Specifics of correctional and speech therapy work on the formation of an active vocabulary with preschool children with cerebral palsy

On time means as early as possible

A child with a birth injury, at risk of developing cerebral palsy, omitting the infrequent cases of late diagnosis, as a rule, from infancy is under the close supervision of neurologists and physical therapists, but rarely on time (and in the case of a child with cerebral palsy, on time - this is as early as possible) to a speech therapist. This is understandable - first you just need to survive. Later, master at least some movements. There is no time for speech anymore - you don’t know what to grab onto.

Meanwhile, early speech therapy work with such children can help both the timely development of speech and correct vital functions - swallowing, sucking, chewing.

In most cases, cerebral palsy causes special speech development. This is due both to damage to certain brain structures, and to a limitation in the amount of knowledge and ideas about the environment, and a lack of objective and play activities as the basis for speech development. Most children with cerebral palsy have a delay in speech development - and a specialist can detect this delay at a very early age, in the so-called pre-speech period - by a monotonous weak cry, poor humming and babbling. Also, at a very early age, problems with sucking and swallowing become noticeable, and later – difficulty chewing.

In the first years of a child’s life, we can often observe a slow pace of speech development - as a rule, at an early age, even in severe cases of the disease, the development of general motor skills is ahead of the development of speech.

Children with cerebral palsy pronounce their first words on average only at 2-3 years of age, but after three years, subject to regular speech therapy sessions, a noticeable leap in speech development often occurs; speech begins to outstrip motor skills and rapidly develop. If the child’s intelligence is preserved, the tone and mobility of the muscles of the articulatory apparatus are changed slightly, then with regular classes with a specialist, speech development at school age occurs within the age norm.

Dysarthria and alalia

Unfortunately, only a delay occurs quite rarely; almost always, a child with cerebral palsy is subsequently given a speech diagnosis - dysarthria. This violation manifests itself only in the pronunciation side of speech - with its understanding intact.

There are several forms of dysarthria depending on the form of cerebral palsy, and several degrees - from the most severe - anarthria, to mild - erased dysarthria. In mild cases, the child’s speech is blurred, slow, and poor in intonation; in severe cases, the movements of the organs of articulation are so limited that they do not make it possible to utter a word. The tongue, lips, cheek muscles are the same muscles as in the rest of the body, and disturbances of tone and mobility, present throughout the body, will also be noted in the organs of articulation.

As a rule, there is always a relationship between the degree of impairment of articulatory motor skills and the state of hand motor skills.

In addition to dysarthria, alalia is quite common in children with cerebral palsy - underdevelopment of speech as a result of damage to the cerebral cortex. In this case, not only pronunciation is impaired - understanding of speech also suffers, problems are observed in the coherent, phrasal aspects of speech, the syllabic structure of the word, that is, problems in the formation of speech as a system.

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The foundations of speech therapy correction of dysarthria in children with cerebral palsy were laid in the 40s of the 20th century.
In particular, Marion Cass wrote that speech impairments in cerebral palsy differ from motor aphasia. Motor aphasia, according to Kass, is an apraxia of the speech organs. With apraxia, the patient knows what he wants to say, but cannot formulate a word plan. With cerebral palsy, the child has a word plan, but cannot implement it due to motor difficulties. Cass believed that theoretically, speech disorders in motor aphasia and cerebral palsy are different, but in practice these differences are minimized, since the automaticity of speech depends on the work of the higher cortical parts. M. Kass formulated “phonetic principles for eliminating speech pathology,” which have not lost their relevance even now. These are a number of provisions that underlie the work to overcome dysarthria:

• When working on pronunciation, the child’s attention should, first of all, be focused on the semantics of the word, its acoustic characteristics, and not on articulation.

• What matters is the quality of perception of speech sounds, which, in turn, depends on reproduction. It is necessary to work on improving the quality of: acoustic perception, contrasting sounds in strength, height, duration; phonemic perception, focusing on phonemic features; kinesthetic perception of articulation.

• The main components of movement develop first with the participation of large muscle groups, and then small ones.

• It is necessary to use similarity of motor mechanisms, i.e. the movement pattern can be modeled using the example of one organ and transferred to another.

• Speech sounds can be produced in different ways. It is necessary to form articulation from the movements available to the child, while relying on the acoustic effect.

• The physiological tendency of the body is to follow the line of least resistance. Therefore, it is necessary to reproduce (automate) movement to form motor stereotypes under control in order to avoid distortion of the movement pattern.

Dysarthria in a child with cerebral palsy is a complex syndrome of disintegration of the act of pronunciation, caused by a violation of the regulation of speech movements due to organic damage to the central nervous system. The symptoms of dysarthria are determined by the localization of the pathological focus, as well as the course of processes characteristic of deficient mental development: the appearance of secondary defects, compensatory and pseudocompensatory systems, the presence of asynchronies.

The core of speech pathology in dysarthria is the distorted development of the phonetic-phonemic system. In this regard, the main efforts of speech therapists should be aimed at correcting this aspect of speech.

Basic principles of speech therapy work: 1. Speech therapy work is aimed not only at correcting pronunciation, but also at developing the child’s entire mental activity. At the same time, the main content of the work is the formation of a phonetic-phonemic system, while the correction and development of other mental processes are of practical importance.

2. The formation of a phonetic-phonemic system should be organically connected with the development of all components of speech. It should be taken into account that pronunciation is not exclusively a motor act, it is a process of implementing a language program in which phonetic elements are closely related to each other and to other components of the language. The efforts of a speech therapist should always be primarily aimed at the formation and development of the child’s linguistic abilities: first in an impressive way, and then in an expressive way. In most cases, the motor implementation of the language program depends more on the child’s phonemic representations than on his motor abilities.

3. Throughout the entire course of speech therapy classes, the formation and development of motivation to improve the sound of one’s speech is carried out. As a child develops, his attitude towards himself and others changes, and his value system changes. This must be taken into account not only for the successful conduct of classes, but also to ensure that the results of the work are irreversible.

Initially, you need to create positive motivation simply in relation to speech therapy classes. To do this, you should focus primarily on the child’s system of relationships with the outside world, determine the leading activity, the predominant form of communication. If emotional and personal communication is dominant in a child, then, in addition to affectionate treatment, perhaps a treat at the end of the lesson will be an incentive. If a child prefers situational and business communication, it is necessary to conduct classes in the most playful form, encouraging with small gifts - for example, pictures. Gradually, the child needs to be captivated by the idea of ​​improving his speech, to draw his attention to the pleasant-sounding speech of artists and people around him. In the process of communication, you need to gently lead the child to the idea that beautiful speech allows you to achieve success in communication, although it is not the main means of winning people's sympathy.

4. The development of the phonemic system must be carried out ahead of the development of the phonetic system. With normal development, a child masters pronunciation, focusing primarily on auditory perception, which is an indicator of achieving the final result in the articulatory functional system. With dysarthria, the role of auditory control increases, since due to disturbances in the tone of the articulatory muscles in the oral region, individualized compensation of motor deficiency occurs. In this case, the child should focus on the end result - a reproducible acoustic effect. In this regard, it is necessary to develop auditory perception and form a conscious focus on achieving the necessary acoustic effect in children with dysarthria.

5. It is necessary to re-form the entire phonetic system, starting with prosodic components. The formation of articulation is carried out as the formation of a functional system. The main feature of functional systems is their focus on the final result. It is known that a similar acoustic effect can be achieved using a different set of speech movements. In this regard, the focus on the primary formation of isolated “ideal” articulation of sound through exercises, adopted in traditional speech therapy, is not always justified. Many articulation exercises are difficult for children with dysarthria. When performing them, much more complex movements of the tongue are required than during pronunciation. As a rule, articulation exercises require a large amplitude of movement of the organs of articulation, while during speech it is minimal, otherwise the required speed would not be achieved.

6. When forming articulatory praxis, you need to remember that this is a hierarchically organized skill. In this regard, it is necessary to first develop the supply of an air stream in accordance with the method of articulation, then, if necessary, connect voice delivery to the air stream and then add articulation elements in the sequence of passage of the air stream, i.e. back to front. The fundamental difference between the speech therapy production of sounds and the production of sounds in deaf pedagogy is the reliance on auditory perception. It is necessary to draw the child’s attention to the sound features of a normal oral exhalation with different configurations of the oral opening, to the sound features with different pitches of the voice, and the sound features with various changes in the configuration of the articulatory apparatus.

Sucking and swallowing - for differential diagnosis

It can be very difficult to carry out a differential diagnosis and determine the main obstacle to speech development.

At an early age, it can be difficult to understand what awaits the child next, how his speech will develop, what symptoms we will encounter later - but it is extremely necessary to help the child master vital functions - sucking and swallowing, and at an older age - chewing.

For differential diagnosis at a later age, it is very important to know how the child coped with the organization of these processes in infancy. If there is no speech, but he suckled well at the breast, perhaps the main reason for underdevelopment of speech is not dysarthria, it may accompany it, but the child must be examined for alalia.

Speaking of diagnostics and my self-confident juggling with neurological terminology, I think many people know that a speech therapist does not write a diagnosis, but writes a conclusion. For example: “General speech underdevelopment (GSD), Phonetic-phonemic speech underdevelopment (FFND).” And terms like dysarthria, dyslalia, alalia are not conclusions, but diagnoses, and only a neurologist has the right to make them. However, speech therapists working with children with cerebral palsy are forced to use the clinical classification of speech disorders, since the mentioned pedagogical classification does not carry any information about a specific child with cerebral palsy.

Often it is the speech therapist who is able to determine the leading symptoms and correctly organize correctional work.

Articulation gymnastics for speech development

The defectologist's program for children with cerebral palsy is often supplemented with articulation gymnastics exercises. The work has a play format, which increases the child’s interest in the procedure and accelerates the onset of positive effects. Gymnastics is divided into 2 main types:

• Passive
  . A speech therapist performs techniques to reduce signs of serious speech pathologies. Among the main techniques are stretching the lips, gathering the lips into a tube, opening and closing the mouth, moving the tongue out and in, raising the organ to the palate, to the lower and upper lips.
• Active.
  During the execution process, the visual, auditory and tactile analyzers are activated. Before the lesson, speech therapy massage and several passive techniques are performed. When performing techniques, it is important to maintain a full range of motion. The technique is implemented smoothly and symmetrically. Exercises include closing and opening the eyes, chewing, raising and lowering the eyebrows, and opening and closing the mouth. As time passes and progress is achieved, the patient performs more complex techniques.

Slippery moments of speech therapy diagnostics

One of the slippery aspects of speech therapy diagnosis of a child with cerebral palsy is the fact that often a specialist, without looking closely, shoots out a diagnosis of dysarthria, famously determines its form and begins to work on muscle function. Cerebral palsy, dysarthria by default. Yes, she is. But if a child involuntarily pronounces a sufficiently large volume of sounds, is involuntarily capable of quite complex articulatory movements, and may even be able to reproduce them by imitation, chews and swallows, then it is unlikely that the reason for his silence is dysarthria, and he is so clearly shown an endless probe massage.

Unfortunately, the specialist does not always have a clear understanding of the most pressing task for a given child. For example, in my practice there was a wonderful, smart six-year-old girl with perfectly developed speech as a result of the efforts of speech therapists and parents, but with residual defects in the pronunciation of L and R. These defects were obvious, and my mother was worried, but at that time I was much more worried about something else - my hands girls.

The hand was absolutely not ready for writing, plus there were spatial orientation problems typical for children with cerebral palsy, which, if not eliminated in time, would be guaranteed to lead to impairments in written speech - dyslexia and dysgraphia. And the sounds - yes, it would be possible to spend time on their production and automation, but I was aware that with dysarthria this work would drag on for months and, possibly, years. And the deadlines are running out - school is approaching, the child’s speech is absolutely intelligible and understandable, with such speech many healthy people live and feel great.

Therefore, hand and letter were on the agenda, there was a lot of work there, and we started it. But my mother continued to worry, and it ended with the fact that they stopped coming to me. But, almost two years later, they returned when the girl’s problems at school became completely obvious, and another speech therapist took the easy path and worked on staging these remaining sounds.

Speech therapy massage can almost always help

At an early age or at the beginning of correctional work at any age, while we can still only guess how this child’s speech development will go, speech therapy massage and passive articulatory gymnastics will be our main assistants.

Even in the most difficult cases, when it comes to tube feeding, it is most often possible to help the child. Classes with a speech therapist can help weaken the pronounced gag reflex and stimulate sucking and swallowing. Later, stimulate chewing.

And at an older age, speech therapy massage and passive, and subsequently active, articulatory gymnastics will be indicated for most children with cerebral palsy - to normalize muscle tone, increase the volume and accuracy of movements of the articulatory apparatus.

If the child is very small or has intellectual problems, the use of edible devices and textures that differ in taste, smell, temperature and tactile properties for massage and gymnastics is successful.

For example, it is easier for a child with impaired swallowing function to feel and swallow something cold in the mouth rather than warm, something sour or distinctly sweet rather than neutral. A child with problems with voluntary organization of movements finds it possible to raise his tongue upward not on command, but by trying to reach for a sweet candy.

Older children also respond with pleasure to such tasty gymnastics, and it is precisely such emotionally brightly colored exercises that allow them to achieve the best results.

Personally, I did not have to work with children with cerebral palsy at an early age, but I was able to successfully develop the chewing muscles in older children, thereby significantly improving the child’s quality of life.

Main directions of speech therapy treatment for cerebral palsy

In the absence of speech in a child with cerebral palsy, speech therapy work is carried out in the following areas:

• motor development;
• restoration of muscle tone;
• stimulation of vocal reactions;
• development of tracking and visual fixation;
• development of auditory attention;
• creating conditions for improving motor and visual coordination.

A special massage is prescribed to stimulate the facial muscles. Such exercises can significantly speed up the appearance of the first improvements.

Speech therapy therapeutic massage

Speech therapy massage is classified into the following types:

• point;
• classical;
• probe;
• reflex.

The doctor prescribes the type of massage depending on the complexity and characteristics of the speech dysfunction. In some cases, it is enough to prescribe several courses of classical massage. For complex deviations from the norm, an integrated approach to speech therapy massage is used. In such situations, rehabilitation takes a lot of time. Features of speech therapy work with cerebral palsy lie in the difficulties that arise when communicating and interacting with the patient. In some cases, massage is the only available method of developing the articulatory apparatus in the first stages of treatment.

Relaxing massage of articulatory muscles for cerebral palsy

A relaxing massage is prescribed for increased muscle tone of the tongue, lips and face. The use of this technique requires choosing the correct position for the child. The doctor determines the position in which tense parts of the body relax as much as possible.

The child can be placed on the couch with a bolster secured under the neck. An excellent position for this massage is the “fetal position.” In one of these positions, dynamic movements are performed to relax tense muscles.

To relax the facial muscles, do the following:

• light stroking in the direction from the center of the forehead to the temporal region;
• from eyebrows to scalp hair;
• around the eyes (from the forehead line);
• from the bridge of the nose to the scalp;
• from the forehead line along the neck, cheeks and chin across the entire face;
• from the bottom of the ear to the wings of the nose and cheeks.

Next, you need to perform light pinching along the entire edge of the lower jaw. After this, make pressing movements in the direction from the roots of the hair to the face.

The next stage of the massage is to relax the muscles of the lips:

• stroking the upper and lower lips in the direction from the corners to the center;
• weak rotational movements (clockwise);
• weak tapping on the surface of the lips.

Each movement should be performed 5 to 8 times.

Stimulating massage for the articulatory apparatus in cerebral palsy

Stimulation is necessary to reduce hypotonia of the facial and tongue muscles. A special massage allows you to strengthen the muscular system and increase the chances that the child will begin to speak in the near future.

As part of this technique, the following characteristic movements are performed:

• stroking;
• kneading;
• rubbing;
• vibration;
• tingling.

First, smooth and soft presses are made, the strength of the movements should increase gradually. Avoid activities that may cause even minor pain

To strengthen the facial muscles, it is necessary to perform the following list of movements:

• stroking the eyebrows, forehead, temples, eyelids and cheeks;
• squeezing the chin with light but rhythmic movements;
• kneading the muscles of the cheeks and cheekbones;
• chafing of the cheek muscles;
• slight tingling of the cheeks.

To strengthen the lip muscles, perform the following exercises:

• stroking the lips, nasal wings and nasolabial folds;
• tingling;
• pinching lips.

Vibration is also a very effective method. Such manipulations can be performed using a special mechanical device. The procedure will improve blood supply to the organs of the articulation apparatus and strengthen the muscular system of the face.

Therapeutic massage of the lingual muscles for cerebral palsy

This type of massage can be more intense or calm depending on the condition of the tongue muscles. If you need to reduce tone, then before the procedure you need to hold a small amount of herbal infusion in your mouth.

When performing a massage, the doctor sets the following goals:

• normalization of muscle tone;
• increasing the amplitude of articulatory movements;
• engaging previously inactive muscles;
• decreased salivation;
• stimulation of speech development.

First, the massage is done in the oral cavity, and then outside the oral cavity. In this case, the tongue is held with gauze.

Articulation gymnastics for speech development

Exercises for articulatory gymnastics are aimed at increasing the activity and development of the following parts of the body:

• lips;
• bridle;
• cheeks;
• language.

Gymnastics is best done in a playful way. This way the child will show increased interest, and therefore a positive result can be achieved as quickly as possible.

Passive articulation gymnastics for cerebral palsy

During the exercises, the speech therapist performs careful manipulations with the organs of the articulatory apparatus. In case of serious pathology, this particular type of gymnastics is recommended, because children with such a diagnosis cannot independently perform the simplest speech therapy tasks. The doctor opens and closes the patient’s mouth, stretches his lips into a smile, collects his lips into a tube, lifts his tongue up using an instrument for examining the oral cavity (medical spatula).

To perform passive gymnastics exercises, you should follow the following sequence of actions:

• bringing the tongue forward;
• tongue retraction;
• bringing to the lower lip;
• approach to the upper lip;
• abduction left and right;
• pressing the organ to the lower part of the oral cavity;
• raising the organ to the sky;
• light swaying movements of the organ in different directions.

Exercises are performed serially from 3 to 5 times, depending on muscle development.

An active type of articulation gymnastics for cerebral palsy

The set of exercises is aimed at stimulating tactile, auditory and visual analyzers. Before prescribing active articulatory gymnastics, the patient undergoes passive exercises and speech therapy massage. When performing exercises, it is important to achieve complete range of movements, optimal speed of switching on and switching attention. Smoothness and symmetry of movements play a vital role.

To develop facial muscles, the patient performs the following exercises:

• closing and opening the eyes;
• cheek tension;
• raising and lowering eyebrows;
• chewing movements;
• sudden swallowing of saliva;
• opening, closing the mouth.

To strengthen and develop the labial muscles, the following actions are performed:

• pulling the lips into a tube and stretching to the side;
• alternating smiling and curling lips;
• closing and opening;
• quick closure followed by breaking (imitation of a kiss);
• performing a slow labial exhalation;
• raising the upper lip with further demonstration of the teeth.

After completing such exercises, you can move on to more complex tasks.

Rehabilitation exercises for the lingual muscles

To stimulate the muscles, the specialist acts on the longitudinal muscles of the tongue. To do this, strokes are made from the middle part to the tip of the organ.

To strengthen the transverse muscles of the tongue, pressure is applied to the area from root to tip with the same rhythm. Intensive manipulations are performed using a special spatula.

To stimulate and strengthen the longitudinal muscles, strokes are performed, directed from one side to the other (in a zigzag).

What is artificial local contrast therapy?

The technique is used to eliminate articulatory apraxia (inability to speak clearly). The essence of the procedure is the effect of high and low temperatures on sensitive areas of the tongue. Use crushed ice, herbal infusions or hot water. The choice of exposure can be alternated to increase the effectiveness of the result. Regardless of the chosen direction, the course of treatment lasts from 15 to 20 days.

Artificial local contrast therapy is performed in the following sequence:

• crushed ice is placed in a gauze bag;
• ice is alternately applied to various muscles of the articulatory apparatus;
• the speech therapist holds the patient's tongue with a gauze pad;
• All parts of the tongue are affected in turn.

One session lasts from 2 to 7 minutes, depending on the level of development of the muscles of the articulatory apparatus.

Development of breathing and correction of its disorders when working with patients

Breathing exercises take into account a whole range of exercises that are aimed at normalizing respiratory function and speech development. Exercises are performed in the following sequence:

1. Position – lying or sitting. Creating a “fan of air” near the child’s nostrils.
2. Position – lying on your stomach, arms under your chest, head down. When inhaling, the specialist raises the child’s shoulders and head. When exhaling, the child’s body returns to its original position.
3. The speech therapist asks the child to hold his breath as much as possible.
4. Position – sitting or lying down. The specialist places his hands on the patient's chest, listening to the breathing rhythm. Press on the chest as you exhale.

Apraxia: actively babbles something, but does not repeat or imitate

If in a child we have identified only a limitation in the mobility of the articulatory apparatus, a violation of muscle tone, the measures described above may be sufficient to initiate speech, but if we see apraxia - a violation of the voluntary organization of movements, then targeted classes are needed to evoke sounds, form the syllabic structure of a word, and subsequently phrasal speech.

How can you define apraxia? It can be indicated by a sufficient variety of involuntary sounds with pronounced difficulties in voluntary reproduction - the child seems to be actively babbling something, but does not repeat, does not imitate, or tries to repeat, but repeats any sound other than the required one, although literally five minutes ago you heard this sound We heard from him by chance.

The same is with articulatory postures - involuntary postures are varied, the tongue is quite mobile, but the child is not able to repeat the movement when requested, or he can repeat it for a short time, but is not able to hold it. However, the last symptom is not very informative - the child may simply not have enough strength to hold the pose, or hyperkinesis may interfere. To understand this, close observation of the dynamics is necessary.

How to work with children with apraxia? It is important to remember that logomassage in this case will not be a panacea; it is necessary to purposefully, relying on intact analyzers, on leading activity, bring out sounds into randomness and consolidate, and later - combine sound complexes into words and phrases. The work is long, painstaking, and often begins too late, although if a specialist has experience, it is possible to determine the leading symptoms already in 2-3 years, or even earlier.

Such children are encountered quite often in speech therapy practice; I personally like to work with them using the play method, and use warehouse reading according to Zaitsev as an additional support.

The earliest possible start of speech therapy correction work with a competent specialist is the key to maximizing the child’s speech potential.

Prices for speech therapist services for cerebral palsy

conducts speech therapy classes with children with cerebral palsy. We use an integrated approach to speech development. Our specialists work with each child individually. The speech therapist takes into account the type and severity of cerebral palsy, the characteristics and character of the child.