Friday, September 7, 2012

Cerebral Palsy Guidebook: Developmental versus Chronological

For those who know me well, this discussion will be a familiar one.  It had taken quite awhile to find an effective way to create a mindset that would, not only resonate and increase understanding, but also facilitate more effective learning and understanding with respect to the journey taken by CP individuals and their immediate and extended families.  I refer to the term "journey" because it most accurately describes the life-long path which is sometimes relatively smooth, sometimes filled with obstacles, and almost always evolving.  Because the "finish line" is never predictable, it is the journey that defines success...therefore it is only logical to make every attempt to instill the proper perspective and overall frame of mind that will ultimately sustain you throughout.  Although there are many different "angles" and ways to approach this topic, I have found that when there is a fundamental understanding of developmental age versus chronological age, the mindset is automatically "re-booted" into a different "mental software". 

Mental Software: DOS 2.2 to Windows 7
I use this familiar comparison in an attempt to illustrate the relative "leap" in many ways, it can be considered a mini-paradigm shift.  Throughout human society, there has always been an underlying understanding / expectation with respect to human behaviour.  To be more precise, behaviour is almost always assessed against the "age appropriate litmus".  Behaviour is defined as either appropriate or inappropriate based on that persons age.  Without going into any complex sociological rant, this is no different within the sphere of Cerebral Palsy.  Moreover, it is equally as rampant in the professional medical mindset as it is within the general population.  In some ways, this is to be expected...we all see life through the same relative prism, therefore why wouldn't this apply to an individual with CP?  This is where the "re-install" of the mental software needs to take place.

The proper perspective is not something that is (or has ever been) fact, it has been under our noses from the beginning.  Alarmingly enough, we have seen and read it over and over again...and never truly latched onto it.  To be more specific, we only need to refer to the definition itself to get a better understanding of the CP journey.  Cerebral Palsy can be considered as a condition that falls under the umbrella of neurodevelopmental delay (NDD).  This is a relatively large umbrella that includes West Syndrome, Miller-Diekers Syndrome, etc...therefore this perspective has implications far beyond CP as well.  By definition, neurodevelopmental delay is a condition that is characterized by the absence or delay of natural developmental milestones.  It is also defined as the persistence of primitive reactions and the absence of postural reactions.  To put this all into very straightforward terms: In the CP individual developmental age does not correspond with chronological age.

Mental Software: User Tutorial
Now that this perspective has been installed, it will require some basic orientation and familiarization.  The reality in the vast majoriy of cases is that children are "evaluated" based on their chronoligical age and the corresponding developmental achievement.  For example, a CP child of 2 years old is typically assigned strategies and tools that are intended to achieve the essential functional goal of "walking".  However the fundamental reality is that the developmental age of the pelvis, hips, knees, and feet are likely much "younger" and therefore unprepared for any load-bearing activities.  This is a simple example, of course, but it speaks to a very complex problem.  Let me illustrate an even more precise example:  Up until the age of 10-14 months, there is a tremendous amount of developmental milestones that take place...development of head control, increased strength and stability in the shoulder girdle, stability in a seated position, crawling, standing, etc...  These are all developmental stages that every human must pass through in order to achieve proper functional competence.  In a healthy child, all of these (and more) are achieved by 10-14 months.  In addition, the primitive reactions (Moro Reflex, Landau Reflex, etc...) have all disappeared by the 8-9th month and have been replaced by postural reactions such as lateral propping and counterbalancing. In the CP individual, these primitive reactions persist long after 14 months of age...and can even be seen into their teens. 

Therefore, the use of chronological age as a template for functional competence / expectation or to assess other important concerns such as bone fundamentally flawed and fundamentally incorrect.  The realistic "litmus" standard should always refer to developmental age rather than chronological age.  If primtive reactions (Moro, Landau) are still present, no matter what their chronological age, the individual's developmental age corresponds to that of a child of 0-14 months.  

There is no debating the internal conflict that exists when a parent is asked to consider their 4, 5, 6 year old as an infant...however the architectural reality and developmental competence is precisely that.  If there is an implied understanding of the definition of neurodevelopmental delay...why does this understanding fail to reach beyond the words on the page?   The developmental age of the individual defines the appropriate therapeutic intervention best suited for the progress of the child.  Although this may be quite a leap in perspective, the fortunate reality is that this concept makes assessing progress much easier.  The gradual disappearance of primitive reactions and the progressive development of postural reactions signal progression through the developmental process.  What is almost ALWAYS overlooked is that functional competence is the spontaneous reaction to a maturing structure!  In a healthy individual there is no need to "train" the muscles or "train" the brain to achieve functional is spontaneous.

Power Down:
Although it may take some time for this perspective to truly integrate, I hope that it at least stimulates some "error messages" popping up when you come to important decisions regarding rehabilitative strategy.  I wrote a few posts on Primitive and Postural Reactions which served as a follow up to a basic post on fundamentals of proper perspective that will contribute to the internalization of this important concept.  I hope it proves insightful and, more importantly, helpful.


1 comment:

  1. It was impressed by a wonderful content.
    I also do long " journey" with children.