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A SURVEY OF SPEECH THERAPIES
FOR THE CEREBRAL PALSIED

BY
Robert Lee Choiniere

AtTHESIS
Submitted to the School of Graduate Studies of Michigan
State College of Agriculture and Applied science
in partial fulfillment of the requirements

for the degree of

MASTER OF ARTS

Department of Speech

1950

 

(5811-25115

 

ACIQIOYILEDGMLNTS

The author wishes to express his grateful appreciation
to Dr. Charles Pedrey, Director, Michigan State College
Speech Clinic, for his invaluable guidance in the writing of
this thesis. Acknowledgments are also due to Dr. A. T.
Cordray, Counselor of Foreign Students, Michigan State
College, for his expert assistance in editing the thesis.

Host deeply and directly the author is indebted to
his wife, Nedra Choiniere, for the time and effort spent,

and the patience exhibited, during the Writing of this thesis.

CHAPTER
I. THE PROBLLJ AND THL STATEKEKT OF PURPOSE
TheProblem..............

The statement of Purpose . . . . . . .

II.. DESCRIPTION OF TYPES Ann DEFINITIONS OF TERMS

III. THE TIOLOGY OF CEREBRAL PALSY . . . . .
of Neurology . . . . . .a. . . . . .
The Causes of Cerebral Palsy . . . . .

Iv. THE SPEECH THERAPIES . . . . . . . . . .
‘The Need for a Cerebral Palsy Program..
Guiding Principles in Speech Correction
Methods . . . . . . . . . . . . . . .
Pre-Therapeutic Procedure . . . . . . .

Speech and Hearing Testing . . . . . .

Actual Therapeutic Treatment . . . . .

Establishment of rapport .
Relaxation o o o o o c o o o e e o 0
Drug therapy 0 o o o e o o o o o o 0

Breathing 0000000000...

E
A Review of Some of the Fundamental Concepts

PAGE

12

12
19
26
26

27
29
31
35
35
36

41

iv

CHAPTER ' PAGE
The speech mechanism . . . . . . . . . . . 42
DevelOpment of speech sounds . . . . . . . 45

Prognosis . . . . . . . . . . . . . . . . 48

V. INCONCLUSION................. 50
VI. BIBLIOGRAPHY . . . . . . . . . . . . . . . . . 58
VILAPPENDIX................... 56

 

 

llll] Ill

CHAPTER I
THE PROBLEM AND THE STATEMENT OF PURPOSE

It is noted that in the early history of man the
cerebral palsied, as well as countless other peeple with
serious physical difficulties, were regarded as derelicts
of society.

Historically, the first reactions of normal persons
to abnormality in others were those of rejection.
Among primitive peoples the rule of survival of the
fittest has always been as paramount in human relation-
ships as it has been in nature.l

As such they received treatment which today would seem un-
just, to the point of being inhumane. Many were willfully
abandoned or killed outright on the premise that they pos-
sessed devils or other evil spirits. 'The palsied person
as well as any other handicapped person was quite likely
to be regarded as a Joke perpetrated by the Almighty or
perhaps by Satan."2 There followed then a period in which
the afflicted were subjected to ridicule and the humble

position of court Jester or comedian.

 

1 C. van Riper, Speech Correction Princi les and
methods (New York: Prentice-HaII, Inc., 19445, p. 2.“

2 M. A. Perlstein, The Problem of Cerebral Palsy
Today (New York: Association for the Aid of Crippled
Children, 1947), p. 11.

The Middle Ages found a great demand for the crip-
pled, blind, and mentally deficient for use as court
Jesters and fools. Thus society reacted to misfortune
in others by laughter and by the consequent heighten-
ing of its own sense of security.3

It would seem that such reactions were the result

of gross ignorance of the condition and its causes rather
than mere lust in satiating sadistic tendencies. It is
also apparent that superstition played an important part
in engendering such response. It wasn't until about 1200
A.D. that any organized work was undertaken to aid the
afflicted. It was at this time that the Order of the Sis-
ters of Charity pitied the misfortunes of these people and
began to care for them.‘

Since that.time the church, the government, and the
educated classes have led in the extension of the con-
cept that the abnormal person not only has a right to
existence, but also deserves pity, protection, and
assistance.5

We are fortunate in having the advantages of rapid

intellectual progress evidenced in our society of today.
Technical advances in all fields, scientific and other-
wise, have been tremendous in the last century. With the

technological advances that have occurred, there has been

a trend toward specialization in the particular phases

3 van Riper, 22, 01 ., pp. 2-3.
4 Ibid., p. 3.

5 Loc. cit.

of a given science or industry. This phenomenon, with
respect to the diagnosis and treatment of the cerebral pal-
sied, has been highly beneficial. Today the person afflict-
ed with cerebral palsy can receive the services of peeple
who are especially trained in the rehabilitation of his
particular difficulty. It is now known that the cerebral
palsied person needs medical attention, neurological treat-
ment, physiotherapy, speech training, and personal guidance,
to mention only the more prominent services rendered.

This paper shall concern itself primarily with the
rehabilitation of cerebral palsy and the part the speech
correctionist plays in it. It shall necessarily include
much material of a nature not directly relevant to actual
steps taken by the speech correctionist in the treatment
of cerebral palsy, but which is needed in his general
background in order to further his comprehensive under-
standing of the problem.l Cerebral palsy is a condition
about which not a great deal is known, even up to the
present day. It has only been in recent years that much
could be found in our libraries about it. The neOphyte
in speech correction discovers that it is a real problem
to find such material to which he can refer. It is only
after long hours and considerable effort that the reading
of the articles and texts on the subject is accomplished.

The purpose of this survey shall be to create a source

of information for the speech correctionist. It will be
a compilation of the leading contemporary theories of the

causes, descriptions, and treatment of persons afflicted

with cerebral palsy.

CHAPTER II
DESCRIPTION OF TYPES AND DEFINITIONS OF TERMS USED

The problem of cerebral palsy presents a variety of
forms of definitions which are necessary in describing the
causes and treatment. "Cerebral palsy" was selected years
ago as a descriptive term because it best fitted the par-
ticular group of conditions exhibited by this condition.

{The term "cerebral” means anything within the head. The
technical term "palsy" describes anything which is wrong
in the voluntary control of the muscles or joints.l Infan-
tile paralysis, for example, is a palsy, but not a care-
bral palsy since the conditions arise in the spine. This
would classify infantile paralysis as a spinal palsy or
paralysis. A peripheral palsy is one in which the damage
or injury is to the peripheral nerves in the extremities
of the arms or legs. Thus, as the terminolOgy indicates,
it can be said that cerebral palsy is any disorder of the
control of the muscles or Joints arising from a condition
within the head. The damage or deterioration of tissue is
known as a lesion.

Cerebral palsy is divided into five subdivisions,
each of which is a distinct and separate entity. The names
of these types are merely descriptive of the particular

disturbance. The first of these types, though not

necessarily the most frequent or most important, is the
spastic. The spastic child is one whose difficulty is
characterized by a hypertension or "over-tenseness" of the
muscles. A muscle itself can only contract. Two muscles,
or groups of muscles, which work in Opposition to each
other are antagonists. As it has been pointed out in
physiology, when a muscle contracts, there is another muscle
which extends. These are known as the flexor and extensor
muscles. It is the contraction of the antagonist which
causes its Opponent to extend. As an example, if one

were to extend his arm in front of him and then raise it

at the elbow, the biceps muscle would contract while the
triceps muscle would extend, since they are antagonists.

To lower the arm to its initial position, the reverse would
occur. The triceps muscle would contract while the bi-
ceps extended. It is in this function that the spastic has
his disturbance. The flexor attempts to contract, but the
extensor also contracts, thus restricting the action of the
flexor. This Opposition, or lack of coordination gives

the movement its "spastic” or Jerky trait. The muscles
appear to be stiff and lack movement. This is known as

the stretch reflex, 1.6., the tendency of a muscle to
contract whenever it is put under tension. Fothergill

and Harrington discuss the phenomenon Of the stretch re-

7
flex and its involvements in greater detail.1 It is a re-
flex action that prevents extension Of the muscle.

The function Of the muscle itself may not be inter-
fered with, but the antagonist does not function pro-
perly. Dr. Phelps says that the stretch reflex is the
only true basis for diagnosing the spastic.2

Quite often the initiation of movement of a spastic

may set up a series Of stretch reflexes which will resemb-
le involuntary motion. Since involuntary motion is one of
the primary characteristics of another type of cerebral
palsy, as will be shown later, this is Often confusing to
the less experienced in their diagnosis of the particular
case.

The second type of cerebral palsy is the athetoid.

It is the athetoid who manifests continuous, purposeless,
involuntary motion. The athetoid's muscles are normal

in structure as Opposed to those of the spastic; the
spastic will often exhibit muscles which are flaccid or
weak, whereas these conditions are not evident in athetosia
There is Often difficulty in the articulation of speech

sounds and in swallowing. On occasion there may even

be a reversed swallowing pattern. Sometimes the whole

 

1 Patti Fothergill and Robert Harrington, "The
Clinical Significance Of the Stretch Reflex in Speech
Reeducation for the Spastic,a The Journal of Speech

Disorders. XIV (December, 1949] 355"-"55. ""

a Juliette m. Gratke, Help Them Hel Themselves
(Dallas: Banks Upshaw and Company, 1947 , p. 32.

 

8
arm will move in a sort Of weaving pattern, but without any
voluntary design. The individual is unable to stop these
athetoid movements. Occasionally he will attempt to re-
sist them by tensing the antagonistic muscles. As a re-
sult of this the tension becomes habitual and the term
”tension athetoid" is used to describe the patient. Con-
versely, the ”non-tension" type makes little or no volun-
tary effort to block the constant involuntary movements.

In diagnosing the athetoid there is the possibility that
he will exhibit what is thought to be spastic tendencies.
In reality, the tenseness, which is a characteristic of the
spastic, is the result of the individual's attempt to volun-
tarily control his involuntary movements.

A third type of cerebral palsy is ataxia, which is
a condition in which there is a disturbance of balance
and directional control. The ataxic patient does not ex-
hibit a paralysis as do the spastics, nor is there any
involuntary motion as in athetosis. The ataxic will stag-
ger as he walks and will fail to exhibit a good conception
of direction and space. He is also prone to falling more
often than is normal. Because of the loss of directional
control he is frequently unable to pick up objects. In
response to questions about the ataxic condition Dr. Phelps
explained that . . . .

. . . . the different types of cerebral palsy are

correlated with differences in the location Of the
brain injury; the part Of the brain involved in
ataxia governs the ability to balance onesself and
to make movements exactly as one needs or wishes.
Whether the child is climbing stairs, trying to
ride a bicycle, or learning to walk or typewrite,
he cannot readily tell just where his legs, arms,
or fingers are, nor how much power he needs to
get them where he wants them.3
However, the ataxic appears perfectly quiet and normal
when he is not attempting to direct purposeful motion.
That is, his difficulty exhibits itself only when he
attempts to make a directed movement. many medical men
believe that with this type of difficulty there may be
involvements of sensation, vision, or speech.

The fourth classification of cerebral palsy is the
rigidity. The rigidity is, in many ways, similar to the
spastic. The muscles are stiff and rigid, but they are
not tense and hyperactive like the spastic muscles. In
rigidity the stretch reflex is not present. In order to
test, it is possible to push a spastic off balance and
this will elicit a sudden reaction of all the muscles as
a compensation against falling. In the same test, the
patient suffering from rigidity will not attempt any pro-

tective muscle contraction, but will merely fall over.

The muscles of the rigidity patient are normal, but they

3 Harry . Bice and Margaret G. Davitt Holden, "Group
Counseling with Mothers of Children with Cerebral Palsy,"
Journal 2; Social Casework, (march, 1949).

10
do not work well, thus bringing about the loss of quick re-
action to a loss of balance.

The fifth type of cerebral palsy is the tremor which
is seen most frequently in old peOple. There are varying
types of tremor but all are forms of cerebral palsy.

It has beenthought for a considerable period Of
time that patients of cerebral palsy could exhibit a com-
bination of its various types but this is refuted by Dr.
Winthrop M. Phelps.

There are not often found combinations of these
diagnostic types in one patient. Years ago a good many
diagnoses of mixed types were made, but on checking
through the records it is found that fewer and few-
er diagnoses Of mixed types are made. Probably where
such a diagnosis was made in the past, it was due to
inaccuracy. However, there are definitely some mixed
types found from time to time. The most common mixed
type is the rigidity-tremor combination which is seen
in patients who have had brain infections like an-
cephalitis which is an acquired type of cerebral palsy.4

Dr. Meyer Perlstein is in agreement with this for he states
that . . . . "although a given patient may exhibit all of
these qualitatively different motor defects simultaneously,
he generally suffers, wholly or predominantly, from only one
of them."5 In their discussion of types of cerebral palsy

Rest, Kennedy, and Carr state that . . . . "an individual

 

4 Winthrop M. Phelps, "Let's Define Cerebral Palsy,”
The Crippled Child, June, 1948.

5 M. A. Perlstein, The Problem of Cerebral Palsy
Today (New York: Association for the Aid of Crippled
Children, 1947), p. 7.

11
who presents only one of these indications of cerebral
palsy is rarely found; on the contrary, there is usually
present a mixture of the three, with one or another of the
symptoms predominating."6 It would seem that this statement
is in Opposition to the theories put forth by Perlstein
and Phelps. The essential difference is in the use of the
term "predominating" by West, Kennedy and Carr. They
assert that although a child may be a spastic, he usually
has other involvements, but it is the spasticity which pre-
dominates. The involvements, however, may be very slight

but are definitely present.

 

6 Robert West, Lou Kennedy, and Anna Carr, The
Rehabilitation of Speech (revised edition; New York:
Harper & Brothers, Publishers, 1947), p. 426.

CHAPTER III
THE ETIOLOCY OF CEREBRAL PALSY

In looking over the great amount of material written
about the nervous system, its structure and functions, it
is Obviously too far-reaching and involved for a complete
treatment of it in this survey. 0n the assumption that
certain fundamental concepts of neurology are understood,
itshould be necessary only to review them briefly. The
nervous system.is composed of tremendous numbers of white
bundles Of fibers and gray cell-bodies. These are called
neurones and they perform one of three functions. .

1. Some transmit the stimulus into a central ner-

vous system from the outside, or from the viscera,
or from the muscles, tendons, and joints. These are
known as the afferent or sensory neurones. "Under
normal conditions the afferent fibers are stimulated
only at their endings in the peripheral tissues, in
the skin, the mucous membranes, the sense organs, etc."1
2. Others go neither in nor out, but their function
is to integrate_the incoming impulse in preparation

for a response. They form the junction or connection

 

1 William H. Howell, A Text-book of Physiology for

Medical Students and Ph s1c1§hs (PhiiadeIphia: w. B.
Saunders Company, 1933), p. 93.

13
between the afferent and afferent fibers, and thus they
are designated as intermediate neurones.
3. Still others transmit impulses which produce ac-
tivity in the muscles and glands. These are known as
the efferent, or motor, neurones.
The Older physiologists believed that one and the
same nerve or nerve fiber might conduct sensory im-
pulses toward the central nervous system or motor im-
pulses from the central nervous system to the periphery.
Bell and Magendie succeeded in establishing the great
truth that a nerve fiber cannot be both motor and sen-
sory. Under normal conditions the efferent fibers are
stimulated only at their central origin, -- that is,
through the nerve cells from which they spring. The
difference in the direction of conduction depends, there-
fore, on the anatomical fact that the efferent fibers
have a stimulating mechanism at their central ends only,
while the afferent fibers are adapted only for stimu-
lation at their peripheral ends.2
The neurones are organized into systems of distinct
function. These are the central nervous system which in-
cludes the brain and spinal cord, and the autonomic ner-
vous system which includes the sympathetic and parasympa-
thetic divisions. The sympathetic and parasympathetic di-
visions of the autonomic nervous system function antagon-
istically. The primary purpose of the sympathetic division
is to activate the body for struggle and to increase its
defensive powers. The parasympathetic division functions
to conserve the life-sustaining body functions. There is

a close relationship between these two divisions and the

 

2 Ibid., p. 93.

l4
central nervous system.

Twelve pairs of nerves emerge from the brain and
thirty-one pairs from the spinal cord. ‘These constitute
the trunk lines which carry impulses to and from the cen-
tral nervous system.

The two major subdivisions are: (l) the cerebrum
and (2) the brain stem.which includes (from.above down-
ward) a the striate bodies at the base of the cerebrum,
b the thalamus, c the mid-brain, d the cerebellumepons,
and e the medulla, from the lower- end of which entends
the spinal cord. The cord acts primarily as a conduct-
or. From the cells in the H-shaped column in the cen-
ter of the cord, axones go out to muscles (motor or
afferent fibers); other axones are sensory (afferent),
carrying impulses to sub-cerebral centers or to the
cerebrum itself; still others are correlating neurones
acting to synthesize nervous activity.3

There is in this system a definite hierarchy Of
control with each unit in the group capable of independent
action, yet subservient to those groups above it. There
has been an evolutionary pattern in the develOpment of
these various sections.

You will note that the spinal cord constitutes the
lowest hierarchy. Above the cord Is the meduDa, a
truncated cone enlargement of the cord, and, posterior-
1y, the cerebellwm. Next in order is the pons, and
above the pons the mid-braip. Much later in neurologi-
cal deveIOpment was superimposed the thalamus, and it
represented for some time the highest gradient Of ac-
tivity. Then a superior coordinating system develOped

3 MiIdred Freburg Berry and Jon Eisenson, The
Defective in Speech (New York: F. S. Crofts & Company,
IBZ5), p. 28.

15

in a group of nuclei contiguous to the thalamus; they
are known as the striate bodies. They still form to-

day an ancestral motor-coordinating system. Finally the
cerebral cortex was developed to be superimposed over
all lower centers.4

The only directly related function of the spinal
cord in the control of speech is in breathing. The higher
centers direct impulses which go out from the lower
motor neurones to innervate the muscles engaged in breath-
ing in the abdominal and thoracic regions.

"The medulla is a continuation within the skull
of the spinal cord. It is about an inch in length, and
larger in circumference than the cord."5 It is function-
ally more complex than the spinal cord and is probably the
lowest level for any integration involving speech.

In the dorsal part of the medulla is the respiratory
center, fibers from which make connection with the lower
motor neurones of the spinal nerves. The center controll-
ing circulation (vasomotor center) also resides in the
medulla. This level is also important because of the
great number of cranial nerves (VIII-XII, nerves to
ear, mouth, pharynx, larynx, and respiratory mechanism)
which issue from it . . . . all the major conduction
paths which maintain efficient relations between re-
ceptors and effectors of the body are to be found at
this level. These great pathways to higher centers and
from lower centers cross to opposite sides in passing
through the medulla so that above the medulla the
right side of the brain controls the left side of the hndy.6

 

4 Ibid., p. 30.

5 Giles W. Grey and Claude M‘. Wise, The Bases of Speech
(revised edition; New York: Harper & Brothers, Publishers,
1946), p. 310.

6 Berry and Eisenson, o . cit., p. 31.

16

"The cerebellum is a fissured structure attached

to the brain stem by three pairs of peduncles."7 It is
just posterior to the medulla and directly under the
projecting posterior wings of the cerebrum.

This center is a 'clearing house' for all impuls-
es sent to the striped muscles of the body. Were it
not for this center, a given set of muscles could en-
gage in only one activity at a time; we would not be
able to stand, breathe, nod, turn the head, and speak
simultaneously, for these acts require the coordination
of largely overlapping sets of muscles, and, in some
instances, require Opposing movements.8

The cerebellum, in expediting the efficient accomplishment
of its functions, maintains a constant state of stretch in
the striped muscles. This tautness is known as muscular
tonus. "The primary purposes of the cerebellum are two:
to provide the requisite tonus to muscles, and to tune up
the motor mparatus so that the muscles respond promptly
and accurately.“9 The cerebellum.also maintains the body
in a state of balance with respect to gravitational pull.

The pons is that portion of the brain which Joins,

or bridges between, the cerebral cortex and the cerebellum.

3 Ernest Gardner, Fundamentals of Neurolo-
(Philadelphia: W. B. Saunders Company,-I947), p. E45.

8 Robert West, Lou Kennedy, and Anna Carr, The
Rehabilitation p§.S eech (revised edition; New York:
Harper & Brothers, Pub ishers, 1947), p. 55.

9 Berry and Eisenson, pp, cit., p. 31.

17
In addition, there are found here two centers im-
portant for speech: (1) the nucleus of the motor sec-
tion of the fifth cranial nerve, which innervates the
muscles of the lower jaw; and (2) the seventh nerve
nucleus, which sends fibers to the remaining facial
muscles.lO
It is through the midbrain that the great ascending
and descending pathways run, but its direct control over
speech is doubtful.
The striate bodies, sometimes referred to as the
basal ganglia, and the thalamus function in the control
of emotions and in the finer coordinations essential for
rhythmic speech. They are the last of the controlling
stations prior to the cortex. Gardner expresses the belief
that the thalamus does even more when he says that it . .
. . "is not only concerned in synaptic relays, but is also
integrated in some manner with cortical functions."11
The cerebrum, largest organ in the cranium, is
deeply creased by fissures. it is divided into two
hemispheres by the great longitudinal fissure. The right
hemisphere generally controls the functions of the left
half of the body, and the left hemisphere generally controls

the functions of the right half of the body. In the con-

 

10 Ibid., p. 53.

11 Gardner, pp, cit., p. 288.

18
trol of the speech organs, however, some of the most im-
portant exceptions to this rule exist.

There are four major areas, or zones, of the care-
bral cortex. They are the frontal, the parietal, the
temporal, and the occipital lobes.

The frontal lobe is the primary motor area which
sends fibers to the skeletal musculature. There are path-
ways which originate in the giant pyramidal cells of the
motor cortex of the cerebrum and these paths are called the
pyramidal tracts. Paths which come from the basal ganglia
area and control associated movement are referred to as
the extrapyramidal tracts. The extrapyramidal area and
Broca's area for motor speech are also located in this lobe.

”In the parietal lobe are the cell bodies of the
highest order for all incoming sensory impulses . . . . a
center for the understanding of speech also is ascribed to
the posterior section of this lobe.“12 It is in this area
that is derived the kinesthetic sensitivity of muscular
movement.

The temporal lobe is very important to the normal
develOpment of speech for it is into this area that all

auditory impulses come for conscious analysis. It is in

 

12 Berry and Eisenson, pp, cit., p. 55.

19
this auditory receptive center that the most frequent
stimulus to speech comes. Intermediate neurones connect
with cells in Broca's area and some fibers run into the
pre-motor area.

In the occipital lobe are the centers for the re-
ception of visual stimuli.

In addition to what has been discussed, there is
considerable that goes into the process of speech and other
motor functions. The endocrine system, the circulatory
system, certain reflex patterns, and many other factors are
included in the overall picture. For the eXplanation of
what occurs in cerebral palsy, however, further discussion
of the involvements of this process is not absolutely essen-
tial.

Among medical authorities there is no disagreement
as to cause. Its causes are the destruction of, or damage
to, brain tissue, or the congenital malformation or mal-
develOpment of the central nervous system. In attempting tn
determine the specific cause of the lesion, or brain damage,
in any given case, the task of the diagnostician becomes
considerably more difficult. "The large number of etiologi-
cal factors acting on the infantile brain to cause cerebral

palsies may be classified into those effective (1) within

20
the uterus, (2) during birth and (3) in early infancy.”13
This theory is also substantiated by Dr. Howard Rusk who
writes, . . . . ”most cases of cerebral palsy are caused
by injury to the brain during birth, or by faulty develOp-

14 He also mentions the Rh blood fac-

ment of brain cells."
tor, encephalitis, and meningitis as possible causes. Dr.
Meyer A. Perlstein expresses the belief that . . . . "most
cerebral palsy is congenital in the sense that it occurs
when the child is born or before the child is born."15
Marsee Evans also contends that there are three general
times when the inciting cause of cerebral palsy may occur:
. . . . "before birth, at or near the time of birth, and
after the birth of the child. These times are generally
referred to as 'prenatal', 'neonatal', and 'postnatal'.”16
The assertion of such theories by the contemporary leaders
in the field of cerebral palsy tends to refute the belief
of earlier leaders in the fight against cerebral palsy.

17

Evans explains that it was the contention of Dr. Little

 

13 Roy R. Grinker, Neurology (third edition; Toronto:
Ryerson Press, 1936), p. 874.

14 Howard A. Rusk, "What Can Be Done For Cerebral
Palsy," The American Mercury, November, 1948.

15 meyer A. Perlstein, "Ask The Doctors," The
Crippled Child, June, 1949.

16 Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal p; Speech Qisorders, XII (March 1947), 88.

17 Ibid, p. av.

21
and his contemporaries that the primary cause of cerebral
palsy, or Little's Disease as it was then called, was in-
jury to the brain in the period of birth. Berry and
Eisenson also substantiate this by stating that . . . .
"by far the largest number of cases can be traced to birth
injury."18 The difficulties at birth might be premature
birth, too rapid birth, or delivery injuries. Some cases
Little attributes to such things as maternal illness during
pregnancy, maternal intoxication during pregnancy, faulty
development in the fetus, hereditary syphilis, or intra-
cranial hemorrhage. Parts of these theories have since
been rejected. It has been shown through recent investi-
gations based on postmortem examinations that in the new-
born, intracranial hemorrhage is far more common than was
previously thought. The theory of inherited syphilis as
a cause has not been substantiated by either clinical or
laboratory investigation. In fact, there is considerable
doubt that definite hereditary or familial causes exist.

Whether or not the condition of the mother before
the child's birth has any bearing upon the situation
is very debatable; and although any or all of the above
named conditions may be responsible for what is known

as Little's Disease, only a very small percentage of
children born under them develOp this difficulty.19

 

18 Mildred Freburg Berry and Jon Eisenson, The
Defective in Speech (New York: F. S. Crofts & Company,
1945) p. 305. .

19 Marguerite K. Fischel, The S astic Child,
(St. Louis: The C. V} Mosby Company, 1934), p. 25.

22
That cerebral palsy may be hereditary is contended by Dr.
Perlstein who says,

There are some forms of cerebral palsy that are
hereditary in the sense that there is a genetic carry-
over. In many of the hereditary forms of cerebral
palsy, the children do not survive for more than four
or five years. These children thus are never seen at
a cerebral palsy clinic, and our knowledge of such
cases may be deficient.20

Cerebral palsy may also be the result of an accident
and may come about even in youth or adulthood, although
this is quite rare in occunence. Pusitz classifies the
causes of the condition into two types, congenital or
acquired, and he attributes most cerebral palsy to the
latter.

The most common cause of the congenital type is due
to lack of develOpment of the pyramidal tract, lead-
ing to atrophy or sclerosis of the lateral columns of
the spinal cord; to large cerebral defects; to por-
encephaly; to hemorrhage; or intra-uterine softening;
also congenital syphilis is the cause of a small
minority of cases.

The acquired cases are those occurdng during
labor, or those coming on later in childhood. Jones
and Lovett consider intracranial hemorrhage, due to
trauma of the child's head during prolonged labor,
forceps delivery, or prolonged asphyxia at birth as
causes. The hemorrhage is usually meningeal, but at
times intracerebral, and gives rise to chronic menin-
geal encephalitis; sclerosis; cysts; atrophies; and
porencephaly. Of those cases occurring after birth,
one can list hemorrhage, embolism, endoarterial and
periarterial changes, encephalitis, cerebral venus

 

2O PerIStein, pp. cit.

23

thrombosis, and chronic meningitis as the productive-
factor.21

It is possible to coordinate the type of cerebral
palsy which is present with the type of lesion which has
occurred. If the lesion is in the motor cortex and
pyramidal tracts, the resulting palsy is spasticity. "In
these cases the cerebral damage is in the pyramidal tracts,
that is, in the cortex or the motor pathways leading down
from the cortex, which govern discrete voluntary movement.“22
This fact is further substantiated by Pusitz who says that
"The lesion involves the cortex or the subcortical areas
of the parietal lobes of the heterolateral hemisphere."25

Injury in the extrapyramidal tracts results in the
purposeless, involuntary movements of athetosis.

Although it is believed that certain lesions of the

frontal lobe may cause athetoid movements, the basic
pathology is found to be involvement of the basic

nuclei, particularly the caudate nucleus (striate body)
on one or both sides.24

 

21 M. E. Pusitz, "Speech Correction in Cerebral
Palsies," The Journal p£.Speech Qisordegp, IV (September,
1939), 206.

22 Evans, pp, cit., p. 90.

23 Pusitz, pp. cit., p. 207.

24 L00. Cit.

24

"The lesion is in the caudate nucleus (striate body),

the so-called extrapyramidal treated“?5

Injury in the cerebellum results in loss of balance

and ataxia. There is poor equilibrium, coordination and
tonus regulations, and the condition is accompanied by a
staggering walk with some exaggerated motions. "Here the
lesion is in the posterior fossa above the tentorium . . . .
muscle tone may be decreased, and ataxia in these cases may
be due to both sensory and motor involvement."‘?'6

There are often certain peripheral involvements of

the body accompanying the lesion. Among various writers
there is some confusion as to the nomenclature of the
various types of involvement, but there is a general
agreement.

When one limb is concerned the name given is mono-
plegia. When both arms are involved it is double
hemiplegia; both legs, diplegia or paraplegia; one
arm and one leg, hemiplegia; three limbs, triplegia;
and four limbs, quadriplegia or tetraplegia, or some-
times diplegia.27

Other involvements are hypermotility, hemiathetosis, and

bilateral athetosis.

 

25—3vans, loc. c t.

._1_
cit.

26 Pusitz, 10c.

27 Evans, pp, cit., p. 91.

25
Hypermotility is that quality of excessive move-
ment of the limbs which characterizes the athetoid. Hemi-
athetosis is an athetoid condition in which there is an
involvement of one hand, or one hand and one foot only.
Bilateral athetosis is a similar condition characterized
by an involvement of both hands, or both hands and both
feet.
Pusitz presents Zentay's classification of central
motor defects and their related peripheral involvements.
CLASSIFICATION. Zentay has presented a very useful
classification of the central motor defects as follows:
'1. Pyramidal lesions (Spastic Paralysis); MonOplegia,
Hemiplegia, Diplegia, Tetraplegia.
2. Extrapyramidal lesions (Hypermotility); Hemiathe-
tosis, Bilateral athetosis.

3. Cerebellar lesions (Ataxia disorders); Hemiplegia,
Diplegia, Tetraplegia.'28

 

28 Pusitz, loc. cit.

CHAPTER IV
THE SPEECH THERAPIES

In regarding the problems of children handicapped
by cerebral palsy, consideration of their speech handicaps
is of primary importance.

It is difficult to know the total number of cerebral
palsied in the United States. It is variously estimat-
ed et from 75,000 to 125,000. There are probably about
as many as there are victims of infantile paralysis.
Out of the public school population in this country of
50,000,000, 300,000 are crippled, 80,000 are deaf and
60,000 are blind. These figures indicate the compare-
tive occurrence of cerebral palsy.l

The condition is one which may affect nearly anyone.
There is no correlation between social, economic, or intel-
ligence factors and the occurrence of cerebral palsy. 0f
the number afflicted with cerebral palsy, it is believed
that nearly two-thirds need speech training of some sort.

When it is realized that these cases require more
specialized and prolonged treatment than the latter
(infantile paralysis), taking many years to effect,
that fully seventy-five percent of these cases have
some degree of a speech disturbance, and that marked
improvement follows prOper therapy in fifty to seventy-
five per cent; it can be realized how important a
field this is for the speech correction expert.2

 

Tl Marsee Fred Evans, ”Problems in Cerebral Palsy,"
The Journal p; Speech Disorders, XII (March, 1947), 88.

2 M. E. Pusitz, ”Speech Correction in Cerebral
Palsies," The Journal p; Speech Qisorders, IV (September,
1939), 206.

27
The value of such training cannot be overestimat-

ed. Because speech gives the child an Opportunity for self
expression, stimulates mental growth and enhances his pos-
sibility of becoming self supporting, it is a vital part of
the rehabilitation program. It is difficult for the speech
correctionist to know where to begin his training program
and how to go about it.

‘ There are certain guiding principles which the
speech correctionist must consider in working with the
cerebral palsied. He must fully realize that the muscles
and organs of speech were not designated primarily for
that function, but rather were designed for meeting the
basic physical and biological needs of the individual.

This is very emphatically stressed by Evans who affirms:
”One of the greatest truths for the speech correctionist
who would deal with these cases, one which should be 'writ
large so that he who runs may read,’ is that speech ;p_pp

overlaid function."3

Speech then, like piano playing,
writing, reading, and any of the other acquired motor
abilities, is a learned process. It does not just occur,
as do the innate processes which man possesses. When a

process is learned, then there must be degrees of ability

3 Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal p; Speech.;§sorders, XII(March, 1947), 94.

28
and this introduces a second principle to be noted.

The cerebral palsied individual is an imperfect
organism. Therefore the correctionist should remember
that it will be physically impossible to achieve perfect-
ion as a result of training. Tremendous improvement is
often made; but, because of a lesion or congenital mal-
develOpment, vital neurological pathways are non-func-
tioning and perfection is not possible. "This does not
mean that the clinician or the patient should be satisfied
with less than is attainable. The highest and best must
always be sought, but the limitations must be recognized."4
"In this discussion the goal we are setting up is achieve-
ment of intelligible speech and not perfect or normal
speech patterns. Normalcy is not the aim.in working with
the cerebral palsied."5

A third important principle for the correctionist
to bear in mind is that he cannot make generalizations
regarding any particular case. No two cases are exactly
alike. "Each cerebral palsied childis an individual
problem. These problems occur in infinite variations, and

each must be solved in terms of its own possibilities."6

 

4 Ibid., p. 95.

 

5 maryann Peins, "You Can Help At Home, "The
Crippled Child, (August, 1949).

6 Winthrop M. Phelps, "They Are Individuals --
Treat Them That Way," The Crippled Child, (June, 1947).

29
It is in this respect that the clinician must take into
account all of the physical, mental, social and environ-
mental involvements of the particular case with which he
is working.

A fourth principle, one which is applicable in any
correction program, whether or not it be with the cerebral
palsied, is the careful planning of a program. Intelligent
plans must be made of the kinds of treatment to be used.
The correctionist, in order that the greatest amount of
help may be given the individual, must work in close co-
ordination with the doctor, the neurologist, the physio-
therapist, the psychologist, the classroom teacher, and
the parents in developing the best program possible.

Keeping these principles in mind, the clinician
must first ascertain, if possible, that the person is
mentally able to gain through speech rehabilitation work.

Careful studies of the intelligence of cerebral-pal-

sied children place approximately 30 per cent in the
feebleminded group and 5 pericent in the superior group,
the remaining 65 per cent falling within the range of
normal intelligence. Speech training for those suffer-
ing from extreme amentia is either contra-indicated

or should be limited to the establishment of the
minimum.speech required for expressing the individual's
needs. For the intellectually normal individual handi-

capped by cerebral palsy, speech training should be
stressed, since self expression is limited in other areas.7

7 Robert West, Lou Kennedy, and Anna Carr, ThJ
Rehabilitation of Speech (revised edition; New York: Harper
& Brothers, Publishers, 1947), p. 430-31.

30
Unless the child has sufficient intelligence, it is futile
to undertake an extended and costly speech rehabilitation
program. Therefore, the clinician should attempt to
accumulate information concerning the intelligence of the
cerebral palsied person from competent sources.
Mental deficiency is often associated with diplegias
and may assume a severe form of idiocy or a relative-
ly mild slowness in develOpment. Many of these child-
ren are, however, exceedingly bright and attend uni-
versities and professional schools. Therefore, prog-
nosis regarding the mental status should be guarded.8
Dr. Phelps stresses this point very explicitly when
he says that . . . . "obviously, in cerebral palsy, the
child cannot respond with motor skills he does not possess.
This means that standard intelligence tests, used in schools
for mass examinations, must be adapted to the needs of the
case."9
In the testing of the intelligence of normal child-
ren there are frequently conflicts of Opinion over the
estimated intelligence. It does not seem unusual then that
in such testing of the intelligence of the cerebral palsied,

which is complicated by a lack of motor control, there is

an even greater difficulty in arriving at a decision as to

 

8 Roy R. Grinker, Neurology (third edition; Toronto;
Ryerson Press, 1936), p. 877.

9 Winthrop M. Phelps, "The Cerebral Palsied Child
Goes to School,” Hygeia, XXVI (April, 1948), 273.

31
the individual's intelligence. The intelligence quotient
is a reasonably good measure of intelligence only when we
have determined that given factors, other than intelligence,
have not affected the child's performance to a significant
degree.

The lack of motor control and coordination is not
the only factor which would bear such significance. Fre-
quently the child suffers from a lack of the environmental
stimulation which motivates good mental develOpment. The
child may also have other defects resulting from injuries
to other portions of the brain which may affect his vision,
hearing, or other senses.

The speech clinician must then formulate as much in-
formation as possible regarding the medical diagnosis
and prognosis of the individual case. He should be familiar
with any conditions of the individual which might involve
limitations of activities.

It is only after such information has been gathered,
interpreted, and evaluated that the speech correctionist

should begin working with the problem.

The next step in the procedure of treatment of the ’an'

cerebral palsied is a testing of the speech and hearing of
the individual. Berneice R. Rutherford made a study of the
loudness, pitch, rate,1hythm.and quality of the speech of

children handicapped by cerebral palsy.

32

These data suggest, however, as has been stated,
that there is some difference in speech reactions
between the two CP groups. They seem to differ in
rate and rhythm trends, and in the pr0portion of
voices which are loud, low-pitched, monotonous, or
breathy. The CPex (athetotic) group seems to tend
toward slower, more Jerky speech than the CPp
(spastic) group. In the CPex group there are also
more loud voices, more low-pitched voices, and more
monotonous or breathy voices.

Examination of the agility of the speech musculature
and breathing {paratus seems to point to at least a
partial basis for this difference. The attributes
and qualities differentiating the two groups--i.e.,
rate, rhythm, loudness, low pitch, monotony and breathi-
ness--seem to be definitely related to control of
the breathing aparatus.

The difference between the two CP groups in breath
control and in mobility of the speech musculature
suggests that a difference in therapy for CPex and CPp
groups is indicated.

This study seems to indicate that there is no special
speech which is characteristic of all children handi-
capped by cerebral palsy; that there is a difference
with respect to some speech trends between the two
main groups of cerebral palsy; and that a difference in
therapy for CPp and CPex groups is indicated.10

The speech testing of the cerebral palsied will prove
that the speech difficulties exhibited will be very similar
to those exhibited by children having speech defects and
possessing a normal motor ability. The primary distinction

is, however, that the normal child's difficulty is basically

 

10 Berneice R. Rutherford, "A Comparative Study of
Loudness, Pitch, Rate, Rhythm.and Quality of the Speech of
Children Handicapped by Cerebral Palsy,” The Journal of
Speech Disorders, IX (September, 1944) 270-71.

33
a functional one, whereas the cerebral palsied child's is
structural. The speech defects are not isolated as such,
but are an integral part of the cerebral palsy itself. The
speech defect must be treated as a part of the whole pro-
gram of rehabilitation.

,It has been pointed out that there are no two cere-
bral palsy cases which are exactly alike and therefore the
Speech difficulties will vary from case to case. For this
reason, and for those pointed out by Berneice Rutherford,ll
it is difficult, if possible at all, to describe spastic,
athetotic, rigid, or ataxic speech. The Speech characteris-
tics of any particular type of cerebral palsy are not dis-
tinctive enough to warrant specific classification. It
is possible, however, to note some very general deviations.

l. The spastic may exhibit what Evans calls general
spastic speech, of which there are two types. "With
one group there is an inability to make the speech

mechanism perform."12

Regardless of the effort put
forth the articulators will not react to produce speech.
The second type . . . . "shows the ability to make the

speech sounds separately in a clinic situation, but a

 

I1 Ibid., PP. 263-710

12 Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal 2; Speech Qisorders, XII (March, 1947), 96.

34
seeming inability to carry over to words, phrases,
sentences.n15 There might also be unusual deviations in
the pitch and quality because of the involvement of
spastic laryngeal muscles. Occasionally the difficulty
will be articulatory because of malocclusion or because
of a tongue which is spastic. Nasality may also be

' present if the spasticity involves ve10pharyngeal
control. Many of these same traits are exhibited by
the rigidity type of cerebral palsy.

2. The Speech of the athetoid and ataxic is not
basically a speech problem. The speech of these
children is usually blurred and indistinct giving the
impression that they are able to make the sounds clear-
ly, but that they speak carelessly.

It is difficult in some respects to isolate the
treatment given for any particular type of cerebral palsy.
The same basic therapies may often be applied to more than
one type and its adaptation is governed by the individual
case. One major point to note is that athetoids and ataxics
profit little from repeated drills. It has been observed
that these two types will exhibit speech difficulties which
are inconsistent; that is, their production of a given sound
in a particular word may be satisfactory or unsatisfactory

at any time. The mispronunciation of the sound is not con-

 

13 Loc. it.

35
sistently wrong. On the other hand, the spastic will ex-
hibit consistent defects in speech. If a particular sound
is faulty, it is always faulty. Thus it can be assumed
that only the spastic will profit sufficiently from re-
petitive drills.

The beginning of the actual therapeutic treatment for
the cerebral palsied is the establishment of good rapport
between the speech clinician and the patient. Rapport is
of the utmost importance and the patient must be accepted
wholeheartedly. Caro Hatcher says that the clinician must
exhibit a . . . . "willingness to touch a drooling chin,
listen to breathing snorts without noticeable reaction, and
Show no concern when an involuntary movement of arm or leg
causes our hair to be ruffled."l4 The importance of es-
tablishing good rapport cannot be overemphasized for much
of the success of the whole program relies upon it.

In many cases the spastic will exhibit drooling,
improper breathing, lack of attention span, as well as many
other such obstacles to the production of speech. Before
drill on any of the specific speech sounds is begun, re-
gardless of the type of cerebral palsy disorder, the clinic-

ian must tackle the Job of correcting the conditions mention-

 

14 Caro C. Hatcher, "Athetoids Relax and Speak,"
The Crippled Child, (June, 1949).

36
ed above. These problems, as well as the overall speech
problem, may be attacked through the use of relaxation.

The fundamental steps in teaching speech to spastic
and athetoid children do not differ greatly. In either
case, relaxation is essential before any other form of
treatment is instituted. It should be pointed out that
the patient with true athetosis can generally show no
improvement without relaxation.15

The importance of relaxation is further pointed out

and emphasized by Kareee Evans.

Several kinds of therapy haVe been found effective.
Someone has said that there are three ways to treat the
speech of the spastic paralytic: first, relaxation;
second, relaxation; and third, aELAhATICN! That is
all very good, but how will you achieve relaxation ?
But speech is generally improved in direct preportion
to how well you do achieve it.16

In formulating lesson plans by which to work, the

relaxation should preceed any given speech training. "Re-
laxation of speech organs cannot be induced until there is

general relaxation."l7

To avoid any misunderstanding, es-
pecially in the treatment of younger children, the place
for play and the place for relaxation, as well as other
training, should be separate and not interchangeable.

Gnnerally, it is easier to achieve relaxation if the child

is lying down. A comfortable room temperature along with

 

15 M. A. Perlstein and Marie Shere, "Speech Therapy
for Children with Cerebral Palsy," American Journal of

Diseases 2: Children, MXXII (October, 1926), 389-3987—
16 Evans, pp, cit.,-p. 97

17 Perlstein and Share, loc. cit.

37
the exclusion of outside stimuli will also contribute in
gaining relaxation. In many cases it may be necessary, in
order to help the athetoid relax, to use cotton ear-plugs
and a blindford. Carlsonlamentions that having the child
do things which will require sufficient attention and con-
centration will help him in attaining relaxation since his
attention is centered on what he is attempting to do
rather than the muscular effort and coordination required
in doing the particular task. Thus the child begins to
learn to willfully exclude the excessive stimuli. "Speech
always improves when the child learns to inhibit the ex-
cessive sensory stimuli which are irrelevant to what he is
doing. In this respect, he resembles the speaker in his
attempts to overcome stage fright."19

Perlstein and Share suggest that "Relaxation may
be encouraged by gently tapping the face, neck and Shoul-
ders; by rolling the head from side to side, and by grasp-
ing the chin and shaking it gently."20

The speech clinician must allow sufficient time

for spasms to subside. With older children this period of

 

18 Earl R. Carlson, Born That izay (New York: The
John Day Company, 1941), 174 pp..

19 Earl R. Carlson, "Give Them Lducation," The
Crippled Child, (December, 1947).

20 Perlstein and Share, loc. ci

38
time can be spent in reviewing centain objectives stressed
in previous lessons or previewing those of today's lesson.
With younger children, casual, easy-going chatter about
events of the day, or some coming event, may be used.

In attempting to help the child gain the ability to
relax, it must be remembered that the direction of the
therapy is toward "conscious" relaxation. The child Should
be taught to recognize the difference between tense and re-
laxed muscles. Much of the ability to relax is the result
of a feeling of confidence. Every effort should be made
to see that he retains his feeling of security Since it
is necessary that the child carry the relaxation which he
has learned into his other activities. zf

In conjunction with the establishment of relaxation,
the subject of drug therapy arises. It would seem that
medical science would be able to develOp drugs with specific
relaxing effect which could be used in treating cerebral
palsy. There exist now certain drugs which accomplish
this, but they tend to have a sleep-inducing effect. One
such drug is alcohol, which often brings about a relaxing
effect. Its method of action in cerebral palsy is not
known, but its main effect is to relieve tension. That
one has more coordination when slightly inebriated is
noted by Dr. Perlstein when recalling a description of this

by Dr. Carlson. "Dr. Earl Carlson aptly describes individuals

39
who are 'more sober when drunk than when sober'."21Therefon£,
alcohol may be recommended for certain types of cerebral
palsy, especially the athetoid.

There is a new drug which seems to act primarily on

the midbrain and is used in the control of the petit mal
form of epilepsy. This is tridione and it has a relaxing
effect similar to alcohol. "It is most valuable in the

/ athetoids and least in the spastics. Although it does
not benefit all athetoids, some improve dramatically."22
However, continued use of tridione may result in toxic

f effects and complications. Its extraneous effects are

ii,more severe in adults than in children.
i It would seem lOgical to conclude that drugs which
have a paralyzing effect would prove beneficial in the treat-
ment of the cerebral palsied since the condition is so fre-
quently characterized by rigidity, tension, or stiffness in
the muscles. "The drug acts in preventing nervous impulses
from reaching the muscles by blocking them at the muscle-
nerve junction. In small doses the drug causes relaxation."“3:5

There are many serious disadvantages to the drug, the great-

est of which is the short span of time that the effects last.

 

2T Meyer A. Perlstein, "The Current Status of Drug
Therapy in Cerebral Palsy," The Crippled Child, (August, 1949).

H‘
d’

2..

{O
t"

00. C

d'

00. ci

03
t"

2

h

40
There is also little difference between the therapeutic
and the lethal dose.
Probably the best known drug used in the treatment
of cerebral palsy is prostigmin.

Prostigmin has caused considerable controversy since
it was first recommended for use in cerebral palsy.
After it was given publicity in a national lay magazine,
there was a "run" on the prostigmin market by all people
who had or thought they had cerebral palsy. Parents
demanded from their physicians that the drug be given
to their children. When the physicians hesitated,
parents sometimes went out and employed prostigmin
on their own responsibility. 24

Prostigmin produces relaxation through its action on the
spinal cord.

In athetosis where the arms are in rapid continuous
motion, prostigmin would only make the arms move faster.

However, in such cases as the rigidities, where the
muscles are rigid and do not move well, prostigmin will
definitely bring about an increase in the facility of
use of the muscles. In spasticity, it may seem.that the
muscles are tight and stiff, and it may be thought that
therefore prostigmin will release that stiffness.
However, spasticity is actually an extremely rapid and
tense series of motions in a muscle, and prostigmin
will step up this rapidity.25

There are other drugs which are used with the
cerebral palsied, such as myanesin, which is eSpecially
beneficial to athetoids; belladona, strepine, stramonium,
which benefit the rigidity and tremor groups; and several

others.

 

24 Loc. i .

25 Winthrop M. Phelps, "Questions Parents Ask with
Answers," The Crippled Child, (August, 1947).

41

Regardless of the effect of any drug in the treat-
ment of cerebral palsy, drug therapy should serve only as an
aid in the overall program of rehabilitation. "Medication
(3 is not a substitution for training; it is merely an aid."26
I The administration of any drugs must be under the careful
supervision of a_competent medical person.

Among cerebral palsied children therearu often
evidenced difficulties in breathing. many of these child-
ren, spastics in particular, have true "reversed breathing."

In normal breathing, the chest and the abdomen should

rise and fall together. In reversed breathing one will
rise as the other falls due to a reversal of diaphrag-
matic movement. This type of breathing can be observed
either directly or by placing one light weight object

on the chest and another on the abdomen infrasternally.27

The speech clinician should be thoroughly familiar
with the mechanics involved in the process of breathing
before he makes any attempt to do corrective work on a
reversed breathing pattern. Any exercises conducted to
correct this condition should be masked by accompanying
activities. Evans asserts that most standard breathing
exercises will suffice and that rhythm should be emphasized.

He further states that "Good breathing should be practiced

from the prone, supine and side-lying positions. After

 

26 Perlstein, loc. cit.

27 M. AA Perlstein and Marie Shere, "Speech Therapy
for Children with Cerebral Palsy," American Journal 2;
Diseases 2; Children, MKXII (October, 1946) 389-98.

 

42
there has been some improvement the patient should do the
same work sitting up and, finally, in a standing position
and while walking."28The importance of correct breathing
is affirmed by narguerite Fischel who states that . . .

. "unconscious proper breathing is, of course, a funda-
mental necessity for ease of tone."29For specific treatment
of reversed breathing patterns, see Appendix, page 59.

Lhen the breathing pattern has become somewhat
normal, the speech correctionist should then begin exer-
cising the basic mechanism of Speech. There should be in-
stituted a program of exercises which will call for tongue
gymnastics. The movements of speaking and eating have a
similar origin and it follows that progress in the latter
would insure progress in the former. It is on this theory
that Froeschels bases his chewing method as a special
corrective technique.

Dr. Froeschels has based his method on the obvious
fact that chewing is one of the functions of those
organs which produce speech. moreover, as there is
only one set of muscles and nerves for both seemingly
different functions, those of speaking and chewing,
and since the two kinds of movement do not interfere

with each other, these functions must be identical,
for chewing and speaking can be performed at the same

 

28 Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal g: Speech Disorders, XII (March, 1947) 97.

29 Marguerite K. Fischel, The ppastic Child
(St. Louis: The C. V} Mosby Company, 1934), p. 53.

43
time.30

The speech clinician should first explain some of the
fundamental movements of speaking and chewing to the patient.
The patient should then chew in the ordinary manner, with
the lips closed. It can be called to his attention that
the tongue is in constant movement. The patient is asked
to allow sounds to escape while in the process as though
he were chewing noisily.

If the chewing is performed correctly, with various
movements of the lips and tongue, a great variety of
sounds will escape from the mouth. If uniform sounds
like 'ham-ham-ham' are heard, the lips and tongue do
‘pgp move sufficiently. Correctly performed, chewing
gives the sound impression of a foreign 1anguage.3l

hhen the treatment is first begun the patient should
chew several times a day, but for periods which are very
short. The length of time of continued chewing is regulat-
ed by the progress of the patient.

It may be necessary at first for the therapist to
assist the weak muscles. Chewing motions are often
particularly difficult for the child. he should prac-
tice on actual food, yet because of his difficulty the
food given him is usually so soft that he cannot chew
it, no matter how much he tries. In such cases caramel
or taffy candy should be substituted. A rather large,
tough but well flavored piece of meat offers good chew-
ing practice. Gum chewing is excellent because it pro-

30 Elly Sittig, "The Chewing Method Applied for
Excessive Salivation and Drooling in Cerebral Palsy,"
Journal of Speech Disorders, XII (June, 1947) 191.

31 Loc. Cit.

44
vides an opportunity for continuous chewing and swallow-
ing. Needless to say, the therapist is always watching
while such exercises are in progress.32

The use of chewing activities not only aids in the
develOpment of the mechanical movements of speech, but it
also helps in working with the problems of drooling, Opened-
mouth, and excessive salivation. If the child is prone to
leaving his mouth continually open then it only follows
that he will drool. This is easily verified, for if one
attempts to swallow while his mouth is open, it will be
noted that the process is difficult, if not impossible.

The application of the chewing method to combat drooling
may activate those muscles required in the control of mouth
closure, and thus bring about the voluntary control of
drooling.

After the child has begun to master some of the basic
problems in this respect, the speech clinician should pro-
ceed to reading-chewing.

The next step in the treatment consists of reading,
which should be frequently interrupted by 'meaningless'
chewing. During conversations in the patient's language
he should be reminded that he must think of chewing, ‘
and that he may once in awhile mingle some meaningless

chewing with ‘English chewing‘SB

Each patient should be treated individually and there

 

32 Perlstein and Share, loc. cit.

33 Sittig, 22, cit., p. 192.

45
should be no group treatment. The sessions should be short,
but frequent. Although it would seem that the process would
benefit only the movement of the articulators, Sittig3*notes
that the chewing technique is an excellent method of ridding
the voice of many kinds of muscle constrictions.

The speech clinician then begins the process of
develOping speech sounds. This may consist of easy repetit-
ion of sounds or groups of sounds. "Quiet emphasis is given
to 'speaking with the mouth only'. The child will frequent-
ly catch himself making extraneous movements."35It is here
that a mirror will come into use. Care should be exer-
cised however to be sure that work in front of a mirror is
desirable. "Some children react unfavorably to mirror work.
If such reaction is observed, the mirror work should be
omitted until such time as the child will enjoy and pro-
fit by it.“36

This point is further substantiated by Gratke who
states that "Some children can use the mirror to very good
advantage in eliminating grimaces. On the other hand,

some severe athetoids are upset much more than helped by

 

34 Loc. cit.

35 John C. Snidecor, "The Speech Correctionist on
the Cerebral Palsy Team," Journal 9; Speech and Hearing
Disorders, XIII (March, 1948i, 68.

36 Perlstein and Share, loc. cit.

46
seeing their own grimaces.37The mirror may also prove
useful in the work to eliminate the Opened-mouth, drooling,
and excessive salivation.

It is a general rule in working with speech defective
children that the therapy is begun with those sounds which
are easiest for the child to observe. This will frequently
hold true in working with the cerebral palsied. However,

, there are some cases in which it would be advantageous to
begin with those sounds which are already reasonably well
develOped. In other words, begin with the sounds he has and
proceed to the sounds which he has not.

The process of teaching the isolated sounds to the
cerebral palsied is quite similar to the process used in
working with other serious speech defectives. The clini-
cian should use all the avenues cpen to him in conveying
to the child the preper way to make any given sound. He
should utilize the senses by presenting the sound through
auditory, visual, and motokinesthetic stimuli. Thus, if
the child fails to see the sound or hear it correctly, he
may make progress through the feel of the sound. It is

well to use all three methods with each sound rather than

 

37 Juliette M. Gratke, "Speech Problems of the
Cerebral Palsied," The Journal 9£_§peech Disorders, XII
(JUne, 1947), 133.

47
just one, for it follows that the carry-over will be
stronger and more rapid if this is done.

When the child becomes able to say simple nonsense
syllables, the work should proceed toward vocalization of
short words. Care should be taken to make sure that the
child hears all of the sounds in the word and attempts to
make all the sounds. It is especially true of spastics
that final sounds are omitted. If the child has difficulty
in closing on a word, Evanssasuggests a game with which
results were satisfactory. A long word is selected such
as Chattanooga, Constantinople, or Indianapolis. Using
the word Indianapolis as an example, begin with the initial
syllable. As he says each syllable he taps his finger on
the table. The first syllable is said, then the first is
repeated adding the second; the first and second are repeat-
ed adding the third; and so on to the end of the word. The
finger is tapped continually and the patient works to attain
a smooth easy flow with rhythm. When the word is finally
completed he says it again three times as rhythmically
as possible, clapping his hands each time he says the
word. ”This, too, puts the child's attention and emphasis
on the goal to be achieved rather than on the way in which

it is done. This is always of value.“39

58 Evans, gp. cit., p. 98.

59 Loc. cit.

48

As the child progresses and he gains some ability
to say words, the clinician should proceed to short poems,
sayings, legans, and nursery rhymes. Again rhythm is
stressed in these exercises. When these have been reason-
ably well accomplished, speech games,story telling, and
singing may prove beneficial. All types of cerebral
palsied patients will benefit some from these articulatory
drills as would the average speech deviate, but it should
be stressed again that it is the spastic who will derive
the greatest benefit from repetitive drills. For addit-
ional articulatory drills, see Appendix, page 60.

When the cerebral palsied child is educahle, and he
receives the benefits of a good rehabilitation program,
well administered, it is to be expected that progress will
be made. It is difficult to predict what progress will be
made and at what rate it will be accomplished for there are
many factors in each individual case which have a definite
bearing upon the progress which will be made. The
complex pattern of involvements resulting from cerebral
lesions may result in such things as poor vision, hearing
deficiency, association disturbance, and many other things
which will have a direct effect upon the acquisition of

good speech. As in treating any other type of speech

49
defect, the clinician should refrain from making any
definite statements to the individual or his family con-
cerning prOgnosis. Any statements he makes must be
carefully qualified, for the clinician has no way of know-

ing for sure if any progress will occur.

CHAPTER V
IN CONCLUSION

The author has presented some of the theories of
the contemporary leaders in the field of cerebral palsy.

In attempting to evaluate the material presented it would
seem logical to make some general comparisons between

the theories of these various authorities. If the author
finds that there is a variance of Opinion among the leaders
in the field, no attempt will be made to determine which
technique, definition, or description is superior.

The field of cerebral palsy, from the rehabilitation
point of view, is in its early infancy. Great strides of
progress have been made, but there is much yet that is un-
known. The author finds that there is positive agreement
among the leaders in this field on nearly every point
concerning the cause of cerebral palsy. Those differences
which do exist are in matters of definition and origin of
cause, as Opposed to the neurological area affected. The
differences, however, are such that they make no actual
dissimilarity in the whole picture.

The methods of therapy in the rehabilitation of the
speech of the cerebral palsied may vary, but the objectives

of the therapy are the same. All are in definite agreement

51

that the most beneficial treatment is the establishment
of relaxation, and especially "conscious" relaxation.

The spastic definitely needs repetitive drills on speech
sounds, as does the rigidity patient. The athetoid and
ataxic will show decided speech improvement when they are

able to attain conscious relaxation.

One very happy thing about cerebral palsy is that
{within certain rather wide limits) practically any-
thing you do for the patient will help him to improve.
If he is of average or better intelligence, and the
majority of them are, he has great potentialities
locked in the prison of a defective body. Any im-
provement you can make, or help him to make, in the
functioning of that defective mechanism will help to
free those potentialities and make for him a fuller

life.1 '

 

l Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal 9; Speech Disorders, XII (March, 1947). 101-02.

 

BIBLIOGRAPHY

BIBLIOGRAPHY

Baker, Harry J., Introduction to Exceptional Children,
New York. The Macmiilan Company, 1949. 496 pp.

 

Berry, Mildred Freburg and Eisenson, Jon, The Defective
‘Lg Speech, New York: F. S. Crofts & Company, 1945.

Carlson, Earl R., Born That Way, New York: The John Day
Company, 1941. 174 pp.

Fischel, liarguerite K, The Spastic Child. St. Louis.
The G V. Mosby Company, 1934. 96 pp.

Gardner, Ernest, Fundamentals of Neurology. Philadel-
phia: w. B. Saunders Company, 1947. 336 pp.

Gratke, Juliette H., Help Them Help Themselves. Dallas:
Banks Upshaw and Company, 1947. 184 pp.

Gray, Giles W., and Wise, Claude H., The Bases 22 Speech.-
Revised edition; New York: Harper & Brothers, Pub-
lishers, 1946. 610 pp.

Grinker, Roy H., Neurology. Third edition; Toronto:
Ryerson Press, 1936. 616 pp.

Howell, William H., A Text-book of Physiology for
Medical Students -and Physicians. Philadelphia:
w. B. Saunders Com3any, 1933. 1132 pp.

 

Jacobson, Edmund, Pregressive Relaxation, Chicago:
The University of Chicago Press, 1929. 429 pp.

Lord, Elizabeth Evans, Children Handicapped py Cerebral
Palsy, New York: The Commonwealth Fund, 1937. 105 pp.

Perlstein, M. A., The Problem of Cerebral Palsy Today.
New York: Association for the Aid of Crippled Child-
ren, 1947.57 pp.

54

Strauss, Alfred A. and Lehtinen, Laura E., Psychopathology
and Education Lf the Brain-Injpred Child, New York:
Grune a Stratton, 1947.206 pp.

Van Riper, C., Speech Correction Principles and Methods.
New York: Prentice-Hall, Inc., 1944. 434 pp.

hast, Robert; Kennedy, Lou; and Carr, Anna, The Rehabili-
tation Lf Speech. Revised edition; New York: Harper &
Brothers, Publishers, 1947. 650 pp.

B. Pi iIODICAL —RTICLES

Berger, Clyde C., "Subjective Observations on Cerebral
Palsy," The Journal Lf Speech Disorders, X (December,
1945), 297-302.

 

Bice, Harry V. and Holden, Hargaret G. Davitt, "Group
Counseling with Mothers of Children with Cerebral
Palsy," Journal 93 Social Casework, (March, 1949).

 

Carlson, Earl R., "Give Them Education," The Crippled
Child, (December, 1947).

Evans, Larsee Fred, "Problems in Cerebral Palsy," The
Journal Lf Speech Disorders, XII (March, 1947),
87- 103

Fothergill, Patti and Harrington, Robert, "The Clinical
Significance of the Stretch Reflex in Speech Re-
education for the Spastic," The Journal Lf Speech
Disorders, XIV (December, 1949 , 353-55

Hatcher, Caro C., "Athetoids Relax and Speak," The
Crippled Child, (June, 1949).

Heltman, Harry J. and Peacher, Georgiana M. "Misarticu-
lation and diadokokinesis in the Spastic Paralytic,"
The Journal Lf Speech Disorders, VIII (June, 1943)
].37" £5 0

Palmer, martin F., "Similarities of the Effects of En-
vironmental Pressures on Cerebral Palsy and Stutter-
ing," The Journal Lf Speech Disorders, VIII (June,
1943) I55- 60

 

55

Palmer, Martin F., "Studies in Clinical Techniques," The
Journal 2: Speech Qisorders, XII (December, 1947),
416-17 0

Peins, Maryann, "You Can Help At Home," The Crippled Child,
(August, 1949).

Perlstein, Meyer A., "Ask The Doctors," The Crippled Child,
(June, 1949).

Perlstein, Meyer A., "The Current Status of Drug Therapy in
Cerebral Palsy," The Crippled Child, (August, 1949).

Perlstein, M. A. and Share, maria, "Speech Therapy for
Children with Cerebral Palsy," American Journal 2;.
Diseases g: Children, MXXII (October, 1946), 389-398.

 

Phelps, Winthrop M., "Let's Define Cerebral Palsy," The
Crippled Child, (June, 1948).

Phelps, Winthrop H., "Questions Parents Ask with Answers,"
The Crippled Child, (August, 1947).

Phelps, Winthrop E., "The Cerebral Palsied Child Goes to
School," Hygeia, XXVI (April, 1948), 272-273.

Phelps, Winthrop H., "They Are Individuals--Treat Them
That Way," The Crippled Child, (June, 1947).

Pusitz, M. E., "Speech Correction in Cerebral Palsies,"
The Journal 32 Speech Disorders, IV (September, 1939),
205“21b o

husk, howard A., "Yhat Can Be Done For Cerebral Palsy,"
The American Hercury, (November, 1948).

Rutherford, Berneice R., "AComparative Study of Loudness,
Pitch, Rate, Rhythm and Quality of the Speech of
Children Handicapped by Cerebral Palsy," Egg Journal
‘9: Speech Disorders, IX (September, 1944) 263-271.

Sittig, Elly, "The Chewing kethod Applied for Excessive
Salivation and Drooling in Cerebral Palsy," Journal 2;
Speech Disorders, XII (June, 1947) 191.

 

Snidecor, John C., "The Speech Correctionist on the
Cerebral Palsy Team," Journal 3; Speech and Hearing
Disorders, XIII (March, 1948) 68.

APPENDIX

I.

APPENDIX

Specific Procedures In The Speech

Treatment Of The Cerebral Palsied

There are centain items of equipment necessary for
the speech room. Among these items should be listed:
(1) a couch and pillOWS, (2) mirrors large enough
for the therapist and the child to see eahh other at
the same time, (3) a hand mirror, (4) tongue depressors,
(5) tissue handkerchiefs, (6) gauze, (7) towels, (8)
sandbags, (9) a table, (10) chairs and (11) a cupboard
or bookcase.

Other items which make the therapy more interesting
and effective are: l. A record player and records.
These are used for relaxation, coordination, rhythm
and speech motivation. 2. A mirrophone or a permanent
recording machine. The latter instrument is useful in
letting a child hear his own speech. however, one
should be watchful to guard against any undesirable
psych010gic effect which might follow when the child
realizes that his speech is unintelligible. Most
children are fascinated by the recording machine and
like to work with it. 3. Rag dolls. These are used
to teach relaxation and to motivate speech. 4. Animals
of wood, pottery or cloth. They are used to motivate
beginning speech. Also, they usually have their
tongues out--which prompts little boys and girls to
do likewise. 5. Pictures of children yawning, blowing
bubbles, dressing themselves and singing. 6. Bubble
pipes. 7. Whistles. 8. Lollipops. 9. A Jar of
peanut butter. 10. A play table with blocks and pegs.
11. A toy xlephone. This is excellent for accompanying
"Rock a bye baby." 12. A toy telephone. 13. A big
"sailor boy" face with a string in his mouth to teach
breath control. 14. A blackboard. 15. A bulletin board.
16. Games. 17. Story and picture books. 18. Candles and
matches.1

 

M. A. Perlstein and harie Shere, "Speech Therapy

for Children with Cerebral Palsy," American Journal 2;
Diseases 2; Children, MXXII (October, 1946), 389-398.

58
II. The following is a prOposed program for teaching
the cerebral palsied to suck through a straw.

To teach a child to suck through a wax or cello-
phane straw, parents are advised to purchase a one-
foot length of dental rubber tubing which has an
internal diameter about equivalent to that of a wax
straw and which has a wall thick enough so that the
tube will cpen again immediately when bitten. The
exterior diameter of the tube should be less than half
an inch. One end is dipped into a fluid which the
child particularly likes. Some children prefer gravies
and meat extracts and others prefer syrups. The
finger is placed over the other end of the tube and
from 2 to 3 inches of the tube is thus filled with
the fluid. (Before using a rubber tube for the first
time, the parents are cautioned to wash it out well so
that there is no rubber taste.) The tube is then
held horizontally and the fluid is allowed to run.
into the child's mouth. This is done at a definite
hour, at least once a day-- preferably two or three
times -- and is done four or five times each period.
This schedule must be rigidly observed. This point
is essential since this is a conditioning program.

The process of holding the tube horizontally is carried
on from four to six weeks, or until the parents

realize that the youngster is aware that the tube con-
tains a very desirable liquid. when this awareness is
noticed, the parent next dips the tube into the solut-
ion and raises it to the child, this time holding the
tube slightly below the horizontal so that it will not
flow. The child is than encouraged to put his lips
around it and see if he can find the taste. The tube
is raised to the horizontal several times and lowered
again below the horizontal so that the youngster

begins to want to work his tongue into the hole, and
pull it away and this tends to produce a weak sucking
motion. The parent manipulates the freedom of flow
with his finger. when a child can suck with the tube
held two inches from the horizontal at the end farthest
from the mouth, the tube should be brought down a littl e,
about once a week. Each time it should be moved down
from the lower position until the child is definitely
able to suck. 2

 

2 martin F. Palmer, "Studies in Clinical Techniques;’
The Journal pg'Speech Disorders, XII (December, 1947), 416-17.

59
III. In attempting to teach the child to chew gum,
Palmer suggests the following program.

The process of teaching a child to chew gum is a
conditioning experiment similar in many respects to
teaching a child to suck through a straw. A stick
of ordinary chewing gum is just as satisfactory as
a piece of bubble gum for this purpose, although
bubble gum, being pink, is somewhat more attractive
to children and the consistency is somewhat better
than ordinary gum. A piece of gum loses its first
sharp flavor about a minute after it is introduced
into the mouth, and it is at this time or after that
the child will attempt to swallow the gum.if he does
not know how to control it. It is a very simple
matter to prevent this. A child is given a small
piece of gum, the amount of it (the number of sticks
or parts of a stick) depending on the size of the child.
This is rolled up and placed in his mouth. The
individual should do this at a certain hour each day,
using a watch for exact timing. (He may do it more
than once, but once daily is sufficient.) At the end
of 40 seconds, the finger is inserted into the mouth
and the gum is retrieved. This is done for about a
weekto two weeks. At the end of the first period,
the time is increased by ten seconds again until the
child is chewing for many minutes without swallowing.
He gradually begins to understand that gum is an
article which is not to be swallowed. If the tongue
is unable to handle gum, special techniques, which
can only be carried out in the clinic, will have to
be used.3

IV. in the treatment of breathing difficulties, Perlstein
and Share suggest the following techniques.

. . . . breathing exercises should be masked by
accompanying activities. Some of these activities
which eanurage breath control without calling the
child's attention to his breathing are singing,
reciting memorized poems, playing wind instruments,

 

__...—:

3 Ibid., p. 417.

6O

blowing soap bubbles, blowing out candles, blowing on a
candle enough to move the flame but not extinguishing
it, holding a piece of tissue paper against the wall
with the breath stream, blowing a feather but not
allowing it to fall, pulling a string from a clown's
mouth and vocalizing a prolonged "ah," panting like

a dog, and laughing (beginning with a slow "ha-ha-ha"
and going faster, until the imitation laugh has turned
into a genuine diaphragh-shaking chuckle). An inter-
esting breathing exercise which also aids the muscles
of voice production is suggested by Emil Froeschels:
"The patient is advised to clench his fists, to raise
them to the nipples, and to push them down with great
strength, synchronically speaking a vowel, a syllable,
shorter and then longer words, and so on. "7.4,

V. To teach non-visual sounds, the clinician can utilize
the patient's motokinesthetic abilities in the following
way.

Tell the child a story about a big old bullfrog,
for instance, and have him sound out the way the
bullfrog does, "guh, guh, guh". With this kind of
introduction, you may then show the child how you
make the sound "g". Let him place his hand on your
throat to "feel" the sound as you say it. Then he
can put his hand on his own throat and try "g". For
contrast between the "g" and "k" tell a story using
the sound "k" so that the child will hear and feel
the difference between the production of "g" and"k".
A story about a duck who says, "quack, quack" will
demonstrate the "k" sound. Once a new sound has
been learned, it must be strengthened by using it
in short syllables -- "ka, ka", for instance, in
connection with the "k" sound. Mother can ask,

"What does the crow say?" (Ka, Ks). From short
syllables, the next step is simple familiar words
that the child knows -- usually the names of animals,
objects in the house, names of persons, things, etc.5

 

4 Perlstein and Shere, loc. cit.

5 Maryann Pains, "You Can Help At Home," The Grip-
pled Child, (August, 1949).

61

VI. Smaller children enjoy adaptations from nursery
rhymes. For instance, the child says, 'One, two,
button my shoe,‘ taking a step with one foot (the
dominant one) on 'one,’ and a step forward with
the other foot on 'two' leaning over as far as his
balance will permit and imitating the motion on
'button my shoe.' He steps forward on 'three,‘
again on 'four,‘ a wide sweep of imitative gesture
with the dominant hand on 'close the door,‘ and
so on to the end of the rhyme. One badly crippled
little boy was delighted with his achievement, and
I think, received some speech benefit from walking
and saying the rhyme 'Ten Little Indians.‘ He
took a step forward with the dominant foot while he
said, 'One Little,‘ another step with the other foot
on 'two little,‘ a third step on 'three little,‘ and
brought the lagging foot up parallel to rest a
minute on 'Indians.‘ This action was repeated on
the next phrases, 'four little, five little, six
little Indians,‘ and 'seven little, eight little,
nine little Indians.‘ Then (with a great deal of
help from the clinician) as he said, 'Ten little
Indian boys,’ he jumped in the air and tried to
turn completely around. As he counted Indians from
ten to one, he walked back to the starting place.
This simple exercise took the little fellow several
minutes to perform but it was helpful to him both in
his speech and his physical balance. He finally
learned to control himself enough to jump around
alone.6

For additional techniques in articulatory drills,
chapters 15, 16, and 17 of West, Kennedy, and Carr7 are
suggested.

For additional techniques in relaxation, see

Jacobson.8

 

6 Marsee Fred Evans, "Problems in Cerebral Palsy,"
The Journal g§_Speech Disorders, XII (March, 1947) 98-99.

7 Robert West, Lou Kennedy, and Anna Carr, The
Rehabilitation Lf Speech (revised edition; New York:
Harper & Brothers, Publishers, 1947), 650 pp.

8 Edmund Jacobson, Progressive Relaxation,(Chicago:
The University of Chicago Press, 1929), 429 pp.

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