the child that addresses the incorrect sound pattern and enables the child to first discriminate, and later produce, the differences between sound patterns; e.g. if the child is omitting sounds in blends, a pair might be Kate/skate or cool/school. If velar fronting is the problem, then a pair of words might be tar/car or tan/can. A good therapist will use a variety of techniques in order to maximize therapy time.

The most important thing to remember about speech production disorders is that therapy can, in most cases, make a huge difference. The earlier and more intensive the intervention, the more successful the therapy. Group therapy can be effective for articulation disorders and some phonology disorders, but children with CAS really need the intensive, individual therapy.

Dysarthria

After a stroke or other brain injury, the muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move at all. The resulting speech condition is called dysarthria. The type and severity of dysarthria depend on which area of the nervous system is affected.

Symptoms

A person with dysarthria may experience any of the following symptoms, depending on the extent and location of damage to the nervous system:

• «Slurred» speech

• Speaking softly or barely able to whisper

• Slow rate of speech

• Rapid rate of speech with a «mumbling» quality

• Limited tongue, lip, and jaw movement

• Abnormal intonation (rhythm) when speaking

• Changes in vocal quality («nasal» speech or sounding «stuffy»)

• Hoarseness

• Chewing and swallowing difficulty

Dysarthria is caused by many different conditions that involve the nervous system, including:

• Stroke

• Brain injury

• Tumors

• Cerebral Palsy

• Parkinson’s disease

• Lou Gehrig’s disease

• Huntington’s disease

• Multiple Sclerosis

Treatment

A speech-language pathologist (SLP) can evaluate a person with speech difficulties and determine the nature and severity of the problem. The SLP will look at movement of the lips, tongue, and face, as well as breath support for speech, voice quality, and more.

Another motor speech disorder is apraxia. An important role of the SLP is to determine whether the person's speech problems are due to dysarthria, apraxia, or both.

Treatment depends on the cause, type, and severity of the symptoms. An SLP works with the individual to improve communication abilities.

Possible Goals of Treatment

• Slowing the rate of speech

• Improving the breath support so the person can speak more loudly

• Strengthening muscles

• Increasing mouth, tongue, and lip movement

• Improving articulation so that speech is more clear

• Teaching caregivers and family members strategies to better communicate with the person with dysarthria

In severe cases, it may be impossible for the person to speak intelligibly and alternative means of communication may be needed. These range from using simple gestures or alphabet boards to more sophisticated electronic or computer-based equipment.

Tips for the Person With Dysarthria

• Introduce your topic with a single word or short phrase before beginning to speak in more complete sentences

• Check with the listeners to make sure that they understand you

• Speak slowly and loudly; pause frequently

• Try to limit conversations when you feel tired, when your speech will be harder to understand

• If you become frustrated, try to use other methods, such as pointing or gesturing, to get your message across, or take a rest and try again later

Tips for the Listener

• Reduce background noise

• Pay attention to the speaker

• Watch the person as he or she talks

• Be honest and let the speaker know when you have difficulty understanding him or her

• Repeat only the part of the message that you understood so that the speaker does not have to repeat the entire message

• If you still don't understand the message, ask yes/no questions or have the speaker write his or her message to you

Aphasia

Aphasia is by definition the generic term for loss or impairment of all forms of language as a result of brain damage. However, in practice, it is more usually confined to loss of the ability to formulate, express or understand spoken words. Individuals who were previously able to communicate through speaking, listening, reading and writing become more limited in their ability to do so. The most common cause of aphasia is stroke, but gunshot wounds, blows to the head, other traumatic brain injury, brain tumor, and other sources of brain damage can also cause aphasia.

Examination of the Aphasic Patient

The examination requires an assessment of the mental operations which transcend the mere mechanical faculty of articulated speech. The best method of evaluation of a patient with a brain abscess or tumour or following a recent head injury is by using a simple battery of tests of higher functions, including aphasia. These include:

• questions designed to assess the patient's orientation in time and space and any underlying confusional state;

• object identification for nominal aphasia or anomia;

• visual tests including reading;

• ability to perform simple tasks to command, e.g. put out your tongue, touch your ear with your right hand - basically testing for apraxia but inevitably involving speech comprehension; and

• tests of writing and drawing.

More profound and detailed testing may be required of anyone involved in the treatment of patients with cerebro-vascular disease, with encephalitis or encephalopathy after the initial stabilization of the head injury, with psychotic states, depression, and dementia. The full neurological examination should include tests of hearing, vision, e.g. visual fields and motor functions.

Formal testing is best performed through a series of short interviews of not more than 15 to 20 minutes ensuring the minimum of distraction. In the first place the patient should be encouraged to talk. Is he able to initiate or hold a conversation? How fluent, monosyllabic or telegraphic is he in his replies? Is there a paucity or superfluity of expression and gesture when speaking? Is his speech precise or empty of content? Is it grammatical? Does he have difficulty finding the right word? Does he paraphrase or show insight into the nature of his problem? Next, his comprehension is tested by asking him to perform a series of verbal commands. He is asked to reply to a series of simple questions and his fluency in reply is compared to his ability to repeat a well-known nursery rhyme or song. He is then presented with an object to name and the test can be made more complex by showing pictures or cartoons and asking him to describe what they are supposed to illustrate. Tests of reading aloud from a newspaper article can be followed by questions designed to test his understanding of individual words or of the passage as a whole. Comprehension may be easier if silent reading is allowed. His capacity in this respect can be examined by a series of written commands of increasing complexity. Agraphia should be tested in two ways: free writing of a short paragraph about some everyday event, his illness or his job. All these tests are combined with tests of visual or sensory inattention, simple calculation, left-right recognition, picture recognition, completing a clock face, telling the time and drawing arrows in specified directions.

Expressive and Receptive Language

Some people with aphasia have problems primarily with expressive language (what is said) while others have their major problems with receptive language (what is understood). In still other cases, both expressive language and receptive language are obviously impaired. Language is affected not only in its oral form of talking and understanding but also in its written form of reading and writing. Typically, reading and writing are more impaired than oral communication. The nature of the problems varies from person to person depending on many factors but most importantly on the amount and location of the damage to the brain.

Amount and location of the damage, along with other factors, e.g., age, educational level, and health status, also affect the severity of the problems. Persons with severe aphasia may understand almost nothing of what is said to them and say little or nothing. At best, their oral communication may be only approximations of «yes» and «no» and maybe common social phrases like «hi» and «thanks.» Persons with mild aphasia may be able to carry on normal conversations in many communication settings. They may have trouble understanding language only when it is long or complex, or they may have some trouble finding the words they need to express an idea or to explain themselves, orally or in written form. Word finding problems (anomia) are common in people with aphasia and is like the common experience of having a word «on the tip of our tongues» but not being able to remember it. The person may forget the word comb even though he or she can show you how to use it.

There are also degrees of aphasia between mild and severe. A person may speak only in single words (e.g., names of objects) or in short, fragmented phrases. Smaller words of speech (e.g., the , of , and ), may be omitted, making the message sound like a telegram. Words may be put in the wrong order. Incorrect grammar may be used. Sounds and/or words may be switched. A bed may be called a table or a dishwasher a wish dasher . Or, the person with aphasia may make up a word. In some cases, nonsense (or real) words are strung together quite fluently, but make no sense to the listener.

It usually requires extra effort for the person with aphasia to understand spoken messages, as if he or she is trying to comprehend a foreign language. The person may need extra time to process and understand what is being said. It may be especially hard to follow very fast speech like that heard on radio or television news. He or she may misinterpret subtleties of language, e.g., taking the literal meaning for a figure of speech like He kicked the bucket. Difficulty with one or more of these skills may lead to communication breakdowns and frustrating communication for both the person with aphasia and his or her listeners. Other conditions may result from stroke, either by themselves or in addition to aphasia. These include dysarthria, apraxia, and dysphagia.

Mental retardation Mental Health Problems

We all hope for mental health: the capacity to enjoy life and cope with its challenges. Problems that affect this capacity are varied in type and severity. In some severe cases the term psychiatric illness, or mental illness, is used. Mental health problems can affect both children and adults. Changes in communication skills, social skills, and swallowing patterns (dysphagia) are features of mental health problems that speech and language therapists may be involved with.

There are many different causes for dementia but sufferers usually have linguistic deficits (e.g. difficulties with understanding, reasoning, talking and memory). With some other mental health problems (e.g. bipolar disorder, depression) there may be no loss of language skills, but people have reduced non-verbal communication, and altered social interaction skills.

A rare disorder of childhood is known as selective mutism (previously known as elective mutism). The children are able to speak but persistently fail to do so in specific situations over a long period. This affects progress in education and social skills. Speech therapists can provide intervention and support for children with selective mutism. Youngsters with a diagnosis of autism spectrum disorder may experience mental health problems (e.g. obsessive compulsive disorder - OCD, oppositional defiant disorder - ODD, anxiety, depression).

Some characteristics of mental health problems:

• Inappropriate social skills e.g. reduced interaction, or being extremely talkative.

• Reduced non-verbal skills e.g. reduced eye-contact, poor posture, reduced facial expression.

• Memory deficits, reduced orientation. (Found predominantly in those with dementia).

• Communication deficits affecting comprehension and expression (with inability to stick to topics of conversation).

• Swallowing deficits (dysphagia).

Speech and language therapists are often involved with multi-professional teams working in mental health settings. The client is always under the care of a psychiatrist and may have a Care Coordinator and/or social worker in the community.

The following may form part of therapy input for people with mental health problems:

• Informal communication assessments and writing guidelines for carers and/or other health professionals with strategies to enhance two-way conversation.

• Informal dysphagia assessments and writing swallowing guidelines (dysphagia management).

• Group therapy for adults: social skills groups targeting non-verbal skills (e.g. eye-contact/facial expressions), assertiveness, problem-solving, negotiation skills, 'small talk' and initiating conversations.

• Group therapy for older people with dementia: groups targeting maintenance of communication skills through reminiscence/validation therapy.

The Exceptional Child? – Mental Retardation

It's not easy to be different in our society. We've all felt the sting of not belonging, of not feeling a part of the group. We've all felt overmatched when asked to do things beyond our skills and capabilities, or bored when asked to do simple things that do not challenge us.

Of course, being different is not always bad. It is what makes us interesting. But it also forces us to adapt to meet social expectations. And when being different means a child is not able to receive information through the normal senses, or is not able to express himself or herself, or processes information too slowly or too quickly, special adaptations are necessary.

There have been many attempts to define the term exceptional child. Some use it when referring to a particularly bright child or the child with unusual talent. Others use it when describing any atypical child. The term generally has been accepted, however, to include both the child who is handicapped and the child who is gifted. Here, we define the exceptional child as a child who differs from the average or normal child in (1) mental characteristics, (2) sensory abilities, (3) communication abilities, (4) social behavior, or (5) physical characteristics. These differences must be to such an extent that the child requires a modification of school practices, or special educational services, to develop to maximum capacity.

How do psychologists go about defining what is normal or abnormal?

The simplest approach to distinguishing normal from abnormal is to label normal whatever most people do. Abnormal then becomes whatever differs markedly from the statistical average.

Another way to define abnormality is to compare a person's behavior with wildly accepted social expectations. The statistical approach to defining abnormality often corresponds to the approach based on social expectations.

But even taken together, these two criteria are not always sufficient.

One way around this problem is to assess abnormality not in terms of some statistical or socially accepted norm, but in terms of some absolute standard of what is psychologically healthy. In theory this approach sounds reasonable enough. But in practice such standards are hard to identify.

Thus no single way of defining abnormality is adequate by itself. We need to apply several criteria before labeling a behavior abnormal. Nor is there any universal agreement as to where the line should be drawn between normal, on the one hand, and abnormal, on the other. Mental health is best viewed as a continuum. At the extreme ends of that continuum, normality and abnormality are easy to distinguish; but in the middle range, one condition shades gradually into the other, making it harder to differentiate the two.

As we have always been aware that some children learn more quickly than others, so we have always known that some children learn more slowly than their age-mates and, as a consequence, have difficulty adapting to the social demands placed on them. Organized attempts to help children who learn slowly began less than two hundred years ago. Over the years, the care and education of children who are mentally retarded has moved gradually from large state institutions to the public schools, and within the schools to the least restrictive environment.

Educators have identified three levels of mental retardation to indicate the educational implications of the condition: mild, moderate, and severe and profound.

Intellectual sub-normality has traditionally been determined by performance on intelligence tests. One of the earliest of these tests was developed by Alfred Binet for the express purpose of finding children who were not capable of responding to the traditional education program in France at the turn of the twentieth century. Mentally retarded children are markedly slower than their age-mates in using memory effectively, in associating and classifying information, in reasoning, and in making sound judgements.

IQ scores can be used as a rough indicator of level of retardation. The ranges for mildly, moderately, and severely retarded are listed below.

Level of retardation IQ score

Mild 50-55 to 70

Moderate 35-40 to 50-55

Severe and profound Below 35

If mild retardation is determined by the expectations placed on the child, some puzzling things happen. A child can become «mentally retarded» by simply getting on a bus in a community where those expectations are low and getting off the bus in a community where they are high. More serious levels of retardation are obvious in any social setting; mild retardation is not. It can change with the expectations of the individual's community. The term mental retardation covers a broad range of children and adults who differ from one another on the severity of developmental delay, in the causes of the condition, and in the special educational strategies that have been designed for them. It's important that we remember these differences.

Mild Mental Retardation

A child who is mildly retarded because of delayed mental development has the capacity to develop in three areas: academically (at the primary and advanced elementary grade levels), socially (to the point at which the child can eventually live independently in the community), and vocationally (to be partially or totally self-supporting as an adult).

Often there are no observable pathological conditions to account for or indicate mild retardation. This means that youngsters who are mildly retarded may go unidentified until they reach school age. But with more and more organized preschool programs, many of these youngsters are being found and placed in special education programs earlier.

Moderate Mental Retardation

The child who is moderately retarded can (1) achieve some degree of social responsibility, (2) learn - basic academic skills, and (3) acquire limited vocational skills. This child is capable of learning self-help skills (dressing, undressing, toileting, eating); of protecting himself or herself from common dangers in the home, neighbourhood, and school; of adjusting socially (sharing, respecting property rights, cooperating); of learning to read signs and count; and of working in a sheltered environment or in a routine job under supervision. In most instances, children who are moderately retarded are identified during infancy and early childhood because of their marked developmental delays and, sometimes, their physical appearance.

Historically, educators and other professionals have underestimated what those who are moderately mentally retarded can do, given the proper training and opportunities. Today these individuals who are moderately retarded are adapting much better to their community than would have been expected in years past.

Severe and Profound Mental Retardation

Most severely and profoundly retarded children have multiple handicaps that interfere with normal instructional procedures. Special instructional environments and programs are essential to help these youngsters develop their limited potential.

Psychologists identified nine groups of factors that cause or contribute to mental retardation:

• Infection and intoxication

• Trauma or physical agents

• Metabolism or nutrition

• Gross brain disease

• Unknown prenatal influences

• Chromosomal abnormalities

• Gestational disorders

• Psychiatric disorders

• Environmental influences

As we learn more about the causes of mental retardation, we are in a better position to prevent it. The objective here is to reduce the number of children who are born mentally retarded or with conditions that could lead to mental retardation.

Emotional disturbance Practical Approaches to Challenging Behaviors

Many families struggle with challenges such as Down syndrome, physical disabilities, mental health problems, and others. These challenges are often expressed through challenging behaviors such as stubbornness, persistent opposition, or even self-injurious behaviors. In these situations love and parents’ attention is not enough, but often more is required.

This article offers some practical experiences in an effort to lessen pressure caused by challenging behaviors. You need to determine which area of your child's life requires specialized attention. Here are some life stories to illustrate each area.

1. Consider the Environment

Pay attention to where your child lives, plays, goes to school, and goes to work. Can the environment be modified in ways that would reduce the negative impact of behaviors?

Our teenage son Steve who has a Down syndrome spends all of his time talking to himself. He engages in two-way conversations with imaginary friends and can be quite loud. It is very hard to be around him for any period of time. Weekends seem like an eternity. While we have ideas on how to help Steve and ourselves deal with this long-standing behavior, we also need to have some peace and quiet.

We came up with a plan to arrange our house so we could live with his constant talking. Our finished basement is now Steve's new '«hangout room.» It has his stereo and other «cool» stuff down there. We insulated the room for sound and added a solid core door at the top of the stairs. Steve likes it. He spends time with the family upstairs and knows» where to go when he has the urge to talk to his imaginary friends. Weekends don't seem quite so long anymore.

2. Consider Your Child's Disability

It is important to be well-informed about your child's interests, motivations, how they learn, and how their disability may play into their attitude. Important information is discovered through reading books about the specific disability, learning about effective teaching strategies, networking with other parents, and talking things over with school personnel and members of your support network. By continually asking questions, seeking new information, and discussing struggles you will find solutions that are often more easily implemented than you could think of alone.

For the past few years bedtime with Jeannie has been a constant battle. Every time I ask her to go upstairs, put on her pajamas, brush her teeth, and get into bed she refuses. The more I ask the worse it gets. I get angry and she ends up crying.

Lately things have gotten better; not because Jeannie is listening better, but because I am a little wiser. I read an article about receptive language and developmental levels and a light bulb went off. I was giving her what they call four-step requests, and that was probably too much for her. She was getting too much information and too many requests at one time. We all know that when Jeannie feels overwhelmed she gets stubborn. Her reactions were reasonable when I understood how much I was asking of her at one time.

Now we are taking the bedtime routine one step at a time, which helps a lot. She still has stubborn moments such as when she'd rather watch a TV show than brush her teeth, but I have become a little more tolerant. From what I read it comes with the territory.

3. Consider Relationships

The primary way children receive support emotionally is through positive relationships with families and loved ones. When challenging behaviors are intense or persistent the important bond between your child and his family members becomes strained or even severed. Ironically, children with the most challenging behaviors are the ones who are most in need of positive relationships.

My son Adam has Down syndrome and autistic spectrum disorder. Last fall we went through a really bad period. He wasn't sleeping at night and spent his entire day spinning objects. Adam always liked to spin but now that was all he wanted to do. I was at my wit's end. It was very hard for me to watch. We met with school staff and others to try to figure out how to get Adam back on track. As we were talking, someone asked the entire group if the way that we were relating to Adam had been affected by his behaviors. It dawned on me that it had. I had not wrestled with Adam in the living room after supper for weeks. We always went out for a father-son donut run on Saturday morning. I couldn't recall the last time that happened. Our bedtime routine had become very rigid.

Over the next few weeks I made a conscious effort to reconnect with Adam. It was not easy and sometimes not so fun (all that spinning). Sometimes I had to set my watch and will myself to be positive with Adam for the next half-hour despite the fact that I was not getting much back. Eventually Adam worked out of that mood. We tried a lot of ideas at once so I am not sure what turned him around. Whether or not it was my efforts to reconnect that made the difference, it sure didn't hurt.

4. Consider Behavioral Approaches

Consider using a behavioral plan when it is apparent that challenging behavior is an inappropriate, but effective, effort in meeting a need. An example of this is when a child has learned if she screams long enough her Mom will give her a cookie. The screaming is inappropriate, but it works.

The essence of a behavior plan is to pair, or match, a positive reaction with a positive behavior that can replace the challenging behavior.

Dan is my adopted son. Somewhere in his early teens he learned that stealing was a good way to get things he needed. It seemed as thought the more we punished him, the worse his stealing became. Within our behavioral plan we decided that the obvious behavior to replace stealing was honesty. Instead of talking to Dan about not stealing we promoted honesty. Between home and school we spent time with Dan working with him on what he needed and how he could get it in an honest way.

We paid attention to the periods of honesty providing a lot of rewards. When stealing did occur, Dan had to return the item and pay restitution. We continued for about a year without much change. Gradually we noticed that the periods of sustained honesty had increased. There were no dramatic changes but things got better. Now Dan is an adult and his employers know him as an honest person.

The Anxious Child

All children experience anxiety. Anxiety in children is expected and normal at specific times in development. For example, from approximately age 7 months through the preschool years, healthy youngsters may show intense distress (anxiety) at times of separation from their parents or other persons with whom they are close. Young children may have short-lived fears, (such as fear of the dark, storms, animals, or strangers). However, when anxieties become severe and begin to interfere with the daily activities of childhood, such as separating from parents, attending school and making friends, parents should consider seeking the evaluation and advice of a child and adolescent psychiatrist.

A child or adolescent with severe separation anxiety may show some of the following:

• constant thoughts and fears about safety of self and parents,

• refusing to go to school,

• frequent stomachaches and other physical complaints,

• extreme worries about sleeping away from home,

• overly clingy behavior at home,

• panic or tantrums at times of separation from parents.

Some anxious children are afraid to meet or talk to new people. Children with this difficulty may have few friends outside the family. Other children with severe anxiety may have:

• many worries about things before they happen,

• constant worries or concern about school, friends, or sports.

Anxious children are often overly tense or uptight. Some may seek a lot of reassurance, and their worries may interfere with activities. Because anxious children may also be quiet, compliant and eager to please, their difficulties may be missed. Parents should be alert to the signs of severe anxiety so they can intervene early to prevent complications. Early treatment can prevent future difficulties, such as, loss of friendships, failure to reach social and academic potential, and feelings of low self-esteem.

Severe anxiety problems in children can be treated. Treatments may include a combination of the following: individual psychotherapy, family therapy, medications, behavioral treatments, and consultation to the school.

The Depressed Child

Not only adults become depressed. Children and teenagers also may have depression, as well. The good news is that depression is a treatable illness. Depression is defined as an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function.

About 5 percent of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders are at a higher risk for depression.

The behavior of depressed children and teenagers may differ from the behavior of depressed adults. Child and adolescent psychiatrists advise parents to be aware of signs of depression in their youngsters, such as:

• Frequent sadness, tearfulness, crying

• Decreased interest in activities; or inability to enjoy previously favorite activities

• Hopelessness

• Persistent boredom; low energy, poor concentration

• Social isolation, poor communication

• Frequent complaints of physical illnesses such as headaches and stomachaches

• Frequent absences from school or poor performance in school

• A major change in eating and/or sleeping patterns

• Talk of or efforts to run away from home

• Thoughts or expressions of suicide

A child who used to play often with friends may now spend most of the time alone and without interests. Things that were once fun now bring little joy to the depressed child. Children and adolescents who are depressed may say they want to be dead or may talk about suicide. Depressed children and adolescents are at increased risk for committing suicide. Depressed adolescents may abuse alcohol or other drugs as a way of trying to feel better.

Children and adolescents who cause trouble at home or at school may also be suffering from depression. Because the youngster may not always seem sad, parents and teachers may not realize that troublesome behavior is a sign of depression. When asked directly, these children can sometimes state they are unhappy or sad.

Early diagnosis and treatment are essential for depressed children. Depression is a real illness that requires professional help. Comprehensive treatment often includes both individual and family therapy. Treatment may also include the use of antidepressant medication.

Teen Suicide

Suicides among young people nationwide have increased dramatically in recent years. Each year thousands of young people commit suicide. Suicide is the third leading cause of death for 15-to-24-year-olds, and the sixth leading cause of death for 5-to-14-year-olds.

Youth experience strong feelings of stress, confusion, self-doubt, pressure to succeed, financial uncertainty, and other fears while growing up.

For some teenagers, divorce, the formation of a new family with stepparents and step-siblings, or moving to a new community can be very unsettling and can intensify self-doubts. In some cases, suicide appears to be a «solution».

Depression and suicidal feelings are treatable mental disorders. The young person needs to have his or her illness recognized and diagnosed, and appropriate treatment plans developed. When parents are in doubt whether their child has a serious problem, a psychiatric examination can be very helpful.

Many of the symptoms of suicidal feelings are similar to those of depression. Parents should be aware of the following signs of adolescents who may try to kill themselves:

• change in eating and sleeping habits

• withdrawal from friends, family, and regular activities

• violent actions, rebellious behavior, or rerunning away.

• drug and alcohol use

• unusual neglect of personal appearance

• persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork

• frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.

• loss of interest in pleasant activities

• not tolerating praise or reward.

A young person who is planning to commit suicide may also:

• complain of being a bad person or feeling «rotten inside»

• give verbal hints with statements such as: «I won't be a problem for you much longer,» «Nothing matters,» «It's no use,» and «I won't see you again»

• put his or her affairs in order, for example, give away favorite possessions, clean his or her room, throw away important belongings, etc.

• become suddenly cheerful after a period of depression

If a young person says, «I want to kill myself,» or «I'm going to commit suicide,» always take the statement seriously and seek evaluation from a psychiatrist or psychologist.

People often feel uncomfortable talking about death. However, asking the youth whether he or she is depressed or thinking about suicide can be helpful. Rather than «putting thoughts in the child's head», such a question will provide assurance that somebody cares and will give the young person the chance to talk about problems.

If one or more of the above signs occur, parents need to talk to their child about their concerns and seek professional help when the concerns persist. With support from family and professional treatment, children and teenagers who are suicidal can heal and return to a healthier path of development.

Teenagers with Eating Disorders

Overeating related to tension, poor nutritional habits and food fads are relatively common eating problems for youngsters. In addition, two psychiatric eating disorders, anorexia nervosa and bulimia, are on the increase among teenage girls and young women and often run in families. In the United States, as many as 10 in 100 young women suffer from an eating disorder. These two eating disorders also occur in boys, but less often.

Parents frequently ask how to identify symptoms of anorexia nervosa and bulimia. Unfortunately, many teenagers hide these serious and sometimes fatal disorders from their families and friends.

Symptoms and warning signs of anorexia nervosa and bulimia include the following:

• A teenager with anorexia nervosa is typically a perfectionist and a high achiever in school. At the same time, she suffers from low self-esteem, irrationally believing she is fat regardless of how thin she becomes. Desperately needing a feeling of mastery over her life, the teenager with anorexia nervosa experiences a sense of control only when she says «no» to the normal food demands of her body. In a relentless pursuit to be thin, the girl starves herself. This often reaches the point of serious damage to the body, and in a small number of cases may lead to death.

• The symptoms of bulimia are usually different from those of anorexia nervosa. The patient binges on huge quantities of high-caloric food and/or purges her body of dreaded calories by self-induced vomiting and often by using laxatives. These binges may alternate with severe diets, resulting in dramatic weight fluctuations. Teenagers may try to hide the signs of throwing up by running water while spending long periods of time in the bathroom. The purging of bulimia presents a serious threat to the patient's physical health, including dehydration, hormonal imbalance, the depletion of important minerals, and damage to vital organs.

With proper treatment, most teenagers can be relieved of the symptoms or helped to control eating disorders. Treatment for eating disorders usually includes individual therapy, family therapy, working with a primary care physician, working with a nutritionist.

Parents who notice symptoms of anorexia or bulimia in their teenagers should ask their family physician or pediatrician for a referral to a child and adolescent psychiatrist.

Schizophrenia

Schizophrenia is a chronic, severe, and disabling brain disease. Around one percent of the population will develop schizophrenia during their lifetime.

Schizophrenia is a medical illness that causes strange thinking, abnormal feelings, and unusual behavior.

Gender and Age Patterns

• Schizophrenia affects men and women with equal frequency.

• Schizophrenia often appears earlier in men, usually in their late teens or early twenties.

• Schizophrenia generally surfaces for women in their twenties to early thirties.

• Children over the age of five can develop schizophrenia, but it is very rare before adolescence.

The behavior of children and teens with schizophrenia may differ from that of adults with this illness.

The appearance of schizophrenic symptoms before age 12 is rare, but studying these cases is important for an understanding of this disorder.

Early Warning Signs:

• Seeing things and hearing voices that are not real

• Confused thinking

• Vivid and bizarre thoughts and ideas

• Extreme moodiness

• Odd behavior

• Concept that people are “out to get them”

• Behaving like a younger child

• Severe anxiety and fearfulness

• Confusing dreams, television or movies with reality

• Problems in making and keeping friends

The behavior of children with this illness may change over time. Children may begin talking about strange fears and ideas. They may start to cling to parents or say things that do not make sense. Children who used to enjoy relationships with others may become more shy and seem to be in their own world.

This Is A Time For Hope

• Research is gradually leading to new and safer medications and unraveling the complex causes of the disease.

• Scientists are using many approaches, from the study of molecular genetics to the study of populations, to learn about schizophrenia.

• Methods of imaging the brain’s structure and function hold the promise of new insights into the disorder.

Schizophrenia As An Illness

Schizophrenia is found all over the world. The severity of the symptoms and long-lasting, chronic pattern of schizophrenia often cause a high degree of disability. Medications and other treatments for schizophrenia, when used regularly and as prescribed, can help reduce and control the distressing symptoms of the illness. However, some people are not greatly helped by available treatments or may prematurely discontinue treatment because of unpleasant side effects or other reasons. Even when treatment is effective, persisting consequences of the illness – lost opportunities, stigma, residual symptoms, and medication side effects – may be very troubling.

Early Signs and Symptoms of Schizophrenia

• Confusing, or even shocking, changes in behavior.

• Sudden onset of severe psychotic symptoms (acute phase of schizophrenia).

• Psychosis (State of mental impairment marked by hallucinations and/or delusions).

• Social isolation or withdrawal.

• Unusual speech, thinking, or behavior.

Some people have only one such psychotic episode; others have many episodes during a lifetime, but lead relatively normal lives during the interim periods. However, the individual with “chronic” schizophrenia, or a continuous or recurring pattern of illness, often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms.

Diagnosing Schizophrenia

Mental health professionals will likely first rule out other possible causes of symptoms with:

• A complete medical history

• Physical Examination

• Laboratory Tests

• Drug Screening

• Ruling out other mental disorders (clinical depression, bipolar disorder, schizoaffective disorder)

A Schizophrenic's View of the World

• Distorted Perceptions of Reality

Living in a world distorted by hallucinations and delusions, individuals with schizophrenia may feel frightened, anxious, and confused.

• Hallucinations and Illusions

Hallucinations and illusions are disturbances of perception that are common in people suffering from schizophrenia. Voices may describe the patient’s activities, carry on a conversation, warn of impending dangers, or even issue orders to the individual.

• Delusions

Delusions may take on different themes. For example, patients suffering from paranoid-type symptoms – roughly one-third of people with schizophrenia – often have delusions of persecution, or false and irrational beliefs that they are being cheated, harassed, poisoned, or conspired against. These patients may believe that they, or a member of the family or someone close to them, are the focus of this persecution. In addition, delusions of grandeur, in which a person may believe he or she is a famous or important figure, may occur in schizophrenia.

Common Schizophrenic Behaviors

• Substance Abuse

• Nicotine Dependence

• Disordered Thinking

• Apathetic Personality

• Changing «Normal VS Abnormal» Behaviors (Changes in behavior can be the result of medication adjustments)

Incorrect Notions About Schizophrenics:

• Schizophrenia is not Split personality

• Schizophrenics are not generally violent

Hearing impairments The Role of the Teacher of the Deaf

A Teacher of the Deaf is a qualified teacher with the skills and knowledge required to provide quality teaching to mainstream learners and with the additional mandatory qualification and expertise in teaching deaf children.

What does the Teacher of Deaf (ToD) do?

1. Specialist assessments and interpretation of results

• Interpretation of audiological information and explaining this to those involved with the deaf child

• Testing and monitoring hearing levels

• Testing and monitoring hearing aid settings

• Monitoring the acoustic environment in the school environment and advising on ways to improve it for the deaf learner

• Assessing the full range of communication: including use of sign and spoken language and any modes of communication

• Participation in multi-agency assessment to identify overall needs and progress of the deaf child/young person

• Contribution to mainstream monitoring and review of progress

• Fitting and monitoring assistive listening devices.

2. Provision of advice

• Discussing the implications of hearing loss with the deaf child, parents and families, teachers, all involved agencies especially in the context of education.

• Sharing information about communication modes.

• Discussion of amplification needs and technological aids.

• Intervention and implementing strategies to meet identified needs.

• Sharing information about other support available.

• Providing information about educational provision; early years/schools/colleges and other educational settings.

3. Direct teaching through an enriched language input through:

• whole class teaching

• small group teaching

• team teaching

• 1:1 with the deaf child

• subject specialism

• key stage specialism

• generic support

• individualised learning programme

• pre-tutoring

• post tutoring.

4. Partnership working

A ToD plays an important part in the production of joint assessments, target setting and programmes of work and visits to enable the effective support of the whole family. This will involve cooperation and joint working with a range of professionals in:

• audiology and oto-acoustics

• general practice

• early years and educational settings

• social care

• speech and language therapy

• mental health

• educational psychologists

• a range of educational support services.

5. Working with children and families:

• providing of clear impartial information

• enabling the child and family to express their view

• facilitating family and child access to professional and extended services

• providing relevant and appropriate support.

6. Continuing Professional Development:

• keeping abreast of mainstream and specialist developments to inform practice

• keeping up to date with audiological developments and technological developments

• keeping abreast of Government strategies in education.

Guidance for Сlass Teachers and Others on the Proper Treatment of Children with Defective Hearing at School.

• Place the child so that he or she can hear what is said in class by the teacher and by the other children. There are, therefore, two factors to be considered. Consequently it is by no means certain that the front desk with be the most suitable - unless the degree of hearing loss is such that the child would otherwise be unable to hear what is said from the teacher's desk. The second of third desk in a row by the window would in most cases be suitable.

• Place the child so that he or she can see what is said during the periods. If the child sits at the second or third desk in the row by the window the light will fall on the teacher's and the other children's mouths and he will be able to lipread.

• Turn your head whenever possible so that the child can see your mouth. This is particularly important when telling a story or dictating or when asking questions. In mental arithmetic it is essential.

• Always speak clearly, but if the child is using a hearing aid be careful not to speak above the normal level. Shouting must be absolutely avoided, for this is unbearable to anyone using a hearing aid.

• It is the class teacher's duty to tell other children in the class of the difficulties of a hearing handicapped child. Other teachers who take the class should also be told.

• Contact with a handicapped child's home is always desirable but where hearing handicapped children are concerned the understanding and confidence of the parents are essential.

• А child with impaired hearing may require to be treated in the same way as other children and not be shown unnecessary attention or consideration. What a hearing handicapped child wants above all else is to be like others.

Peculiarities of Mastering Speech by Deaf Pre-School Children from Two to Five Years

Early teaching has a significant effect on the deaf child. The earlier he is introduced to speech the earlier he begins to master speech and consequently starts to communicate by speech with others, and to form his verbal thinking. In kindergartens children of 2, 3, 4 and 5 years of age are admitted to groups of the first year of teaching. The beginnings of speech and teaching is the same at first for all of them, but progress varies.

1. Children of all ages master dactylic reading, are able to designate each letter in a word with a dactylic sign and to associate the read word with the object, action, quality, etc.

If the deaf child is taught dactylic reading, at 2 years he can master this in 5/6 months, at 3/4 years he can master this in 1 month, at 5 years he can master this in 2 weeks.

Provided teaching begins at 2 years of age, the deaf pre-school child can master dactylic reading by 2,5 years. Although this is a longer period of learning than is necessary at an older age, nevertheless the earlier it is begun (but not before the age of 2 years) the better the final production of speech and also personality.

2. Deaf children of different ages passing their first year of learning in the kindergarten have different vocabulary levels both in volume and quality.

After the first year in the kindergarten, 2 year old children accumulate up to 86 words, 3 year old children accumulate up to 448 words, 4 year old children accumulate up to 472 words and 5 year old children accumulate up to about 500 words.

By the end of the first year of learning children aged 5 years had a vocabulary of 500 words. Children of the same age who have been learning for 3 years had an average of 1,000 to 2.000 words. The vocabulary differed in quality as well as quantity. After 3 years studies children aged 5 years mastered grammatical generalisations and elementary narrating. They used in their speech 70% of all mastered words. With this level of speech development, direct communication became a valuable source of speech development. Lack of speech delays general mental development. If a child of 2 years knows even 50-80 words it allows him to take the first steps in overcoming this lag and has an effect on formation of the deaf pre-school child's personality.

Children with Partial Hearing Loss

Due to the diminishing number of childhood infections and the effective use of antibiotics the number of auditorily impaired children has decreased. Hereditary forms of hearing disorders have not been overcome. Modern equipment has made possible accurate measurement of hearing and improved perception of speech sounds.

However, problems of diagnosis and treatment of hard of hearing children remain complicated and urgent. In investigating these problems the Institute of Defectology set for itself the following tasks.

1. To determine the minimum degree of hearing impairment which may become an obstacle for normal development.

2. To determine the degree of residual hearing for the child to be considered deaf.

3. To discover the peculiarities of hearing-impaired children's development in order to use these findings to develop adequate methods of education.

4. To work out principles of differential diagnosis of speech and intellectual development of hearing-impaired children.

5. To work out a special school structure.

Over 3,000 children in schools for the deaf, partially hearing, mentally retarded and children with grave speech disorders as well as normal school children retarded due to hearing defects were studied.

The relationship between hearing and speech and the child's development was of special theoretical significance to us and therefore all children were subjected to investigation of their hearing on the one hand and speech on the other.

Two important conclusions were made from these data.

1. A very high degree of residual hearing is necessary for developing a child's speech.

2. The more a child's speech is developed the better he is able to use his partial hearing for communication and cognition.

Pure tone and speech audiometric tests were carried out. There was a continuum of hearing impairment from complete deafness to almost normal hearing. Taking into account the special role of the acoustic analyses in speech development we have proposed a special criterion of assessing a child's hearing defect. Its basis is the possibility of mastering speech with the given state of hearing.

In this way we have established a border-line between deafness and partial hearing.

1. The deaf child is one whose hearing cannot be used for accumulating a vocabulary. Any residual hearing is used only for voice modulation and helping towards pronunciation.

2. Children who can use their hearing to accumulate a minimal vocabulary are partially hearing. These are usually those who can hear speech of normal conversational loudness near their ear (hearing loss of 30/70 db).

Thus we have established one of the principles for placing children in a school for partially hearing children. But besides these children who have grave hearing losses there are those who have slight hearing losses (25-50 db) who are handicapped but many of whom may remain in normal schools if help is provided. Even with a very slight loss (1 5-20 db) a child may face difficulties and lag behind in school work.

Thus there are three categories of children with impaired hearing.

1. Those placed in schools for the deaf.

2. Those placed in schools for partially hearing.

3. Those placed in normal schools but needing additional lessons in speech. The level of speech development is not usually correlated to the degree of hearing. Age of onset, environment, school conditions and individual ability are important factors in this relationship.

Our experience of placing children in schools for partially hearing has convinced us that the main criterion should be the level of speech development and not state of hearing. Within the school we have two grading, those with reasonable speech and those with little speech. The programmes for these two groups are different. From these schools pupils go on to secondary, technical and higher educational establishments for normally hearing people.

Signing

Signing is used by the deaf community and is a very useful part of Total Communication with children and adults who are born, or become, deaf. Speech and language therapists use signing with other groups as well. It can provide an extra tool for working with children who are struggling with the comprehension and acquisition of language as they are greatly helped by 'seeing' the words in signs. (This applies even where hearing is normal, or only intermittently impaired.) Others who benefit from signing include those with learning disability; those with vocabulary and word-retrieval difficulties; and older people who have lost their speech but retain the desire to communicate. A certain amount of manual dexterity is obviously required to sign, but many who have poor control of hand movements still learn to sign well enough for familiar adults to understand their message.

Russian Sign Language is the sign language of the deaf community in Russia. It has a grammar unlike the (spoken or written) Russian language, although there is a «signed Russian» which has been used on television in interpreted news programs.

The Russian Manual Alphabet is used for fingerspelling in Russian Sign Language. In general, fingerspelling is used for the following types of words:

• proper nouns (names, cities, titles, brand names, etc)

• foreign borrowings.

• scientific terms.

• short conjunctions, prepositions, interjections, modal particles, etc., e.g. v-in, nu-well,

• da-yes, by-would.

• words lacking a sign representation.

The Moscow Bilingual School for the Deaf, which uses Russian Sign Language in classrooms, was opened in 1992.

Much of early research on Russian Sign Language was done by Galina Lazarevna Zaitseva, who wrote her 1969 PhD thesis on spatial relationships in Russian Sign Language, and in 1992 devised the now standard term for Russian Sign Language «Russkii Zhestovyi Yazyk». Ongoing research into the language takes place at the Centre for Deaf Studies in Moscow.

Cochlear Implant

A cochlear implant is a special type of hearing aid that is surgically implanted. These aids may be used by adults who were born deaf, or who have become profoundly deaf. Children born with profound deafness, or progressive hearing loss, may also be candidates for a cochlear implant following assessment by a specialist team on a cochlear implant programme.

Depending on when the device was first implanted, cochlear implant users may have:

• difficulties understanding speech, especially in noisy surroundings

• problems producing intelligible speech

• significant difficulties with all aspects of speech, language and literacy

• skills in a sign language or sign-supported communication

Specialist speech and language therapists are often involved with multi-professional teams working on cochlear implant programmes. Therapy may begin before the individual receives the implant, and continue throughout the assessment process.

For an adult, therapy will continue for a limited period after surgery. For a child, therapy may be needed throughout the preschool and school years. The specialist therapist on the cochlear implant team would also be involved with ongoing review and monitoring.

The following may form part of therapy input for those with a cochlear implant:

1. all aspects of the development of communication skills with specific emphasis on:

   • auditory training and listening skills

   • speech intelligibility and voice work

   • vocabulary building

   • understanding and use of grammar

   • following speech without sign

2. parent-child interaction therapy and social skills work

3. deaf awareness (for family members, school staff or employers)

Deaf children are, of course, no less susceptible to speech and language difficulties unconnected with hearing status than hearing children so some children may need more special help.

Visual impairments

Visual Impairment

The term 'visual impairment' is used for a number of different vision problems which may be present at birth or acquired later. People may be partially sighted or severely sight impaired. Common 'reduced vision' problems (like low levels of short-sightedness) corrected by wearing glasses are not included. (However, young children may show some delayed development with language skills when a correctable problem is not recognised. Minor problems with reduced vision and hearing - both of which could be corrected - can appear to have a disproportionate effect on language development.)

Recognised characteristics of visual impairment include:

• blurring of vision

• loss of a part of the visual field (e.g. central vision)

• difficulty maintaining a steady gaze and coordinated eye movements

• a cognitive problem understanding what is seen

• colour blindness

Some children have visual impairment as one feature of a multi-sensory impairment, or group of difficulties. It can occur together with, for example, learning disability, cerebral palsy, epilepsy, hearing impairment, or autism. Children's development can be affected by the complex interaction of two or more problems.

Speech and language therapists working with visual impairment will be involved with other professionals.

Visually impaired children may attend mainstream nurseries and schools, or specialist units. Therapists work with specialist teachers for visually impaired children. Therapy may begin before school entry and continue into the school years. Therapy for children with visual impairment may target some or all areas of language development (depending on need): comprehension, expressive language, speech intelligibility, and/or dyslexia. Careful modification of resources is needed, particularly when a child has more than one difficulty. Teachers and therapists need to work together.

Adults may have 'acquired visual impairment' following head injury or stroke. Therapists working with clients who have language difficulties after the injury may need to take account of the interaction between dysphasia and any visual impairment.

What if my child is blind?

Why doesn't my child move very much?

Children learn tо crawl and walk because they see something across the room that they want, or because they watch people around them moving. If your child cannot see an object and it doesn't make any noise, he probably does not know that object is there - and thus has no reason to go and get it.

It's easy to try so hard to create experiences for your child that you bring the world to him too often. You will not always be able to do that for your child. What you really want to do is encourage your child to «go for it» - to be curious, to explore, to find out that another world exists beyond his fingertips. You can encourage him to do this by helping him

• to put two and two together:

«Hear that? That's the timer in the kitchen. Let's go and see if the cookies are done… I’ll take them out of the oven… Let them cool a little bit… Here's one for you!»

• to go after what he wants:

«Daddy is over here. Come and get me!»

• to play games like ball throwing and hide-and-seek.

All this teaches your child that people and objects still exist even when he is not touching them, or hearing them or tasting.

It is also a good idea to show your child how to crawl, walk, run, and jump. Your child cannot watch other children crawling, so he may not be crawling simply because he doesn't have any idea what crawling is. You can show him how to do it by getting on the floor with him and putting him through the movements until he does know what crawling is, and does it himself.

What if my child is blind?

Many children and adults are totally blind - and they do okay. Blind people still live and learn and love and work and do everything that sighted people do. When you see a blind person, remember: He was probably once a blind child. The teenager or adult your child becomes will in large part depend on what you, as his parents, do now.

• If you do not teach him to take responsibility, he won't.

• If you do not expect him to succeed, he won't expect himself to succeed.

• If you always do things for him as a child, someone will have to do those things for him as an adult.

Certainly, growing up without vision makes it a little harder to learn about the world and about moving around in it. But your blind child doesn't know that his way of learning is any different from anybody else's.

In practical terms, blindness in early childhood means that:

• What seem like ordinary, everyday happenings may need to be explained. Let your child know that scrambled, fried, and hard-boiled eggs all begin as raw eggs.

• Some events are outside of your child's direct experience. Tell your child about birds flying and let him have a chance to touch and hold one.

• Your child may need help in putting parts together to form a whole. Your child cannot touch an entire dog at one time, but he can feel the nose, ears, body, legs, paws, and tail separately. You can then help him figure out that all these separate parts make a whole dog.

• Imitation is harder. Your child will need to be shown how to play «So big!» because, while the words may still make him laugh, he will not be able to see you raise your hands above your head and will not know-what he is supposed to do.

• Some learning does not come naturally. You cannot take for granted that your child will stand up and walk one day if he has never seen anyone walk before. Nor can you expect him to steal a cookie from the cookie jar if he doesn't know where the cookie jar is.

Why doesn't my child play with toys very much?

Until your child knows what a toy is and how to use it, she won't have a very good idea of how to play with it. Many of the toys we give to our children we choose because we like the colors - not because the sound is particularly appealing to the child, or because it feels pleasant, or because the child can do something with it. The crib mobiles we buy are a striking example of this. They look so cute from where we stand, but from where the baby is lying in the crib, they hold no interest at all unless they are moving or making noise.

Again, we do not know a great deal about why some toys are more interesting than others for blind and visually handicapped children. We do know, however, that blind children cannot play with toys if they don't know toys are out there. You can help your child find toys in front and behind her, across the room, in drawers, in closets. And you can make it fun by playing with your child and giving her feedback on how she is doing:

«Very nice! You put the round block in the round hole!» «See how these stacking rings fit together, one on top of the other?»

When you purchase toys for your child, look for the ones that have the following characteristics:

• unbreakable

• no sharp edges

• bright colors (red, yellow, orange, hot pink)

• high contrast (yellow and black, black and white)

• moving parts sound

• pleasant to touch.

Many of the stuffed animals, puppets, and dolls we buy are not played with by blind and visually handicapped children until they have an imagination. A stuffed dog doesn't feel, smell, or sound like a dog, and a doll's hard, plastic face doesn't feel like a real baby's face. When children can imagine what it's like to be someone else, or can copy what mom and dad do, then this step of playing with toys and stuffed animals is easier. This doesn't mean that you should not give your child dolls and stuffed animals; it does mean that you will need to play with your child and show her how to use these toys and how she can use her imagination.

Why does my child walk funny?

Many parents have noticed that their blind, visually handicapped, or multihandicapped children walk - or shuffle - with their feet wide apart and/or their toes pointed slightly out to the side. They wonder if all blind children walk this way.

If you have other children, you may remember that they, too, first learned to walk with their feet wide apart and their arms held high. They do this because it helps them keep their balance. As they become better walkers, they no longer need this wide base of support.

Visually handicapped children, however, may continue to walk this way. As they gain confidence in moving their bodies, this usually disappears. But this confidence only comes from lots of movement activities from early infancy: rolling over, pushing up on their tummies, reaching, twisting, crawling. It is important to keep your child physically active, because he has no other way of learning about his body, how it can move, and how it feels when it does move.

If your child is past the toddler stage and still seems to walk funny, continue to work on physical activities, including such things as swimming, kicking, bicycling, and walking up and down steps. These activities will help increase his self-confidence while giving him practice in hip and trunk rotation to help reduce the shuffling.

How will my child know where she is?

If you are not visually handicapped yourself, it may be difficult for you to imagine how your child will learn to identify where she is. You rely on your vision to tell you where you are. Your child will rely on her hearing, touching, and smelling to tell her.

Each room in your home gives off different clues by what covers the floors and walls and what the room is used for. For example, the kitchen may have a linoleum floor and smell like food; the bathroom smells damp and the walls may even feel slightly damp; the living room may have a rug on the floor and a loud clock ticking; and the bedroom may ' sound «soft» because the bed absorbs all the sounds in the room. As your child grows, she begins to use other landmarks to help her know where she is:

• driveways

• grass and sidewalks

• mailboxes

• the bakery

• the gymnasium.

If you teach your child early to pay attention to these things, it will not be difficult for her to learn. Prove it to yourself by covering your eyes and walking slowly around your home or other familiar places, listening, feeling, smelling for clues to tell you where you are. Your child will learn in much the same way: through exposure and repetition.

Seeing Fingers

Little Louis was often told never to touch «Papa's» tools. But one day, when he was only three years old, he wanted to work with a knife in his father's workshop. The knife was too heavy for the little boy; it slipped out of his hand and hit his eye. Within a few weeks Louis Braille was totally blind.

At the village school nobody could teach the poor blind child to read. Louis's father devised a method of teaching his son. He drove some nails into a wooden board arranged in the form of the letters of the alphabet and taught him to read. Thus Louis learned to read a few words.

At the end of the 18th century a Frenchman, Valentin Haug by name, began to teach the blind boy. He made some wooden letters to teach the boy the whole alphabet. One day when the boy was dusting the master's desk he touched some papers - on which there was some writing. He discovered that he could feel the places where his master's pen had pressed on the paper. He followed the pressure-marks with his fingers and found that he could read the writing. Thus, the discovery was made that the fingers of blind people could be taught «to see».

By the time that Louis was ten, Valentin Haug's school had turned into the National institute for Blind Children in Paris. That is how the first school for the blind was opened in the world. The children were taught by menus of raised letters made on cardboard sheets pressed upon lead type.

The Girl Who Could Not See, Hear or Speak, Helen Keller

This is the story of Helen Keller, who could neither see nor hear from the time she was a baby, so that for many years she did not even learn to talk. Yet this brilliant girl was able to overcome all these handicaps, to be graduated from college with high honours, and become a useful citizen.

Helen Adams Keller was born in Tuscumbia, Alabama, in 1880. There was nothing wrong with Helen Keller when she was born. Her father and mother were very proud of their pretty baby.

Her parents looked forward to the time when their pretty daughter would be going to school with the other children of the neighbourhood and running home afterward to tell them all that she had seen and heard in the classroom.

For nineteen months Helen grew bigger and stronger. She was able to walk when she was a year old, and she was even able to say a few words. But one day the child refused to eat her breakfast and started to cry when her mother tried to make her eat her cereal. Then the mother felt the child's head and knew that little girl was sick with a high fever. She put the child to bed and called the doctor.

For days the child lay ill. At last she began to get better, and her parents were happy once more. But their happiness did not last long, for they soon discovered that their darling little Helen would never again be able to see or hear.

The little child was now doomed to a life of silence and darkness. She could not hear what was said to her and did not know how to talk, so she was unable to play with the other children.

Helen Keller was taken to Baltimore to a famous doctor to find out if he could do something to make her hear and see again, but the doctor could do nothing. The child was hopelessly deaf. However, he told her parents that perhaps Dr Alexander Graham Bell in Washington might be able to help the little girl. Dr Bell, the inventor of the telephone, had worked with the deaf for many years.

Dr Bell looked at Helen and shook his head. «I am sorry,» he said. «There is nothing that can be done to make the little girl hear or see, but I suggest that you write to the Perkins Institution for the Blind in Boston and ask if they can send someone to help the child».

It was a wonderful day for Helen Keller when Anne Sullivan arrived in Tuscumbia in March, 1887, to take change educating the child who could not see or hear and, at that time, could not even speak.

Helen Keller was nearly seven years old. Anne Sullivan was just twenty. From the first day they became good friends. For the next fifty years, until Anne Sullivan died in 1936, they were close companions. It was due to the patience and skill of Anne Sullivan that Helen Keller developed into one of the most remarkable women of our time.

Anne Sullivan found a way to make herself understood. She gave the child a doll, and, taking Helen Keller's hand, she slowly spelled out «d—о—1—1». The child did not at first know that things had names, but she thought that this finger play was fun and repeated it back into the hand of her teacher. This was the beginning of a new world for Helen Keller.

When Miss Sullivan later spelled into the little girl's hand the word «w—a—t—e— r», and then let the water from the pump run over her hand, a new light seemed to brighten the face of the child. Helen Keller knew then that her teacher was trying to tell her the name of fresh cool water that poured over her hand. It was now a race for Helen to learn the names of all the things that she had known before only through the sense of touch. During the next three months, she learned almost 300 words and could even put some of them into sentences. Helen Keller wanted to make up for lost time.

Miss Sullivan loved her pupil who was so quick to learn. She lived with Helen, played with her, and worked with her every hour of the day. By means of the hand language, Helen and her teacher were able to talk to each other. Helen learned to read books that had been printed for the blind with raised letters. She also learned to use the typewriter to write what she wanted to say, although

She could not read what she had written. That did not matter, however, for she soon was typing without making any errors. By this time she was also able to go on a vacation trip, to swim, to ride a pony, and to do many of the other things that any other child might do.

Helen was determined that she would learn to speak, too.

At first she had difficulty with her speech, but Anne Sullivan understood what she was trying to say. Helen practised speaking day after day until at last she developed a clear voice. Later she was able to speak before large crowds which came to hear her whenever she lectured.

For two years she studied in a school for the deaf, and then, when she was 16, she entered the Cambridge School for Young Ladies in preparation for entering Radcliffe College. There were not many books printed in raised type that she could use in studying her lessons, but it did not matter. Miss Sullivan spelled into her hand everything that the teachers said. Helen took her final examinations in a separate room so that she could use a typewriter to answer the questions» At the age of twenty Helen Keller passed all the difficult entrance examinations to Radcliffe College, which were the same as those given to the young men entering Harvard College.

All through college she had at her side her beloved Miss Sullivan, who never grew tired of spelling into her hand what was said by the teacher. Helen did extremely well in her classes and was able to keep up with the other students. One of Helen Keller's professors was so pleased with the things that she wrote for her English classes that he suggested she write the story of her life. Helen did write The Story of My Life while she was in college. It was such a cheerful, inspiring account of how this young girl was able to live a happy, useful life in spite of terrible handicaps...

In her writings and lectures Helen Keller did everything possible to help and encourage others who were blind.

The life of Helen Keller is the inspiring story of a woman who has done much for herself and for others to live a happy and useful life in spite of terrible handicaps.

Genetic disorders About Down Syndrome

What is Down syndrome?

Down syndrome is the most common genetic condition. One in every 733 babies is born with Down syndrome. More than 50 percent of miscarriages are caused by a chromosomal abnormality. As many as 25 percent of all miscarriages are caused by a trisomy, which is the presence of three copies of a particular chromosome, rather than the normal two.

The most common form of Down syndrome is called Trisomy 21, because it involves an extra copy of the 21st chromosome.

What impact does Down syndrome have on society?

Individuals with Down syndrome are becoming increasingly integrated into society and community organizations, such as school, health care systems, work forces, and social and recreational activities. Individuals with Down syndrome possess varying degrees of intellectual disabilities, from very mild to severe. Most people with Down syndrome have IQs in the mild to moderate range of intellectual disability.

Due to advances in medical technology, individuals with Down syndrome are living longer than ever before. In 1910, children with Down syndrome were expected to survive to age nine. With the discovery of antibiotics, the average survival age increased to 19 or 20. Now, with recent advancements in clinical treatment, most particularly corrective heart surgeries, as many as 80 percent of adults with Down syndrome reach age 60, and many live even longer.

What is the cause of Down syndrome?

The additional copy of the 21st chromosome which causes Down syndrome can originate from either the father or the mother. Approximately five percent of the cases have been traced to the father.

Who has the highest risk of having a child with Down syndrome?

Down syndrome can occur in people of all races and economic levels. Older women have an increased chance of having a child with Down syndrome. A 35-year-old woman has about a one in 400 chance of conceiving a child with Down syndrome, and this chance increases gradually to one in 110 by age 40. At age 45 the incidence becomes approximately one in 35.

Since many couples are postponing parenting until later in life, the incidence of Down syndrome conceptions is expected to increase. Therefore, genetic counseling for parents is becoming increasingly important. Still, many physicians are not fully informed about advising their patients about the incidences of Down syndrome, advancements in diagnosis, and the protocols for care and treatment of babies born with Down syndrome.

Why are medical researchers today so keenly interested in Down syndrome?

Down syndrome is a developmental condition. As researchers learn more about the molecular genetics and other aspects of Down syndrome, they also obtain valuable information about human development and can advance the study of many biological processes.

In addition, individuals with Down syndrome have a higher incidence of certain medical conditions, and the study of Down syndrome may yield important breakthroughs in those areas. Research in Down syndrome provides a way for looking at many important problems:

Heart disease: Up to 50 percent of individuals with Down syndrome are born with congenital heart conditions. The majority of heart conditions in children with Down syndrome can now be surgically corrected with resulting long-term health improvements. However, scientists continue to search for the cause of these heart conditions and look for means of prevention.

Alzheimer's disease: Estimates vary, but it is reasonable to conclude that 25 percent or more of individuals with Down syndrome over the age of 35 will develop the clinical signs and symptoms of Alzheimer's-type dementia.

Leukemia: Approximately one in every 100 individuals with Down syndrome will develop leukemia; or, to put it another way, 99% of people with Down syndrome will not develop leukemia. The majority of cases are categorized as acute megakaryoblastic leukemia, which tends to occur in the first three years of life, and for which there is a high cure rate. A transient form of leukemia is also seen in newborns with Down syndrome, disappearing spontaneously during the first two to three months of life.

Down Syndrome Fact Sheet

• People with Down syndrome have an increased risk for certain medical conditions such as congenital heart defects, respiratory and hearing problems, Alzheimer's disease, childhood leukemia, and thyroid conditions. Many of these conditions are now treatable, so most people with Down syndrome lead healthy lives.

• A few of the common physical traits of Down syndrome are low muscle tone, small stature, an upward slant to the eyes, and a single deep crease across the center of the palm. Every person with Down syndrome is a unique individual and may possess these characteristics to different degrees or not at all.

• People with Down syndrome attend school, work, participate in decisions that affect them, and contribute to society in many wonderful ways.

• All people with Down syndrome experience cognitive delays, but the effect is usually mild to moderate and is not indicative of the many strengths and talents that each individual possesses.

• Quality educational programs, a stimulating home environment, good health care, and positive support from family, friends and the community enable people with Down syndrome to develop their full potential and lead fulfilling lives.

• Researchers are making great strides in identifying the genes on Chromosome 21 that cause the characteristics of Down syndrome. Many feel strongly that it will be possible to improve, correct or prevent many of the problems associated with Down syndrome in the future.

Escape the Hopelessness. Autism is Treatable.

Definitions/Symptoms

Autism is a bio-neurological developmental disability that generally appears before the age of 3.

Autism impacts the normal development of the brain in the areas of social interaction, communication skills, and cognitive function. Individuals with autism typically have difficulties in verbal and non-verbal communication, social interactions, and leisure or play activities.

Individuals with autism often suffer from numerous physical ailments which may include: allergies, asthma, epilepsy, digestive disorders, persistent viral infections, feeding disorders, sensory integration dysfunction, sleeping disorders, and more.

Autism is diagnosed four times more often in boys than girls. Its prevalence is not affected by race, region, or socio-economic status.

Autism does not affect life expectancy. Currently there is no cure for autism, though with early intervention and treatment, the diverse symptoms related to autism can be greatly improved.

According to the National Institute of Child Health and Human Development, there are five behaviors that signal the need for a doctor to immediately evaluate a child for autism…

• Does not babble or coo by 12 months of age

• Does not gesture (point, wave, grasp, etc.) by 12 months of age

• Does not say single words by 16 months of age

• Does not say two-word phrases on his or her own (rather than just repeating what someone says to him or her) by 24 months of age

• Has any loss of any language or social skill at any age.

What Causes Autism

You will hear many theories about what causes autism. To date, no one has found the exact cause of autism.

In the early 1950's-1970's it was thought that the mothers of children with autism were neglecting and not loving their children which in turn caused them to regress into a world of their own. These mothers were labeled «Refrigerator Mothers.» Thanks to Dr. Bernard Rimland, we've come a long way since then.

It's important to do your own research into the various causes that are being investigated. We believe that families should have access to all information including environmental insults, vaccines, genetics, etc.

Autism and Genetics

There are many in the scientific community who believe that there is a strong genetic component or pre-disposition to autism spectrum disorders.

It's important to note that in the past 10 years of looking for the «autism gene,» none has been found which leads many researchers to believe that something had to trigger the gene to turn on and cause autism.

According to officials at the National Institutes of Health, while there is most likely a genetic predisposition, there must also be an environmental component to autism. The rapid rise in the rate of autism over the last 15 years cannot be attributed solely to genetics.

Autism is no longer considered a heritable, genetic disorder. It is an environmentally triggered, therefore preventable and treatable disease. Environmental research holds the key to finding the cause and developing effective treatments for those affected.

Autism is treatable. Children do not «outgrow» autism, but studies show that early diagnosis and intervention lead to significantly improved outcomes.

Here are some signs to look for in the children in your life:

• Lack of or delay in spoken language

• Repetitive use of language and/or motor mannerisms (e.g., hand-flapping, twirling objects)

• Little or no eye contact

• Lack of interest in peer relationships

• Lack of spontaneous or make-believe play

• Persistent fixation on parts of objects

Various Treatment Options:

• Early intervention

• Behaviour modification

• Dietary intervention

• Vitamins and supplements

• Sensory integration dysfunction

• Occupational therapy

• Physical therapy

• Speech therapy

• Music therapy

• Vision therapy

• others

Destroying Myths of Autism

Here we are going to discuss some of the major myths and misconceptions about autism and autism related disorders that may be outdated or misunderstood. It’s important to remain up-to-date on the latest information and research so that we can sort out fact from truth.

There are so many misconceptions about autism out there. We hope to leave everyone here with an understanding of what autism is and just as importantly, what it is NOT.

Myth № 1 – Autism is caused by “Refrigerator Mothers”.

In the early 1950's-1970's Dr. Bettelheim claimed that autism had a psychological causation, in that the mothers of these children, intentionally or not, did not love their children. The term «refrigerator mother» was born, referring to the fact that the mother was cold toward her child.

For many years, this was believed to be the cause of autism. Parents, desperately seeking help for their children, were told by professionals whom they trusted, that they were the cause of the condition. This caused much needless guilt on the part of the parents.

Dr. Rimland was the first to publicly disagree with Bettelheim. As the father of a son with autism, he knew that his child was indeed loved very much by his mother and believed that the symptoms of autism were biological, not psychological. Dr. Rimland is the founder of the Autism Society of America and Defeat Autism Now! He is a true hero to the autism community.

Myth № 2 – No Emotion

A common misconception is that children with autism are unloving and do not have any emotional feelings. On the surface this may seem to be the case because these children don’t always express their emotions in a way that we recognize. But it’s neсassary to know that although children with autism are unable to show their emotions in a traditional way, they certainly do have them and many of them are very attached to their parents. For anyone willing to take the time to recognize them, he will be able to pick up on the ways these children do show emotions and love. It takes looking at things from a different perspective, to see the many ways individuals with autism show their emotions. After all, how do we explain autistic children’s behavioral issues if there are no emotions. Don’t emotions elicit behaviors?

Myth № 3 – Your child just needs a good spanking!

We’ve all been out to a grocery store or running errands when we come across a child throwing a temper tantrum, including screaming, throwing, and hitting. We may wonder why a mother or father is letting their child do this without any discipline or reprimands. If this is a child with autism, he has most likely lost control due to sensory overload. The sounds, visual stimulation, and the overwhelming crowds are just too much for this child to take in which results in a melt down. Parents are unrightfully blamed for not disciplining their children.

Imagine not being able to filter out sounds. So many of us are used to having the power to control what we take in of our environment that we cannot conceive how this child’s brain just went into overload. Individuals with autism often are not able to filter out all the other sounds in the environment, isolate sensitivity issues about bumping into people in crowds, or be capable of sorting out all the visual stimulation that exists around them at once. All this that we take for granted, an individual with autism usually has to handle item by item and sometimes they just can't take it, their brain just gets too confused from all the input, resulting in a «blow out» or «overload».

Myth № 4 – You’re born with autism.

On average, autism is diagnosed at 44 months.

Many children with autism meet all developmental milestones before the age of 2 and suddenly regress into autism. What causes a typically developing child to suddenly regress into autism? The answer to this question will only come from research. At this time, it is widely believed that certain children are genetically pre-disposed to developing autism. But it takes exposure to some sort of environmental insult or “trigger” for them to regress into autism.

Myth № 5 – Vaccines do not cause autism.

The jury is still out on this one. Although the recent Institute of Medicine report appears to refute an association between vaccines and autism, the major autism organizations including the National Autism Association all agree that more research needs to be conducted in this area.

A recent study shows that children receiving vaccines containing the preservative “Thimerosal” are many times more likely to develop autism than those who receive thimerosal-free vaccines.

Thimerosal is 49.6% Mercury by weight. Mercury is the 2nd most toxic substance on Earth and a known neuro-toxin.

In the 1990’s the number of required childhood vaccinations dramatically increased. So did the rate of autism.

We encourage you to do your own research on this topic before forming an opinion.

Myth № 6 - Dustin Hoffman’s character in Rain Man is typical of a person with autism.

The character in Rain Man was a high functioning ASD person and a savant. In reality, only 2% of the ASD population exhibits such savant capabilities. All individuals with autism are different. Some are on the mild end of the spectrum with very few signs and symptoms while some are at the severe end. Caring for an ASD person can be like caring for a toddler of 18 months - they may need constant supervision, may have very few communication skills, may not sleep well, may throw tantrums when they don’t get what they want or can’t communicate what they want, and may not tolerate change very well.

Myth № 7 - Autism is a Neurological Disorder

We’re told by many experts and psychiatrists that autism is strictly a neurological disorder but based on countless parental reports, many children with the diagnosis of autism have the following physical ailments in common:

• Allergies

• Asthma

• Sleep disturbances

• Inflammatory bowel disease

• Food Sensitivities

• Epilepsy

• Digestive Disorders

• Persistent Viral Infections

• Feeding Disorders

• And more…

Current research by Dr. Richard Deth, Dr. Jill James and several other researchers confirms that autism is a bio-neurological disorder, affecting brain function. Research is now showing us that autistic symptoms are caused by bio-medical disorders in the body that in turn affect brain function.

Myth № 8 – The increase in the rate of autism is due to better diagnosing.

10 years ago, the rate of autism was 1 in 10,000 births. Today it is 1 in 166. This is a 5,000% increase in 10 years. If this astonishing increase is due to better diagnosing, where are the thousands and thousands of autistic adults who should have received a diagnosis 10, 20 or 30 years ago?

Myth № 9 – Autism is a rare disorder.

With 1 in 166 children being diagnosed with autism, it can certainly no longer be considered rare. To the contrary – we have an epidemic on our hands. Every 16 minutes another child is diagnosed with autism. Add to that the number of children with Pervasive Developmental Disorder, Asperger’s Syndrome, Child Disintegrative Disorder, ADD and ADHD, and we have a frightening number of disabled children.

Myth № 10 – Autism is incurable.

We are happy to say that Autism is no longer hopeless. Children ARE being helped through bio-medical treatments including dietary intervention, nutritional supplementation, heavy metal chelation, anti-viral treatments, and therapeutic interventions such as Applied Behavior Analysis, Auditory Integration Therapy and other treatments. Many are indistinguishable from their peers.

The Educational Needs of Autistic Children

Lorna Wing, England

1. Autism is a comparatively rare condition. About 1 in 4 or 5,000 children have the tupical symptoms of the syndrome. Autism is 3 or 4 times commoner in boys than in girls, but the child to be described is a little girl Sally, now aged 9. She is an only child, born at full term after a normal pregnancy and delivery. She appeared to be a healthy baby, but from the outset she sucked very poorly, and feeding difficulties continued until she was 3 months old. She was restless and difficult and she would scream for hours at a time, especially at night. She could not be comforted and was not at all a cuddly baby. She never made herself ready to be picked up when approached by her parents. She smiled, sat up and crawled at the usual ages but she did not seem at all interested in things that were going on around her. Unlike other babies of the same age she did not lean out of her am to see what was going on, even when she could easily sit up and move around. Instead she would lie babbling quietly and scratching or tapping on the pram cover with her finger nails. She was fascinated by bright lights and would laugh and coo at the electric light. She had a fey elfin quality, but she was most like an ordinary baby during active tickling and romping which she loved.

2. Her parents were worried about her but could not define their fears and no one else confirmed them. They consulted their G.P. about the screaming, poor sleep and sleeping difficulties but were reassured that these troubles were very common. There were a number of indications that her future development might be abnormal, but only a very sophisticated observer could have suggested that she might be autistic. No one has any practical experience of how best to manage babies with these symptoms, but it is possible to make some suggestions which seem reasonable. The parents needed help with the feeding and sleeping problems, and serious consideration should have been given to them when they expressed their fears about the child. An experienced observer would have noticed the baby's lack of interest in the environment, the search for tactile stimulation (the scratching on the pram cover) and her special pleasure in physical contact, contrasting with her lack of interest in visual stimuli, all of which are reminiscent of the behaviour of blind or partially sighted babies. It might, in fact, have been helpful to have tried some of the methods of management which have proved useful for partially sighted children; although in Sally's case there was no question of poor vision due to bad eyesight. The problem was one of dealing with visual stimuli once they had reached the brain. When she was about 15 months old - the age when a normal baby begins to speak, it became clearer that the problem was complicated by an inability to understand and to use words, which had even more profound effects than the visual handicaps.

3. Sally walked at 15 months, and this initiated the most difficult phase of her development. She was as active as any normal toddler, but was completely unresponsive to speech, including her own name, although she quickly learnt the moaning of non-verbal sounds, such as the rustle of a sweet paper. She continued to babble to herself, but she produced no recognizable word and made no attempt to use sounds or gestures for communication. If she wanted something she would catch hold of someone's hand and lead them to the desired object. Her play was limited to collecting sticks, stones and leaves and arranging them in lines and patterns. If she lost something she had collected she would scream until it was found. At times she would scream for hours on end, for no apparent reason, and could not be comforted. At one point she refused to wear shoes, at another would wear only a pink dress, and would scream if made to turn a corner when out walking. When excited she twisted and flapped her arms and legs and clenched and unclenched her hands.

4. With increasing motor skill her interest in the feel of different surfaces became more obvious. She would also examine things by twisting and turning them on the edge of her visual fields, holding them near and then far away. She looked past or through other people and also did not appear to look where she was going when walking downstairs or running in the garden. She seemed to have difficulty in finding small objects that she wanted, even if they were lying on the ground near her feet. If they were rolled along, however, she saw them in a flash and picked them up immediately. When she was four, her mother took her to a small nursery school and stayed with her in the classroom. Sally was restless and wanted to turn out the cupboards just to add to her collection of odd bits of wood. She paid no attention to the other children while they were sitting down, but screamed and covered her ears and eyes when they began to run about and shout and play. The experiment was obviously not a success and Sally did not attend any school again until she was 8.

5. She started to say one or two words when she was 3 1/2, but speech development was painfully slow. Even when she did learn to recognize her own name she seemed to have difficulty in locating the direction of the sound if called from any distance. Similarly she did not seem to recognize people she knew unless they were within a few yards of her. Although disinterested in speech she loved music and her first words were attempts to supply the last part of the line of a familiar nursery rhyme. During this stage it was difficult to find any meaningful pattern of Sally's strange behaviour. However, looking back it was possible to see that she was severely handicapped because she could not make sense of any words that she heard, and very little sense of the things she could see. The way she used her eyes suggested that her peripheral vision was better than her central vision, so that fine details meant nothing to her. These handicaps prevented her from learning about the world, about her own body and about other people. They also led to a variety of secondary problems, such as the temper tantrums, the odd repetitive behaviour, the search for sensory stimulation from touch, taste and movement. Worst of all were the secondary consequences of the communication difficulty. Sally's parents were puzzled and distressed by her seeming indifference and the fact that she was an extremely attractive child and appeared bright and alert only added to their bewilderment. They consulted a doctor but all he said was that she would probably improve as she grew older.

6. What could have been done to help Sally? Again, no one knows all the answers, but growing experience suggests certain important points of management. ; Parents can be encouraged to adopt a kind but firm and consistent attitude to screaming, temper tantrums and destructiveness. If they say 'no' they must stick to their decision even if it means that the child makes a scene in public. The difficult behaviour must never be rewarded. Insistence on routines and on collecting strange objects must also be met with firmness. Otherwise the life of the whole family may be upset, without any profit to the child himself. A sensible policy of this kind should be combined with simple teaching to help circumvent the perceptual problems. Ideally there should be nursery classes which have enough experienced teachers to take even very difficult autistic children for a short time each day to begin with, and longer when the child settles down. However, even if a class is available, the parents also must know what to do. The child's environment and experience should be organised so that he can understand at least a small part of it.

7. He should be spoken to clearly, using a very small vocabulary at first. Many children listen happily if words are whispered right in their ear. The number of words used should be increased very slowly, and each one that is added should be demonstrated until the child knows what it means It is best to begin with familiar things like cup, plate, bed, dog and cat or words connected with any special interests the child may have. Motor skills such as eating, doing up buttons, riding a tricycle have to be taught, by moving the child's hands and feet through me motion, since they cannot learn through words.

8. All of this requires persistent effort, especially because there is a constant battle to obtain and keep the child's attention.) However, once the parents understand the basis of their child's problems, they find satisfaction and an easing of their distress in the fact that they have some concrete policy to pursue. I tally's parents learned the correct diagnosis when she was four and a half. By the time she was 5 she had begun to improve a little and this improvement seemed to be related to the acquisition of a few words with which to express her needs. Also her parents were beginning to understand how difficult it was for her to learn and they tried to help her by using non-verbal ways of teaching. She became more affectionate and responsive, and changed from being a sad puzzled elfin creature into a cheerful little girl who enjoyed family activities which did not require words, such as outings to the seaside, swings in the park, and runs on busses, tubes, and trains.

9. When Sally was six and a half she began to make more us of her central as opposed to peripheral vision. This happened almost overnight. She started to look at pictures which previously were of no interest at all, and to identify them. She still has difficultiy in recognizing tiny models of, for example, farm animals, but she likes looking at large clear and simple pictures and has no trouble with recognizing large models of real things. At the same Sally began to look at people she knew instead of right through them, and she stopped examining things by misting them in her hand. This development opened a whole new world for her an. made teaching much easier. Expeditions could be prepared in advance by looking at appropriate pictures, and the events of the day recalled in the same way. Sally loved to look at the family photographs, learning to name even- person who appeared. Illustrations to go with her favourite records, such as Peter and the Wolf increased her interest and understanding. She also began watch television but tended to identify the characters as people she knew. Once this interest in pictures had developed it was possible that she might eventually learn to read. Anyone who teaches autistic children should be aware that these sudden spurts in development can occur; be ready to recognize such an opportunity when it arises.

10. Sally's speech did not show any sudden improvement but developed slowly and steadily. Her vocabulary of nouns was built up most easily because she willingly learnt the names of things as long as the name and the subject were linked by demonstration. Unlike a normal ch she did not learn new words from other people's conversations. Her speech showed all the characteristics of a child with developmental aphasia: echolalia, reversal of pronouns, a telegraphic style due to missing out the little linking words, and a tendency to mix up word order; «take park to doggie» being a typical example. Now she is 9, can communicate her needs, express affection and pleasure in the company of people she likes and can point out things in environment. She is beginning to answer simple questions, but she cannot hold a conversation. She can understand simple sentences, but is still confused by complicated instructions. She is very willing to do what she is told when she grasps what is required, but becomes anxious and upset if asked to do some thing in words that she does not understand or if the speaker is in; hurry and impatient.

11. She is attending a special school for autistic children, where she receives considerable individual attention. The teaching utilises all sensory channels including touch and movement and is designed to overcome her problems in understanding speech. She is beginning to read, count, recognize and write figures, to add up, to tell the time and to draw and paint. She has greatly improved her practical skills such as dressing, washing, laying the table, eating, etc.; because these skills are specifically taught in the school as well as more usual school subject She is also learning to swim and to play ball with the other children. Sally's attempts to perform these physical activities have demonstrated that she has considerable difficulty in imitating movements, although at first sight she appears dainty and graceful.

12. To begin with Sally bitterly resisted each new step, and there was no doubt that learning was extremely difficult for her. As she began to achieve some success the resistance gradually lessened. Since attending school she is happier and easier to manage at home, not least because she sleeps much more soundly at night.

13. This story illustrates most of the problems of educating an autistic child, and the aims of education, which are to overcome basic handicaps, minimise the secondary consequences of those handicaps and to develop any skills the child may possess.

14. To sum up, the first requirement is early diagnosis and assessment - not just attaching a label to the child, but a careful analysis of the child's specific handicaps. The basic handicaps are the disturbance of sensory perception, and the difficulty of linking sense experiences together to make a coherent picture of the world, but each child has his own special pattern of difficulties. The parents should be given a clear explanation and taught how to help their child develop as normally as possible. They need guidance in dealing with the difficult behaviour, and in how to teach specific skills. When the child reaches school age, he should be able to attend a school when he can receive plenty of individual attention from teachers who are well informed about his handicaps and who are able to remain firm and confident in the face of intensely difficult behaviour. Ideally the teacher should be in touch with educational psychologists and neurologists who can make the initial assessment and review the child's progress with the specific aim of helping the teacher to develop the most suitable leaching techniques. At the moment, tests for subtle perceptual disturbances arc being developed by research workers and ace not generally available, but it is to be hoped that the provision of schools for these children will stimulate wider interest in the possibilities of this kind of testing.

15. When she was 3 or 4 years old it was not possible to predict that Sally would improve at all. It is important to provide the kind of environment in which the chances for improvement are maximised. Some children will not respond but they should all have the best possible opportunity.

16. Looking back it is interesting to speculate how much difference it would have made if Sally's education had begun considerably earlier in life. She was extremely uncooperative from 3-6 years and teaching would have been a real struggle. Could this have been avoided by a different kind of management in babyhood? Would she have been much more advanced now had she attended a special school from the age of 4 or 5? How valuable was the time that was wasted in the first 8 years of Sally's life when a normal child would have learnt the basic skills necessary for social and academic progress? Perhaps now that more autistic children are receiving special education from an early age, these questions may be answered.

17. It is useful to see it not as an isolated phenomenon, but as one syndrome in a whole series, all of which give rise to learning problems. These include developmental aphasia, dyslexia, minimal brain damage with hyper kinesis, distractibility and perceptual problems, and a large number of other syndromes which are only just being clarified. They also include deafness, blindness and other physical problems which limit a child's experiences. All of these syndromes lead to many secondary difficulties including emotional disturbances, but the way to deal with them is through the primary basic handicaps. Autism differs from the others only in the severity and multiplicity of the handicaps involved. The teaching problems are that much more difficult, but by no means impossible to solve.

What is Williams Syndrome?

Williams syndrome is a rare genetic condition (estimated to occur in 1/10,000 births) which causes medical and developmental problems.

Williams syndrome was first recognized as a distinct entity in 1961. It is present at birth, and affects males and females equally. It can occur in all ethnic groups and has been identified in countries throughout the world.

What are the common features of Williams syndrome?

• Characteristic facial appearance

• Heart and blood vessel problems

• Hypercalcemia (elevated blood calcium levels)

• Low birth-weight / low weight gain

• Feeding problems

• Irritability (colic during infancy)

• Dental abnormalities

• Kidney abnormalities

• Hernias

• Hyperacusis (sensitive hearing)

• Musculoskeletal problems

• Overly friendly (excessively social) personality

• Developmental delay, learning disabilities and attention deficit

Characteristic facial appearance

Most young children with Williams syndrome are described as having similar facial features. These features which tend to be recognized by only a trained geneticist or birth defects specialist, include a small upturned nose, long philtrum (upper lip length), wide mouth, full lips, small chin, and puffiness around the eyes. Blue and green-eyed children with Williams syndrome can have a prominent «starburst» or white lacy pattern on their iris. Facial features become more apparent with age.

Heart and blood vessel problems

The majority of individuals with Williams syndrome have some type of heart or blood vessel problem. Typically, there is narrowing in the aorta, or narrowing in the pulmonary arteries. There is a broad range in the degree of narrowing, ranging from trivial to severe (requiring surgical correction of the defect). Since there is an increased risk for development of blood vessel narrowing or high blood pressure over time, periodic monitoring of cardiac status is necessary.

Hypercalcemia (elevated blood calcium levels)

Some young children with Williams syndrome have elevations in their blood calcium level. The true frequency and cause of this problem is unknown. When hypercalcemia is present, it can cause extreme irritability or «colic-like» symptoms. Occasionally, dietary or medical treatment is needed. In most cases, the problem resolves on its own during childhood, but lifelong abnormality in calcium or Vitamin D metabolism may exist and should be monitored.

Low birth-weight / low weight gain

Most children with Williams syndrome have a slightly lower birth-weight than their brothers or sisters. Slow weight gain, especially during the first several years of life, is also a common problem and many children are diagnosed as «failure to thrive». Adult stature is slightly smaller than average.

Feeding problems

Many infants and young children have feeding problems. These problems have been linked to low muscle tone, severe gag reflex, poor suck/swallow, tactile defensiveness etc. Feeding difficulties tend to resolve as the children get older.

Irritability (colic during infancy)

Many infants with Williams syndrome have an extended period of colic or irritability. This typically lasts from 4 to 10 months of age, then resolves. It is sometimes attributed to hypercalcemia. Abnormal sleep patterns with delayed acquisition of sleeping through the night may be associated with the colic.

Dental abnormalities

Slightly small, widely spaced teeth are common in children with Williams syndrome. They also may have a variety of abnormalities of occlusion (bite), tooth shape or appearance. Most of these dental changes are readily amenable to orthodontic correction.

Kidney abnormalities

There is a slightly increased frequency of problems with kidney structure and/or function.

Hernias

Inguinal (groin) and umbilical hernias are more common in Williams syndrome than in the general population.

Hyperacusis (sensitive hearing)

Children with Williams syndrome often have more sensitive hearing than other children; Certain frequencies or noise levels can be painful an/or startling to the individual. This condition often improves with age.

Musculoskeletal problems

Young children with Williams syndrome often have low muscle tone and joint laxity. As the children get older, joint stiffness (contractures) may develop. Physical therapy is very helpful in improving muscle tone, strength and joint range of motion.

Overly friendly (excessively social) personality

Individuals with Williams syndrome have a very endearing personality. They have a unique strength in their expressive language skills, and are extremely polite. They are typically unafraid of strangers and show a greater interest in contact with adults than with their peers.

Developmental delay, learning disabilities and attention deficit

Most people with Williams syndrome have some degree of intellectual handicap. Young children with Williams syndrome often experience developmental delays; milestones such as walking, talking and toilet training are often achieved somewhat later than is considered normal. Distractibility is a common problem in mid-childhood, which appears to get better as the children get older.

Older children and adults with Williams syndrome often demonstrate intellectual «strengths and weaknesses.» There are some intellectual areas (such as speech, long term memory, and social skills) in which performance is quite strong, while other intellectual areas (such as fine motor and spatial relations) are significantly deficient.

Is there any treatment?

There is no cure for Williams syndrome, nor is there a standard course of treatment. Treatments are based on an individual’s particular symptoms. People with WS require regular cardiovascular monitoring for potential medical problems, such as symptomatic narrowing of the blood vessels, high blood pressure, and heart failure

What is the prognosis?

The prognosis for individuals with WS varies. Some degree of mental retardation is found in most people with the disorder. Some adults are able to function independently, complete academic or vocational school, and live in supervised homes or on their own; most live with a caregiver. Parents can increase the likelihood that their child will be able to live semi-independently by teaching self-help skills early. Early intervention and individualized educational programs designed with the distinct cognitive and personality profiles of WS in mind also help individuals maximize their potential. Medical complications associated with the disorder may shorten the lifespans of some individuals with WS.

Cleft Palate and Velopharyngeal Disorders

Cleft lip (cheiloschisis) and cleft palate (palatoschisis) (colloquially known as harelip), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening - a gap. It is the non-fusion of the body's natural structures that form before birth.

Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks and forehead. In 1976, Dr. Paul Tessier described fifteen lines of cleft. These craniofacial clefts are rare and are frequently described as Tessier clefts using the numerical locator devised by Dr. Tessier.

A cleft lip or palate can be successfully treated with surgery soon after birth. Cleft lips or palates occur in somewhere between one in 600 - 800 births.

Cleft lip

If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.

Cleft palate

Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.

Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the secondary palate).

The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity.

A direct result of an open connection between the oral cavity and nasal cavity is velopharyngeal insufficiency (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions. Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations (e.g., glottal stops and posterior nasal fricatives). Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures.

Submucous cleft palate (SMCP) can also occur, which is an occult cleft of the soft palate with a classic clinical triad of bifid uvula, a furrow along the midline of the soft palate, and a notch in the posterior margin of the hard palate.

Causes of cleft

The cause of cleft lip and cleft palate formation can be genetic in nature. A specific variation in a gene can have abnormalities causing the Van der Woude Syndrome, increasing threefold the occurrence of these deformities. This has been identified by Zucchero et al. in 2004 as reported by the BBC.

Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. Some environmental factors that have been studied include: seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids- which are members of the vitamin A family; anticonvulsant drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc).

If a person is born with a cleft, the chances of that person having a child with a cleft, given no other obvious factor, rises to 1 in 14. Research continues to investigate the extent to which Folic acid can reduce the incidence of clefting.

In some cases, cleft palate is caused by syndromes which also cause other problems. Stickler's Syndrome can cause cleft lip and palate, joint pain, and myopia. Loeys-Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm. Cleft lip/palate may be present in many different chromosome disorders including Patau Syndrome (trisomy 13). Many clefts run in families, even though there does not seem to be any identifiable syndrome present.

Communication and other problems related to Cleft Palate (or Cleft Lip and Palate):

• Speech sound difficulties. Some sounds may be difficult to make if the palate is allowing air to escape into the nose because of the malformation. Speech sounds may be weak, or be replaced by incorrect or unusual sounds.

• Disorders of nasality. Speech may sound nasal (hypernasality) - this is the opposite of how you sound when you have a cold.

• Language Delay.

• Voice Problems.

• Feeding difficulties.

Speech and language therapists are often involved with multi-professional teams working with Cleft Palate. Owing to the success and early timing of surgery many children will not develop speech and language difficulties. Speech therapists on a 'cleft team' assess children at key ages - usually around 18 months and 3 years of age - seeing children within the multi-disciplinary team appointments. The Specialist Speech and Language Therapist will review the child to assess the speech and language development, and advise parents as necessary. Depending on the severity of the cleft, speech therapy may begin as early as 18 months - 2 years, and continue until late adolescence.

Treatment

Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft.

Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood. Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.

Speech and hearing treatments

A tympanostomy tube is often inserted into the eardrum to aerate the middle ear. This is often beneficial for the hearing ability of the child.

Speech problems are usually treated by a speech-language pathologist. In some cases pharyngeal flap surgery or augmentation pharyngoplasty is performed to reduce the escape of nasal airflow in speech sounds requiring oral air pressure, to improve the pronunciation of those sounds, and reduce nasality in those parts of speech that are not normally nasalized. The speech-language pathologist may also be called on to correct incorrect speaking habits that the child developed before the cleft was corrected surgically.

Can a Child with a Cleft Palate Learn to Talk?

Most frequently parents of young children are worried about how their children will talk. Defective speech has been one of the most serious results of cleft palate. Cleft of a lip alone rarely produces an important speech problem, but palatal clefts make difficult producing many sounds.

Observations indicate these children begin to talk at about the same time as other children, but their speech is distorted. Parents should expect this, because if the palate and throat cannot work together to shut off the nose from the throat, the speech will sound nasal and the child will distort some sounds because he can't produce enough air pressure in his mouth. This type of speech should not be alarming because after the palate is repaired the children can develop good speech.

Before the palate is repaired, parents can help most by remembering to speak plainly when talking or reading to the child.

After the palate is repaired the specialist may suggest some speech training activities for the parents to carry out at home. For some children no other speech training will be necessary. Other children, however, will need the help of a trained speech therapist. Correct production of speech sounds is developed gradually over a period of several years. Generally the average child doesn't learn to produce all speech sounds accurately until he is about seven or eight years of age. However, with adequate help, many children with cleft palates are speaking as well as their classmates when they enter school.

Orthopedic impairments Cerebral Palsied Children

Cerebral Palsy is an umbrella term for a group of persistent disorders of posture and movement caused by damage to the immature brain. It is non-progressive, but associated complications may occur later. The physical impairment resulting from the initial damage can vary from mild to very severe. Cerebral Palsy can affect walking, feeding, talking, and hand use. Sometimes other parts of the brain are also affected which may lead to difficulties with hearing, sight, perception, or learning skills.

There are three main types of Cerebral Palsy which correspond to injuries to different parts of the brain. Physical difficulties vary accordingly:

• With Spastic Cerebral Palsy some muscles become very stiff and weak especially with increased effort. This can affect control of movement.

• With Dystonic or Dyskinetic Cerebral Palsy (Athetoid Cerebral Palsy) there will be some loss of control of posture, and a person affected with this type of Cerebral Palsy tends to make unwanted movements. Children may drool.

• With Ataxic Cerebral Palsy (Ataxia) there are usually problems with balance. People may also have shaky hand movements and irregular speech. This form occurs less frequently.

• With Mixed Cerebral Palsy there may be symptoms from more than one of the other types.

This condition occurs in one cerebral palsied child to 1,200 – 1,600 population. It may rise from damage during birth or from infections in the prenatal period of early childhood. The most common forms are the spastic, the athetotic, and the ataxis. Speech is disturbed in about 70% of cases of cerebral palsy.

Recognised characteristics of Cerebral Palsy (which are very variable from mild to severe) can include:

• Different sorts of abnormal muscle 'tone'.

• Involvement of one or more limbs.

• High incidence of speech and communication problems. This includes some people having no speech.

• Higher incidence of epilepsy compared with the normal population.

• Higher incidence of sensory impairments (vision or hearing problems) than the normal population.

Speech and language therapists are often involved with multi-professional teams working with Cerebral Palsy. Therapy may begin at birth (particularly if there are feeding difficulties involved) and continue indefinitely. On the other hand Cerebral Palsy may not be diagnosed until the infant fails to achieve the usual developmental milestones (e.g. for sitting, crawling, eating, drinking, speech).

The following may form part of therapy input for people with Cerebral Palsy:

• Early communication skills, including raising awareness of self and the environment.

• Information on early play to encourage communication e.g. eye-contact, facial expression, body language.

• Multi-disciplinary work towards safe feeding, swallowing, and adequate nutrition.

• Maximising the potential for speech.

• Multi-disciplinary work towards effective communication using the most appropriate method. The following may be used: speech, signing, communication boards, non-verbal skills, Augmentative and Alternative Communication (AAC), 'high tech' communication devices, communication switches.

• Attention to any particular difficulties parents with a child affected by Cerebral Palsy encounter.

• Maximising special qualities a child has.

Their speech is slow, the voice is often monotonous and relatively uncontrolled, and the articulation suffers because of the impaired muscular coordination. Cerebral palsied speech is a problem for the professional speech pathologist, but the classroom teacher plays a vital role in giving him opportunities of the training recommended by the speech pathologists and by other specialists.

The treatment of cerebral palsy is a complex needed: the therapist, the neurologist, the pediatrician, the orthopedist the speech pathologists and others. The majority of cerebral palsied children have several handicaps and therefore they need many kinds of help. They have the motor handicap by which their condition is defined and diagnosed, but they also have sensory difficulties and perceptual impairments. It is difficult for them to adjust to their handicaps and get through school and find a place in the life. Sometimes the child is emotionally unstable; sometimes he is mentally retarded.

Cerebral palsied children attend a special school or a regular school. Sometimes they require permanent clinic care, some get education at home.

For many cerebral palsied children in overall program would include the following.

1) Relaxation and voluntary control of the speech musculature.

2) The establishment of breath control for vocalization and articulation.

Such children breathe too deeply or too shallowly for purposes of speech.

For most cerebral palsied children a normal length of phrase is not to be expected. Short, uninterrupted phrasing is a more modest and more possible achievements. For breath control blowing through a straw is helpful.

3) Control of the organs of articulation.

Considerable exercises are needed to establish directed and independent action of the tongue and to overcome the frequently present tendency of such a child to move his jaw as he attempts to move his tongue and lift his tongue independently of his jaw.

Children enjoy such exercises as licking honey from their lips, or reaching for a bit of honey placed on the upper gun ridge.

The child should be shown what he does by observing himself in a mirror.

The speech therapist emphasises muscle training for cerebral palsied person

4) Work on individual speech sounds.

5) Incorporation of sounds in words and phrases.

Many cerebral palsied children have considerable difficulty in making the translation from the production individual sounds to connected speech.

Articulation must be coordinated with breathing and vocalization, and then children speak better. The speech of the cerebral palsied children may be normal when the muscles of the articulatory and respiratory organs are not affected but in general the speech is slow, jerky and laboured. The rhythm is faulty with unnatural breaks. The consonants, particularly those which require precise articulation are apt to be inaccurate. Language development may be retarded.

Список литературы

1. Бочарова Г. В. Английский язык для психологов: Учебное пособие / Г. В. Бочарова, Е. В. Никошкова, З. В. Печкурова, М. Г. Степанова.- М.: Флинта: Московский психолого-социальный институт, 2004. – 576с.

2. Материалы многоязычной универсальной интернет - энциклопедии Википедия http://en.wikipedia.org/wiki

3. Материалы интернет - сайтов

• NICHCY (the National Dissemination Center for Children with Disabilities) http://www.nichcy.org

• BATOD (The British Association of the Deaf) http://www.batod.org.uk

• The Williams Syndrome Association http://www.williams-syndrome.org

• The National Autism Association http://www.nationalautismassociation.org

• The world's leading web site on learning disabilities and ADHD http://www.ldonline.org

• The child and youth health website http://www.cyh.com/

• The International Dyslexia Association http://www.interdys.org

• The National Down Syndrome Society http://www.ndss.org

• Autism Society http://www.autism-society.org

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

Содержание

Введение….………………………………………………………………….…….3

Special Education Teachers………………………………………………………...3

Specific Learning Disabilities....................................................................................9

Speech and Language Impairments.........................................................................29

Mental Retardation…………..................................................................................62

Emotional Disturbance………………………………………………………...….68

Hearing Impairments…………………………………………………………...…81

Visual Impairments………………………………………………………………..91

Genetic Disorders………………………………………………………………..100

Список литературы……………………………………………………………..132

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