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in Communication Disorders
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Summary of Clinical Practice Guideline

New York State Department of Health, Early Intervention Program; U.S. Department of Education 
 
Clinical Practice Guideline: Report of the Recommendations. Motor Disorders, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4962, 322 pages. 
AGREE Rating: Highly Recommended

Description:
This guideline provides recommendations regarding assessment and intervention for young children with developmental motor disorders and cerebral palsy, a static central nervous system disorder.  The target audiences for this guideline are parents and professionals. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done.

Recommendations:

  • Assessment/Diagnosis

Assessment Areas

  • Cognition - Cognitive evaluation should include assessment of information-processing, conceptual development, memory, attention, problem-solving, perceptual motor function, functional motor skills, and adaptive behavior (Evidence Level D2) (pp. 83–84).
  • Hearing - It is important to consider the possibility of hearing loss and make appropriate referrals as necessary (Evidence Level D2) (pp. 85–86).
  • Speech and Language - A communication evaluation for children 6 months to 3 years should include: standardized tests of receptive and expressive language, assessment of gestures and nonverbal communication, oral-motor and speech-motor assessment, language samples and parent report (Evidence Level D2) (pp. 85-86).
  • Swallowing
    • All infant developmental examinations should include questions pertaining to the child's feeding and swallowing history, feeding milestones, and parental concerns (Evidence Level D2) (pp. 70-71).
    • If a feeding or swallowing problem is suspected, an accurate diagnosis should be made by an experienced physician and feeding specialist prior to management (Evidence Level D2) (p. 71). 
    • Assess feeding in a natural environment; feeding position; lip, tongue, and jaw actions during feeding; fine motor skills; efficiencies with varying textures; time to clear the oral cavity; mastication skills; and coordination of breathing and swallowing during feeding (Evidence Level D2) (pp. 72-73).
    • Signs of impairment to watch for during the initial oral-motor feeding assessment include: increased heart rate or loss of breath, excessive coughing during or after meal, gagging, spitting, tongue thrust, squirming or withdrawal, and oral loss of liquid (Evidence Level D2) (pp. 72-73).

Assessment Instruments

Cognition

  • Norm-referenced cognitive assessments are generally not recommended as a measure of cognitive function before 6 months of age (Evidence Level D2) (p. 83).
  • A curriculum-linked assessment is recommended as part of the cognitive assessment from birth to 12 months (Evidence Level D2) (p. 84).
  • A standardized/norm-referenced test is recommended for children ages 1 to 3 years (Evidence Level D2) (pp. 83-84).

Swallowing

  • Oral Motor Assessment - No standardized assessment test or scale is recommended for universal use to assess oral motor skills in children with cerebral palsy. Assessment instruments may include:
    • Neonatal Oral-Motor Assessment Scale;
    • Pre-Feeding Skills: A Comprehensive Resource for Feeding Development; 
    • Schedule for Oral-Motor Assessment;
    • The Multidisciplinary Feeding Profile (Evidence Level D2) (p. 74).
  • Videofluoroscopy/FEES - Some children may need additional evaluation using instrumental assessments such as a videofluoroscopic swallow study (VFSS) or flexible endoscopic examination of swallowing (FEES) (Evidence Level D2) (pp. 68–75).
  • Treatment
Speech and Language
Augmentative and Alternative Communication (AAC) 
  • Prior to initiating the use of augmentative and alternative communication (AAC), ensure that the child and parent are clear on the purpose and meaning of the device (Evidence Level D1).
  • When selecting devices, identify options that promote the highest level of independence. Generally, low-tech options allow the child the highest level of independence (Evidence Level D1).
  • Consider age and cost when determining the appropriateness of the device for individuals (Evidence Level D1).
  • The child and family must be trained on how to use the device (Evidence Level D1) (pp. 146–149).  

Swallowing

General Findings

  • Growth and nutritional status of children with motor disorders and feeding problems should be carefully monitored (Evidence Level D2).
  • Feeding interventions may consist of preparatory methods implemented prior to feeding, compensatory strategies, medical or surgical management, or behavioral methods (Evidence Level D2).  
Oral Motor Treatment
  • Oral-motor intervention should be targeted to the specific phase or phases of swallowing which are impaired (Evidence Level D2).
Tube Feeding
  • Non-oral feeding should be considered for infants with severe dysphagia, children with persistent swallowing problems, and children who are chronically unable to meet nutritional needs with oral feedings alone (Evidence Level D2).
  • Safe transitions from tube to oral feeding should be facilitated and encouraged (Evidence Level D2) (pp. 156–160).
 

Keywords: Cerebral Palsy

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