Spastic Cerebral Palsy.
The word ‘spastic’ means ‘stiff’ and so children who have spastic cerebral palsy have a tendency to have stiff muscles. That stiffness may show itself only in one limb, two limbs. Three limbs or four. There are various names for the different combinations of limbs which are affected in all types. I will not highlight these at the end of this section.
Spastic cerebral palsy is usually caused by injury to the cortex, especially the motor cortex and to a bundle of nerve fibres called the corticospinal tract. Obviously, spasticity is very uncomfortable and has negative consequences for the child’s development, depending upon how many limbs are involved and it’s severity.
Athetoid Cerebral Palsy.
This type of cerebral palsy is caused by injury to a structure below the cortex called the ‘basal ganglia.’ The basal ganglia plays a role in motor function, cognitive processes, emotional processes and our ability to learn. It also acts as a ‘braking’ mechanism on the thalamus, a part of the brain which mediates our sensory experiences. So, without this inhibitory role, one can imagine a thalamus in effect operating without its ‘braking system’ which might produce many of the sensory distortions we see in some children who have cerebral palsy. It also acts as a ‘braking system’ for movement, which enables us for instance, to sit still. In order to sit still a ‘brake’ has to be placed on all other movements. Consequently injury at this level hampers the ‘braking system’ and we see children who cannot sit still and are in constant movement and children whose sensory perception is distorted. Injury to this part of the brain also exhibits itself in many children by retention of the primitive postural reflexes, as it is the role of the basal ganglia to suppress these in order to enable the child to move.
Children with basal ganglia injury are also more likely to have hypotonia, (floppy muscle tone) and persistently impaired balance and ambulation performance.
Ataxic Cerebral Palsy.
Children who have this type of cerebral palsy are usually injured in a structure right at the back of the brain called the ‘cerebellum.’ The word ‘cerebellum’ actually means ‘little brain’ and it is not without justification, as at first sight it does look like a smaller version of the brain. It is located behind the brainstem and it forms massive connections with this structure and with the cerebral cortex. It is the only structure within the brain which is not fully formed at birth, taking a further two years to develop to it’s full complement of neurons.
The proper functioning of the cerebellum ensures that any movements we make are smooth and well coordinated. It seems that the motor cortex supplies commands to the body musculature, which are then refined by the cerebellum to ensure smooth coordination. Feedback on the success of the movement is then supplied from the cerebellum back to the motor cortex where the original movement command can be refined if the movement has been unsuccessful.
One might imagine then that an injury to the cerebellum will interfere with these functions. Movement can become slow and uncoordinated, the child may display problems with balance and equilibrium, the child might experience an ‘intention tremor’ – (a tremor which is made worse when the child tries to move). Injury to this part of the brain causes ‘Ataxia’ – this is where the muscle tone is hypotonic (floppy).
Higher cognitive functions, like language and visual processing, have long been thought to reside primarily in the brain’s cortex, however recent research involving premature infants is documenting an important role for the cerebellum — previously thought to be principally involved in motor coordination and shows that cerebellar injury can have far-reaching developmental consequences. This work also demonstrates that the cortex and cerebellum are tightly interconnected. Sophisticated MRI imaging of 74 pre-term infants’ brains revealed that when there was injury to the cortex, the cerebellum failed to grow to a normal size. This means that our children with spastic cerebral palsy will usually also experience some of the difficulties associated with injury to the cerebellum.
When the injury to the cortex was confined to one side, it was the opposite cerebellar hemisphere that failed to grow normally. The reverse was also true: when injury occurred in one cerebellar hemisphere, the opposite cerebral hemisphere was smaller than normal. So, there seems to be an important developmental link between the cortex and the cerebellum, – it seems that the two structures modulate each others growth and development. So it appears that the way the brain forms connections between structures may be as important as a direct injury to a brain structure itself.
The cerebellum has also been implicated in the development of some types of literacy problems, including dyslexia.
Mixed Cerebral Palsy.
This quite simply is where several brain structures are injured, producing a mixture of symptoms of all three of the previous types mentioned.
Cerebral palsy is not limited to injury to the brain structures I have mentioned here, it is just that in the overwhelming majority of cases there is injury to one or more of these structures. An injury to one or more additional brain structures or nerve pathways can also add to the mix of symptoms, which is why no two children with cerebral palsy are exactly the same. They may have some shared symptoms, but they will not be totally alike.
What is the difference between hemiplegia, diplegia, quadriplegia, etc ?
These terms are quite simply a reference to how many limbs are affected.
Quadriplegia indicates that all four limbs are affected.
Diplegia indicates that the legs are affected.
Hemiplegia indicates that one arm and leg on the same side of the body are affected.
Double Hemiplegia is a term which is used when all four limbs are affected, but with different features on the right and left sides.
Alternatively, your doctor might use the term, hemiparesis instead of hemiplegia, and quadriparesis instead of quadriplegia. ‘plegia’ indicates a form of paralysis or difficulty in moving the affected limbs, whereas the term ‘paresis’ indicates a weakness in the affected limbs.
What problems can cerebral palsy produce in a child?
A child with cerebral palsy can experience difficulties in one, several or all areas of development, to a greater or lesser degree, depending upon the nature and severity of the brain injury. An injury can be so mild as to merely slow down development a little in just one area, or can be so severe as to completely stop development in all areas, rendering the child totally dependent in every way for every aspect of his care. Let’s do a quick A – Z tour of the kind of problems you could be facing.
Anxiety. – Some children with cerebral palsy suffer from anxiety. This can be due to the discomfort produced by stiff musculature, or can have other neurological causes such as the overproduction of norepinephrine in the brain, leaving the child on a hyper-anxiety inducing ‘high.’ There are techniques, which Snowdrop employs to relieve this situation, but in the most severe cases intervention can be necessary with anti – anxiety medications.
Breathing. – The respiratory rate of a newborn baby is between 40 – 70 breaths per minute, but by the time he is ready for pre-school at four years of age this has dropped to 25 breaths per minute. By the time a child is ready for secondary school, this has again dropped to approximately 16 breaths per minute and by adulthood the rate is around 12 per minute. In many children who have cerebral palsy this developmental pathway is either slowed or stopped, leaving for example a four year old child, who should have a rate of 25 breaths per minute, with a rate of 50 breaths per minute. As the breathing rate of a newborn is also shallow, this can mean that the oxygen levels in the brain are more difficult to maintain, exacerbating other problems such as epilepsy. It also makes the coordination of swallowing, chewing and breathing more difficult.
Constipation. – This is a big problem in many children who suffer spastic cerebral palsy, but to a lesser extent in the other types too. It is produced by lack of mobility, muscular stiffness, lack of muscular strength and bad co-ordination. Fortunately there are medications such as lactulose, senna and sodium picosulfate, which can ease the problem. On a more natural note, there is also Magnesium Oxide which can have a beneficial effect. Even so, many children still have have regular enemas. It is important to try to control this problem as constipation exacerbates so many more of the child’s problems, such as muscle tone, anxiety and epilepsy.
Digestion. – The digestive system of the child with cerebral palsy might also be compromised, with the child having poor absorption of nutrients, or having trouble in keeping food down, through excessive vomiting.
Epilepsy – This is more prevalent in spastic cerebral palsy, but does occur to a lesser frequency in all types. Epilepsy can be a big problem. I have seen children who are taking the most powerful medication cocktails you could imagine and still they have seizure after seizure. Often it is well controlled by medication, but sometimes depending upon the severity of the brain injury, it is more problematic. Epilepsy is simply the propensity of brain cells to misfire. Sometimes this sets of a chain reaction causing other cells to misfire and we then see the child having a seizure. Depending upon the extent of that chain reaction, the child may have a mild seizure such as an ‘absence’ where he simply ‘fazes out’ and stares into space for a few seconds, or he might experience a more violent, generalised seizure where he loses consciousness and his body rhythmically shakes.
Usually there is no danger from the fit itself, – even in the most violent looking seizures, the child will regain consciousness within a few minutes, the only danger being that when the fit begins, he might lose consciousness, fall and hurt himself. Very rarely however, some children will experience repeated seizures from which they cannot be roused, this is called ‘status epilepticus’ and is a situation where medical help should be sought without delay. For a more detailed description of different types of epilepsy, go to my book ‘Brain Injured Children. – Tapping the Potential Within.’
Feeding and drinking. – These are two more areas which are affected by breathing. It is sometimes difficult for the child with brain injuries to co-ordinate swallowing, chewing and breathing, – something we do unconsciously and which we take for granted. This can result in the child aspirating (breathing in) liquid and food with the consequent risk of infection such as pneumonia. Other problems include the fact that the child might not have the required muscular co-ordination to chew, or might have so strong a suckling reflex that instead of chewing, he suckles his food. Actually getting some children with severe cerebral palsy to take solid food at all can be a difficult task. Sometimes, as a result of all these difficulties a doctor might recommend that a naso-gastric tube be fitted, or that the child has an operation called a gastrostomy, through which they are fed.
Homeostasis. – Some children with cerebral palsy who have injuries to a part of the brain called the ‘hypothalamus,’ or connections to and from it have trouble with several aspects of maintaining their equilibrium. This may display itself as a lack of a drive for hunger, thirst, etc, or too much of a drive for these. So some children might not realise they are hungry, whilst others might be incessantly so. It may also display itself as an inability to maintain body temperature, the child either becoming cold or hot easily.
Learning Difficulties. Many people assume that most children who have cerebral palsy also have learning difficulties, – this is not the case. Many children with cerebral palsy have difficulty in displaying their intelligence because of their sensory, physical, and / or communication difficulties, but that intelligence is often most certainly there! Only approximately three out of ten children with cerebral palsy have severe learning difficulties.
Orthopaedics, Orthopaedic impairment can take many forms in the person with cerebral palsy. One or more limbs can be impaired, different muscle groups in the body can be affected, there can be difficulty due to stiffness of the muscles with ligaments and tendons tightening, there can be difficulties due to low muscle tone too. Children can suffer from contractures and dislocations. There can also be problems with scoliosis of the spine. There are surgical procedures which can help to alleviate some of these difficulties, and there are also medications such as muscle relaxants. The best way of maintaining your child’s body however is regular physiotherapy. The physiotherapist is so important to the child with cerebral palsy and to Snowdrop. They help to prevent the development of orthopaedic and associated problems, thereby preserving a clear developmental base upon which to build.
Salivation. – Many children with cerebral palsy produce excess amounts of saliva. This can cause big problems with choking, aspiration and infection, chewing and eating, drinking and language development. It can signal an imbalance in the autonomic nervous system, which has two branches, – the sympathetic and parasympathetic nervous systems. When the parasympathetic branch is over-active, production of saliva increases. Over salivation can also be stimulated by problems with the brain’s vestibular system. There are medications which can be used to help slow down the rate of salivary production, one of the more common being ‘scopolomine patches,’ which are gently stuck on behind the ear.
Sensory Problems. – This is a huge problem area for many children with cerebral palsy, whose sensory perception can be dulled, distorted or amplified in one or more of the sensory modalities. Children can have a mixture of these problems in different senses, so that a child might for instance have acutely oversensitive hearing and simultaneously be undersensitive in vision. As specific sensory systems supply the information necessary for the efficient operation of motor systems, problems here can have the effect of retarding the development of mobility, hand function, language and communication and socialisation.
Let’s take a brief look at this. If a child’s visual development is delayed or stopped, then language development, socialisation, mobility and hand function can be affected. Mobility speaks for itself, if a child cannot see it could be dangerous to move. Language and socialisation development will be affected because the child will not be able to complete the essential developmental stages of making eye – contact, regulating mutual attention and will not be able to see the face of a communicating partner. All of which are vital precursors to the development of language and socialisation.
If a child’s auditory development is affected then it is obvious that language and consequently socialisation, which in turn depends so much on language development, will also be affected. The development of spoken language is dependent upon exposure to spoken language. If tactile development is affected then mobility and hand function will also be problem areas. If you cannot feel where your body, limbs and hands are, then you will have difficulty in the conscious control of them. So we can see how important sensory development is in enabling other developmental functions to operate normally.
Sleeping, – There are two categories of children to talk about here, the first is the child who cannot sleep. The second is the child who can sleep but does not do so at the correct times. The effect is the same for the parents who have to stay awake to ensure the child’s well-being. In the first category, the child has a neurological reason why he cannot sleep, – he perhaps for some reason does not produce enough serotonin, or maybe he overproduces ‘noradrenaline.’ In the second category it could be the child’s body clock which is askew, or it might be sensory oversensitivity which is preventing him from sleeping. Ultimately this child will sleep, usually when he collapses from exhaustion.
Teeth, Dental problems can occur, especially if the child is hypersensitive to touch in his mouth, or if he produces excess saliva, or grinds his teeth.
Teeth grinding, – Apart from being like the Chinese water torture for the person having to listen to it, this can cause dental pain for the child who does it. Often, it is done when the child feels stressed and more often than not is linked to overproduction of saliva.
Can Cerebral Palsy be Treated?
The answer to this problem is an emphatic ‘yes!’ Snowdrop treats many children who have all types of cerebral palsy. We believe that treatment in the past has either focussed upon treating symptoms, -which is why it has failed, or it has focussed upon erroneous theories about the way in which the brain works and how children develop. Indeed, we point to plentiful evidence in the literature, which can be seen in my book, ‘Brain Injured Children: Tapping the Potential Within,’ which prove these systems of treatment to be failures.
We point to the fact that our system of treatment, which we call ‘neuro-cognitive therapy,’ is informed by the evidential findings of eminent researchers such as Vygotsky, Bruner, Rogoff, Dunn, Woods and Mercer to name but a few.
Our approach is based upon certain irrefutable facts concerning brain function, which are applied to the treatment of children’s developmental difficulties. The first of these is brain plasticity. It is now unchallengeable that the brain is capable of changing its structure and functioning in response to the environment in which it finds itself. We can see this in the growth of new synaptic connections and the pruning of inefficient ones.
The question then is, what do I mean by ‘environment’ and how can we manipulate this variable in order to encourage the brain to respond in the way we wish?
The brain takes in information from the sensory environment, through the eyes, ears, nose, mouth and skin. It processes this information and then re-routes it to the appropriate part of the cortex for further attention, evaluation and action. When the brain is working as it should, then all of this is achieved with the maximum efficiency, without us noticing what is going on. However, as both you and I are aware, the brain does not always work as it should.
In many children with cerebral palsy, this sensory information has great difficulty in reaching the relevant part of the brain at all, or if it does, the signal has been weakened sufficiently so that processing becomes almost impossible. In other children, the sensory stimuli is passed to the cortex for processing in a distorted manner and the child is overwhelmed by the world it perceives.
These ‘distortions of sensory processing’ are primary problems which affect many neuro-developmental conditions, not just cerebral palsy. What I try to do is to manipulate the sensory environment to which the child is exposed in order to encourage the regions of the brain which are responsible for processing the sensory stimuli, (the sensory attentional filter of the brain, – the ascending reticular activating system, the thalamus and the limbic areas), to re-tune and to process information more normally. I do this sometimes by providing an adapted sensory environment designed to dampen the incoming sensory stimuli (in cases where children are hypersensitive) and sometimes by designing activities intended to enrich sensory experience. In this way, because as I have said, we know as fact that the brain grows new synapses and prunes disused ones, we can influence not only brain function, but it’s development.
Another aspect of my approach is aimed at any learning difficulties the child might have and is informed by research from Vygotskian psychology. Recent research has provided ample evidence concerning how children learn. (unfortunately, often children do not learn in the manner by which schools teach)
As I have already pointed out, the research findings which inform my work in this field are all provided by respected, mainstream psychologists so you know in advance that I am not operating some ‘fly by night’ fanciful theory on brain plasticity and learning; – everything I do has an evidential basis.
Basically, utilising Vygotky’s concept of the ‘zone of proximal development,’ I look at the child’s current developmental level in terms of his / her cognitive development and reinforce this. I then look at the next stage of development for the child (his proximal development) and in recognition that learning is a social activity, provide support to enable him to attain that ability (this support is Bruner’s concept of ‘Scaffolding.’). This may also entail breaking the developmental task down into smaller, simpler sub-components thus enabling the child to succeed. As the child improves his functioning at the desired task, the scaffolding (support) is gradually removed until he is performing the desired task automatically. This is not just the way in which children learn, – this is the way we all learn.
What does a Snowdrop programme look like?
This would depend upon the specific difficulties faced by a child and how much time the family could practicably spend on it. It might consist of as little as thirty minutes of structured stimulation per day, up to two hours per day. The programme consists of a series of activities, each lasting a few minutes, which are designed to stimulate development in the seven major areas, visual, auditory, tactile, language, mobility and social development, in addition to the seventh, – hand function. What the programme is designed to do is to ameliorate the symptoms of developmental delay in all these areas of development.
Where do I go from here?
After many years as a parent of a profoundly brain-injured child, almost as many years in academic research and working in schools with children who have special educational needs, I decided the time had arrived to fulfil a long held ambition. Having travelled internationally to clinics, both as a parent and as a researcher, I have become aware of just how little of the vast amount of knowledge possessed by the discipline of psychology is being applied to the treatment of children with cerebral palsy.
I have personal experience and knowledge of the serious consequences for the family, which the presence of a child with cerebral palsy can bring, not least of all the problem of stress, which family members bear. As I have previously stated, a child with brain-injuries, with his myriad of associated difficulties, is likely to create tired, stressed parents, – understandably so! This needs to be taken into account when dealing with the family and in this sense, we are not merely treating the brain-injury, nor merely the child; – We are treating the whole family and if we are to have a significant impact upon the problems presented by cerebral palsy and other brain-injuries, we must surely do so!
With these thoughts in mind, and having worked alongside parents and brain-injured children for many years, I have established a child development consultancy called ‘Snowdrop.’ Snowdrop is already successfully treating many children (and adults) both in the UK and in many other countries.
My personal crusade is to ensure that Snowdrop remains ‘research friendly’ and eclectic. By this, I mean we should not develop a set philosophy or rationale, which will effect our methodology. – Down that road lies academic egoism and inflexibility, which I have witnessed at so many other institutions and which would lead to stagnation. We should always look to research and to evidence to provide our treatment methods and not be afraid to change.
It is my hope that this short text has been informative and that most of all it has given parent some good information about cerebral palsy and also some hope that their children can make progress! To make an appointment, simply use the contact details below.