This is Joey who is about 13 months and we're looking at Joey today in terms of his potential for communication, whether this be for speech or for some other form of communication. When we're assessing Children, one of the first things that we want to look at is how they are overall physically uh and what kind of impact their overall physical problems with postal tone and movement play in controlling or directing what happens in the mouth area in the breathing in foundation in all of the areas that are going to be critical for speech acquisition later. OK. Should we take a look at you, Joey is not too happy about being put down on the mat at this point. So perhaps we can just look at him, right? One of the first things we see is he wants to turn his head to the side and as he does, so he pushes it back, this left arm straightens, but he can bring it back into the middle. We want to know when Children show these kinds of patterns. Do they get stuck? Joey is not stuck in terms of his inability to move the head, but he doesn't seem to like it in the middle. He does a lot of pushing back and startling in a moral response. What are you going to do on my, we're going to talk. Yes. That's nice talking. Is that nice talking? What are we going to do now? Huh. Let's see what I do with the ball. Look at this. Can you get it? Can you get it the stimulation on his tummy initially causes him to push back. He does a lot of pushing back and a lot of pushing to the side. See what happens, Joe. If we just put you on the mat, I would just like to see what you look like because I think we'll see your shoulders a little bit more clearly and also what your legs do. Ok. Ok. You seem to like the music box. Let's see, this will bring him back when a child keeps his head to the side. Much of the time we want to know. Is it always to one side or does he turn it equally to both sides? Oh, lucky, lucky. When you start out evaluating a youngster, it works best to simply let them move themselves to not do a lot of handling, but to take a look at what their typical kinds of patterns are on their backs, on their tummies and sitting and then to see how it works when perhaps you intervene with some handling or some physical feelings with them? Oh, ok. Let's see what you do when I touch you here. Huh? Do you get your head over this way, Jo Joey? Um, it's important to note that he does make some noise but that most of the noise we've heard from him that hand, you can see why he is not turning his head himself. It is very, very bound in the side position. We put it in the middle, he pushes it back and goes right back to the left side. A strong startle. Ok. You all right. Ok. Alright. Very good. Uh we take advantage of this to listen to his cry. Ok? It's a tight cry and it's a breathy cry. It's not the kind of cry one would anticipate hearing in a year old child. Ok. What happens if you sit up? Huh? When he sits, he flops, he's a stiff baby but underneath he's a very floppy baby. He's very, there's a lot of hypotonicity in sitting. He does not use his arms for support in any way at all. He doesn't get his head up. Let's see, Joe. Ok. Ok. Ok. What do you do sitting on a lap? You do any better? Yeah. Ok. Ok, Mr squeaky cry. Ok. That's enough crying to hear it. Is that enough crying to hear? Notice that all the way through the position of his shoulders is in a back position. It's they're quite retracted and with the arms back, we haven't seen him attempt to put his hands to his face. He's going to going to make a lot of noise. Look at this. That's the best word. Yeah. 00 my goodness. You didn't like it when I put you on the mat, did you? No, this is better. Look at this. Ok. Particularly with a young child. We want to know are they capable physically of, of grabbing on something of putting something in their mouth or even of getting their own hands to their mouth? A normal infant is mouthing his own fingers often at the moment of birth and certainly within the first month and a child like this is not, he's missing a lot of oral stimulation. Joel. Hello. Hello. You don't seem to like that on your tummy. Do you? Are you a jumpy boy? Are you a jumpy boy? Ok. I'm gonna try you on your tummy, but I think we're gonna try something else first. Huh? You got a little frightened when I put you down. Yes. Our goal and assessment is not just to look at the worst things a child can do if we start out with just the things that are a problem for him. We're going to lose him during the evaluation. He's not going to stay with us. And so we want to intersperse. Yeah, some kinds of things that we might guess may make him physically feel better and be more able to respond effectively to us. I'm bringing his head more forward and keeping it in the middle simply as a way of assessing also of what he can do. But in doing this, trying to prevent a lot of the getting stiff that he does, that does make him uncomfortable. Ok. Yes. Look, here's this nice little ball right down here. Look at this. Joey doesn't use his eyes very well and there is a question as to how much he actually sees. Ok. I feel he does see some things though. He was very much aware of the lights here in the studio. Um He was aware of the red ring. Ok. Let's just see you some things that will make you not quite so stiff. Ok? When Joey is not stiff, he particularly in the trunk and the head area becomes very hypotonic, very floppy and alternating with this are the strong extensor spasms that you see. Now, like many young Children developing cerebral palsy, his legs are still rather nice. They don't show the scissored patterns that they may show later as he develops more spasticity. They're in a very flexed kind of a, a fairly normal baby kind of pattern and the problem begins in the head and trunk area. Ok. Let's see you as we're going along, we want to look very carefully at the child's head and trunk control. I'm going to do this just in my handling with Joey rather than in a more formal kind of way because we don't want to upset him and to bring out simply the worst he can do. But you can see that his head control when he's leaned back is zero. Um So very floppy head, we saw when he was sitting that he shows almost no control at all. We're going to want to get him onto his tummy because prone is the first way that Children develop control with their heads. But I'm gonna do this a little bit gradually so we don't lose him. Ok. What shall we do? Should we get over on here? Can find a toy that you like? We've not really found any toys that really turn him on at this point. Ok. I'm gonna get you all wound up in my mic cord. Ok. Ok. Just in turning him over, you see the tendency for the head to go back. Ok. Can we roll you over? So you don't do that? Ok. And I'm going to use my lap right now just as a way of getting him onto his tummy, particularly with very young Children or really with any of them. Our laps are the best place we have for assessment and the best place we have for treatment Children accept being on a lap much more readily than they do on a mat. What I'm feeling with him in prone is a good bit of pulling down in the shoulders, which is why I'm using my legs as I am under his shoulders. Can you get your head up? Let's see what we do. Yeah. Ok. Very little attempt to get. There we go and get some up. Let's see. Can you put your head up, Joe? What little attempt he's making to get his head up on his tummy is also with the head turned to the left side. There we go. There you go. There we go. Ok. There's a big boy, there's a big boy. Ok, so he is able to bring it up a little bit. It's not done. Well, it's done very suddenly. I don't know whether you can see how he suddenly is. Brings it up in a big jerk and then he loses it. Let's see a little bit here. Just a minute. I know, I know, I know what happens if we bring your arms like that. What happens here? Can you try this? We're interested not just in whether a child does, but qualitatively how they do it here. We see things that are very different even from a normal baby at one month. Wanna listen to us crying and prone. Is it any different from what it was on the land? Ok. Let's see what we do with you here. Can you get it if I help you? Can you get it up if I help you? Is that better? Is that better? Ok. Yeah. Ok. So he does bring it up a little bit in prone, but there are problems of pulling down in the shoulders, getting very stiff in the arms. He doesn't like it. He can't really get his head up. A normal infant at birth is able to momentarily lift the head up, turn it from side to side and protect the airway. And this is something that even for this little boy a little over a year is a very difficult thing for him to do. We want to look at typical patterns of movement in the arms and in the legs with joy. We've seen that particularly in the arms, a pattern of shoulders back but arms extended. Uh Most of this in accompaniment with the head extension with the legs. There is some extension of the legs, but most of it is still with a primitive baby flexion. But head movement causes the legs to move even as he's sitting here now and turning his head from side to side and moving, you see the legs, OK. There have also been times that I've noticed with him that as the head goes back, the tongue has much more of a tendency to protrude it also in an extensive pattern. And at other times when the head goes back, the tongue pulls quite far back in the mouth, almost retracted into the fringe area and almost interfering with breathing from time to time. Ok. Now, what I want to begin, I've got a feeling of where he is in terms of his problems and postural tone. He is basically a floppy baby. He does not have good head and trunk control. He has very strong extensor spasms with a tendency to turn the head primarily to the left side. Some of this has an impact on the mouth area with particularly causing an increase in tongue extension and some retraction of the tongue along with the shoulder girdle, retraction from time to time. We want to know how available he is for stimulation. If I'm going to be using stimulation in the rest of my assessment and in treatment and just in helping this baby learn about his world. How well is he able to integrate it? What does touch particularly do to him or if he's listening to music or to speech? Does this cause him to become stiff? Does it cause more in coordination? The same type of thing with visual stimulation? I think today I'm going to be partially because of the questions in the visual area. I'd like to play with this just a little bit with some of the music and particularly with touch. Because if we're physically handling Children in treatment, we need to know what their response is to touch with. Many of these youngsters, they tend to be very hyper sensitive so that touch on the body or particularly in the mouth and face area will cause a much greater amount of spasm in coordination and and actual dislike on the child's part. Ok. In testing him for this, I want to use a position or handling with him, which has seemed to make him more comfortable and to make him less stiff. And this involves using my hand more on the top of the head rather than at the back of the neck. If I put my hand here, we're going to get more head going back. If I put it here, there often is a tendency for the Children to push. Whereas if I get it more up a little toward the top, keeping it in the middle and using just a little bit of rocking movement with my hand to stop a lot of the tendency for these shoulders to go back. Ok. That's a big boy. Is that nice? That's a very nice boy. Ok. He's quite, quite loose. Can you get your hands to your mouth? What do you, what do you do with that? Let's just try and see what Seuss touch on your. Oops. Ok. When I test for tactile stimulation, I start out usually with my hand on the trunk. Ok. Easy, easy. Ok. Take it easy and, ok, let's just bring your hand in. I know that if I were to do this with him when he was terribly stiff, it's gonna just make him stiffer. It doesn't seem to like it that much unless it's just with my voice. Easy. Well, let's try it this way. Huh? One of the things we also do in an as any good assessment is experiment a little bit with what may be effective kind of treatment for a child. I don't feel that it's enough just to do an assessment which lists what a child can't do. Most parents can tell you what their child can't do the minute they bring them in for evaluation and this is not why they brought them to us. They bring them to a therapist to an evaluator to find out how to get the very best out of the child to get an idea of what the child may be able to do under good treatment. And what is all that? Huh? You really want that going that direction? Ok. All righty. Let's just see. Oh you're going to talk, shall we talk, Joey? Oh, such a big boy. You are such a big boy. Look at that. Let me are your feet cut your foot? Oh, I'm gonna touch you here. I'm gonna get you to pigs. Yes, you got a blink. You blinking when I touched your foot, it was just an accident. Ok. Alrighty, let's see what happens when I touch your head. Ok. Ok. Get your head in the middle. Do we do that? Got you here and on your cheeks. Is that a big yarn? Ok. Ok. As I'm getting closer to the mouth area, I'm getting more consistently a tendency for him to want to stiffen into extension Ok. Ok. Easy, easy, easy. He's a boy. You don't like that, huh? Where's your cheek? We want to check it out more than once to just see whether it's just a question of chance. And so each time I go back to getting his tone more normal and perhaps touch him in other places where I've gotten a fairly normal response, then go back to the area that's given us the abnormal response that's fairly nice now. But still when I start getting onto the gums, he goes into this kind of a response. But without at this point seeming to really object, it, uh look easy. Always to that side. All is to that side. How am I going to be able to use my hands to help him with things around the mouth? Perhaps for feeding? If I'm getting a res this kind of a response? Part of what this may mean is that when spoons come into the mouth to be fed with a bottle with a nipple, he may tend to do more chewing, he may tend to get stiffer. These are the kinds of guesses I can make even before I try him with food, which may give me some idea of the problems that we're going to be dealing with. Ok. Ok. That's fine. Ok. He can deal some with this, but there is a tendency I'm sure you can see some of it can see some of it, but I can feel a great deal, even if it's not visible of it, getting stiffer, wanting to turn the head to the left, wanting to push back. So that all hyper sensitivity is something we're going to want to check out much more carefully with them as we go along in an assessment and is something we're going to have to take quite into consideration when it comes into treatment. We usually try to stimulate on the gums initially and then often in the palatal area and on the tongue. That's nice. He doesn't seem to object to touch on the front part of the tongue. Occasionally, we'll find Children with very, very strong gag reflexes elicited like from the tip of the tongue. I would say that what we're seeing in terms of oil sensitivity here is primarily a problem, but a problem which is intermittent, a problem which probably depending on lots of things going on in his system is there or he can handle it much better at some times than others. Ok. I'm going to keep this. Oh, my goodness. What do we do to your head? Do you notice as this head goes back, how much more of the tongue out there is when we see these tendencies for patterns in the mouth to go with patterns in the entire body, we're not talking about something that's a consistent 1 to 1 thing, not something that happens every time that a child's head goes back in a sense what we're saying is that some extensor movement like a jaw thrust or like a tongue thrust has a greater probability of occurrence at times when the head is back or when there are other patterns of extension in the body. Ok, Jo Joey takes the bottle ordinarily, if I have a most instances when I'm evaluating a child, I have a parent there. And at that time, I usually have the parents show me how the mother feeds or the father or whoever is doing the feeding with the child. Because I want to know, I want to be able to see, not just have them tell me how things are going, how they typically hold a child. Uh, what the child's typical response is. Ok. You see this? Ok. Mhm. What is that? Uh, yeah. Ok. His first response to the nipple is to thrust back. Are you thirsty? And as it contacts his teeth or his gums, he begins to push, he's not really doing much of anything with it. Does that mean you're not hungry? He bites on it. Ok. Let's just put something up here. So we don't dribble on your tummy too much, huh? Yes, we know that Joey has had quite a history of feeding problems. The ones that have been reported most consistently involve choking on food, some difficulty in sucking. Let's see what you doing tomorrow. Oh, what is that? So, you're not very enthusiastic about this today. Not very enthusiastic. Young man. Ok. Let's see what he does with the liquid that's just in the mouth, in terms of swallowing. Hold the jaw closed a little more to see if we can give him a little more leverage for a good sack. Mhm. You were just not with it for that, huh? I know. How about that? You're right. There's no way I can make you eat. Let's see what we can do with some apple sauce. Let's see what you do with some apple sauce. Now, I have a choice of the kinds of even the kinds of equipment I'm gonna use for assessment. I have two spoons, one, a latex or rubber coated, 11, simply a plain one. I'm going to use the information that I've gotten on Joey up until now. The fact that there is some hyper sensitivity in the mouth and I'm going to select even for evaluation, the one which is coated simply to keep him with me. If he happens to bite down on a spoon, this is going to be less uncomfortable for him and it also may be less over stimulating to the mouth. Yeah. Ok. What have we got? In fact, I think before we even use a spoon, let's see what we, that's apple sauce. What is it? Huh. No. Is it? He's quite floppy right now. Although these strong kinds of movement spasms and again, the desire to turn this head to the left side, I want to try to feed the child in the best position for him, of all of the things that we looked at with him, he seemed to be better with his hips, slightly bent, they're flexed a little bit and against my in kind of in a hole in my lap, the head and shoulders more forward and the head in midline. So this is the way I wanna want to do my feeding evaluation, not strapped in a tight chair, not back like this. There would be a tendency for a child like this to be fed in this way. Why there's a logic to it. He pushes things out with his tongue, uh things don't go down very fast. And so sometimes people think, well, if you keep the head back then more is going to go down. So we often see Children coming in being fed like this. We also see them being fed in a way that you can do with a normal child with this arm back and turn to the side. But feeding a child like Joey, this way is going to simply accent his asymmetry, accent, his tendency to turn to the side. Anyway, this would be particularly the case if his tendency to turn the head were much more to the right than to the left. As we see in a lot of youngsters who, of course, our head is held in this kind of position by mothers who feed with their right hand. Ok. Now, when I see this kind of a response to food, one of the things I'm asking myself is, is this his response to a more solid food or is it his response to the taste of apple sauce to the tartness of apple sauce? This happens to be all that we have with us today, but this is something which I might want to explore further in therapy with him. Tomorrow. Is there in addition, a sensitivity problem or an over responsiveness problem to certain tastes, to certain kinds of, of acid or non acid kinds of foods. Ok. Well, let's just try you with another bite and see what happens if I leave it there. Yeah, maybe they gave you too much breakfast this morning. Ok. His tongue is going a little bit up in a very early baby suck pattern, but it basically is showing an in and out type of suckle response that again that we see in very young Children, but it's not very well coordinated right now. It's very poorly coordinated with breathing. You hear a lot louder breathing as he's trying to swallow it. Ok, let's try and simply the touch of the spoon in the mouth each time seems to be initially really setting him off. That's a boy. How about that? Let's look at your mouth, huh? What are you doing with your mouth? You're making a couple of socks and again, it isn't the response I'm getting is not the apple sauce that's coming in. It's my contact of the spoon on the gum ridge. And without you just made a liar out of me, did you just make a liar out of me? It sure was before. Maybe it is. The apple sauce assessment is a pro a process of thinking on your feet. It's a process of assessing, looking, observing something, interpreting it, figuring out what it means, guessing what it means and then checking out your guess. A lot of times we play too safe in our assessment, we collect a lot of information on the child and then we sit down to figure out what it means. Whereas I think a much healthier process is to try and figure out what it means what the child is doing, what impact this is going to have on the rest of his behavior as we're going along. If we guess wrong, if we guess incorrectly, we still are a jump ahead because we have information on the child we didn't have before. No, I think you're just totally disinterested in apple sauce. Ok. Let's see if after that, you'll do anything with a bottle and then we'll try you with a cup. What's your milk? Mhm. Right. Now, when I put the bottle in his tongue goes up and sticks quite heavily against the roof of the mouth, making it difficult even to insert the nipple initially. So I would say this is called, won't rather than can't. Would you like to try some in a cup? Let's just see what we do. I usually will assess some attempt at cup drinking in any child who is over the age of about six months. This boy has not had much experience of any experience with the cup, but we can see what he'll do. Hm. And what is that? I don't want to give him the cup tipping the head back and simply pouring it in, simply put it to the lips, bring it up a bit and see what happens and doesn't quite know what to do with it. Ok. I'm just gonna let it run right out, aren't you? Ok? If I see this type of thing with a child and I'm assessing, I want to really explore with the parents. How typical is this either in this kind of situation when a child's not hungry? Um, the probability here is that this boy probably isn't too hungry. Um, I usually will also will tell parents prior to they're coming for an evaluation that we're going to be feeding the child and to bring the child, uh, a little bit hungry. I don't want them starving, but uh at least so that they're more interested in food. But then again, we don't know, is this a child whose response in even a hunger feeding situation is this sort of lethargic kind of response interspersed with pushing back into extension. These are questions which have to be answered as we go along. And I think that I think the most the the comment that I could make about an assessment is your initial assessment is geared at getting basic information on a child and trying to get some ideas of where the problems lie. Even what he took was not handled in a mature way, was not even handled in a way that you would expect of a child of 2 to 3 months. So that we know he has feeding problems specifically how much of them are sucking problems and how much of them are swallowing problems. Uh This is something we'll have to explore next time with him. Uh How much of them are related to problems with the pushing back and problems with the hyper sensitivity. These are very strong possibilities, but again, something we're going to have to explore in greater depth. Um We know that in terms of language that this boy does not have going for him, the things that any normal baby has in terms of, of being able to bring the language world to him, he can't get his hands to his mouth, he can't roll over, he can't lift his head up to look at things and irrespective of whether he has any retardation, basically going for him. He is going to become more retarded because he cannot, he does not have the mobility, he doesn't have the movement to do the things that are going to help him learn about his body, to help him learn about the world around him. Um, what else do we know about you? We haven't really looked at breathing that I think he's going to sleep. I think that's part of the problem. Maybe we can just look at the breathing a little bit even as oops, even as he sleeps. Um, I've been informally evaluating respiration as we've been going along. Uh, we want to look at at how fast he is, how regular he is in sleep. He's going to be much more regular and much slower than at other times. Um He is predominantly a belly breather in the, the basic movement is in the abdominal area. This is quite normal for a child of his age. Yeah. Ok. He does not show a pattern of reverse breathing, which is a very good thing when things move, they move fairly well together. There is a very, very slight amount of movement in the thoracic area almost to the point where I would question whether there is, but I don't know, maybe you're not a thoracic breather that much yet. Um, predominant movement is here and, but we don't see a collapse in the chest area as we do in a lot of youngsters who do show the reverse breathing pattern. The one thing he does show that we don't see too much in normal infants is there when he breathes in, particularly when he was awake and active. There is an indentation or a retraction here in the jugular notch area of the sternum. And part of this is related to the kind of noisy breathing that he's doing. I don't know if you can hear. Let me put you near the mic Joe. No, he quiets down. Ok. His breathing is a fairly noisy pattern and most of the noise is centered in the area. Yeah. Part of which may tell us maybe he doesn't handle his secretions very well. Part of it may be related at sometimes to the tongue being more retracted. But again, these are things we explore as we go along, we've heard very little sound play from him. Uh He was really doing a little bit more before we started the formal assessment. Most of what he does in terms of happy sounds are just a very short kind of not particularly good phonation, a little bit breathy, a little bit tight. Um These then are the basic kinds of things that we see with this youngster, a child who has a lot of problems in movement, who has problems in the pre speech areas of head control, feeding, coordination of breathing and voicing and sound play. And in addition to this is quite handicapped in terms of his physical ability to bring the world to him through the use of his hands or through being able to kind of scoot and explore around himself. He's really stuck wherever you put him, these are some of the very, very important reasons why we need to assess these youngsters at a year or younger and to begin treatment programs with them as early as possible to try and fill in some of these gaps before it becomes appropriate for the child. Really to have developed a lot of speech. It's not enough anymore for us to wait to assess youngsters until they're two years old and they haven't really developed the kind of speech that will allow us to predict whether they're going to be speakers or not.