Early Recognition and Intervention is the Key to Recovery for Hypotonia

 by Shannon Munro Cohen, RNC, BSN; Teresa Whitt, Ph.D.

For more information about this disorder, visit the Benign Congenital Hypotonia website at http://www.lightlink.com/vulcan/benign/index.htm.

Abstract

Benign congenital hypotonia (BCH) is a nonprogressive neuromuscular disorder that is present at birth. Children with BCH exhibit decreased muscle tone with varying degrees of severity. Hypotonia affects many areas of a child’s life leading to developmental delays that include cognitive development.
Early collaborative intervention for the child with hypotonia is imperative. Supportive treatment aids in meeting developmental milestones as educators are involved in the essential work of encouraging cognitive development. Through the development of Individualized Family Service Plans, educators improve the chance for success. Early intervention programs are the key to optimal outcomes for children with hypotonia.

The following is a very brief overview of the topic presented by Shannon Munro Cohen at "Overcoming Great Barriers", the 6th annual International Association of Special Education Conference in Sydney, Australia July 18-22, 1999.



Early recognition and intervention is the key to recovery for Benign Congenital Hypotonia
Shannon Munro Cohen, RNC, BSN; Teresa Whitt, Ph.D.

Hypotonia, an ongoing problem for many children, is defined as decreased muscle tone or floppiness with varying degrees of progression. It occurs in multiple neuromuscular, metabolic and genetic disorders. Many areas of a child’s life are affected by hypotonia leading to developmental delays that include cognitive development. Educators working in collaboration with parents and health care professionals improve the chances of success for children with hypotonia. Early intervention programs and the use of Individual Family Service plans (IFSP) are the key to optimal outcomes for children identified with hypotonia.

The severity and progression of hypotonia varies with each child and their diagnosis. For example, children with Down syndrome and hypotonic cerebral palsy have low tone that remains stable or nonprogressive. Neuromuscular disorders such as muscular dystrophy are progressive in nature; their hypotonia worsening with time. Lastly, infants born prematurely experience hypotonia that improves with maturity of the central nervous system.

Benign Congenital Hypotonia
Benign congenital hypotonia (BCH) is a diagnosis of exclusion given to many children after all tests have been exhausted. In some cases, families are never given a diagnosis for their child. BCH is a nonprogressive neuromuscular disorder that does not worsen but tends to improve with time and intervention. The cause of BCH is unknown and there is no cure. Researchers have found a high familial incidence that may indicate BCH is of autosomal dominant, genetic origin (Cohen, 1998). There is no genetic testing available for BCH at this time.

Signs and symptoms
Children with BCH are quite hypotonic as infants with very flexible joints; this presents many problems for the child. It is difficult for the child to maintain head control or a sitting position. Parents handle their infants with hypotonia gingerly as they develop head control quite late. They feel fragile and limp like rag dolls and are unable to bear weight on their legs. The child with BCH may slide out or fall over in a high chair. Positioning of the infant for feeding is a particular challenge for parents as the child lacks head and chest control and exhibits low tone in the face and mouth. Sucking, chewing and swallowing are difficult for these infants and toddlers. Drooling food and saliva from the mouth is common and may persist in the school age child.

Abnormal postures assumed by these children cause many permanent skeletal deformities such as dislocated hips, clubfeet and contractures of the ankles, knees, elbows and wrists (Cohen, 1998). The infant may prefer to sleep prone in a frog like position increasing his chances of hip and chest deformities. Toddlers with hypotonia have difficulty maintaining balance and often sit on their forelegs with their feet behind them. This abnormal sitting posture leads to hip and knee problems as well. Torticollis, a neck deformity, develops in some children who hold their head to one side. Pectus excavatum, a depressed breast bone, may result from adapted trunk control patterns as well. In the older child, gymnastics is a particular hazard as they possess joint hypermobility without pain. Adults with BCH may continue to experience muscle and joint problems. Recurrent shoulder dislocation, back injury and scoliosis are common (Boehme, 1990; Cohen, 1998).

Developmental delay and diagnosis
For the child with BCH, “every movement is a fight against gravity” (Brown, 1998). While other children are reaching out for toys and exploring their environment, the hypotonic child is struggling to maintain his position. As a result of this struggle, development is delayed for the child with BCH. In the United States, approximately 750,000 infants are born each year at risk for developmental delay (Haber, 1991). Early intervention programs are available for children at risk. However, parents often do not seek medical evaluation until early developmental milestones such as sitting, crawling, walking, independent feeding and talking are missed. Parents carry the child with BCH like a young infant and lay the child flat for dressing. As a result, the hypotonic child becomes a passive onlooker. The child with BCH also talks late due to facial muscle weakness. Nonverbal communication is frequently limited which is interpreted as low cognitive ability.
Diagnosis is a lengthy, grueling process for families. When hypotonia is not progressive and no causes are found, the decision is often left to parents at what point they wish to stop looking for answers. The lack of a definitive diagnosis is a source of frustration for parents. Parents must also deal with their grief over the loss of a “perfect child.”

Cognitive development
Additional disabilities may be found in children with BCH. Due to a limited ability to explore one’s surroundings, cognitive development may be delayed. Children identified as having BCH may fill the void with self stimulating activities such as banging motions (Cohen, 1998).

Family coping and intervention
Parents of a child with BCH cope with many stresses. Their lives change immediately with the birth of the child. The child does not develop at the same rate as his peers. Parents may not recognize or may deny that there is a problem with their child. Denial is common among extended family members which eliminates a source of support to parents. Parents need education and support as they readjust expectations and accept their child’s challenges. Families face many decisions regarding diagnosis and treatment of their child. The family may face financial hardship and social isolation as well (Trachtenberg & Batshaw, 1997).
Concern regarding a child’s development is the basis of early intervention services. However, early intervention has a broader focus. Successful programs emphasize a family centered, developmental approach providing education and support (Bailey, 1991a). Primary care providers are the first step in the early intervention process. Thorough assessments of at risk children are essential (Allen, 1993). Referrals to developmental specialists are initiated by the primary care physician. Children with hypotonia and developmental delay are then referred to individualized programs including early education, speech, occupational and physical therapy.

Early intervention is an umbrella term covering many different services funded by a variety of public and private sources. Available services are determined by each locality. Public Law 99-457, 1986 that was reauthorized in 1991 as PL 102-119 led to expanded services for young children with disabilities. Part C of the Individuals with Disabilities Act (IDEA), a state formula grant program, has assisted in developing comprehensive services and mandates a family directed approach.

Individualized Family Service Plan
In order to best meet the needs of each child and their family, an Individualized Family Service Plan (IFSP) is developed in collaboration with the family and the education team. The plan is ongoing and meets the changing needs of each child. The steps in this process are outlined by Handley and Spencer (1986): 1) problem definition and information gathering, 2) investigating alternatives and the selection of alternatives, 3) implementation, and 4) monitoring and evaluation of the process.
The IFSP is developed with a family centered approach with respect for the family’s knowledge about their child and their desired outcome (McGonigel, Kaufman & Johnson, 1991). Careful consideration of cultural differences and family values are a part of this process (Lynch & Hanson, 1992). Through collaboration, the team discusses priorities and alternatives and chooses the services that will best meet the needs of each child and family. Family involvement in IFSP planning and final decision making has become “best practice” in early intervention (Bailey, 1991a, 1991b; Bjorch- Akesson & Granlund, 1997; Kramer,1991; Leviton, 1991).

Early collaborative intervention for the hypotonic child is essential. Supportive treatment helps children meet their developmental milestones. The need for physical, occupational and speech therapy is evaluated on an individual basis. Physical and occupational therapists work to overcome the gross and fine motor delays caused by low tone. Speech therapists work on speech delays and feeding difficulties.

Educators are involved in the essential work of encouraging cognitive development. Collaboration between family members, educators and health care professionals is essential for children with hypotonia. Educators improve the chances of success for these children through the development of carefully planned Individualized Family Service Plans. Early intervention programs are the key to optimal outcomes for these children.

References
Allen, M.C. (1993, June). The child with developmental disabilities: the high risk infant. Pediatric Clinics of North America 40(3), 479-488.
Bailey, D.B. (1991a). Building positive relationships between professionals and families. In McGonigel, M.J., Kaufman, R.K. & Johnson, B.H. (Eds.). Guidelines and recommended practices for the individualized family service plan (2nd ed., pp.29-38). Bethesda, MD: Association for the Care of Children’s Health.
Bailey, D.B. (1991b). Issues and perspectives on family assessment. Infants and Children, 4(1), 26-34.
Boehme, R. (1990). The hypotonic child. Arizona: Therapy skill builders.
Bjorch- Akesson, E., & Granlund, M. (1997). Changing perspectives in early intervention for children with disabilities in Sweden. Infants and Young Children 9(3), 56-68.
Brown, N. (1998, December). A testing time for low-tone kids [On- line]. Available: http://www.lightlink.com/vulcan/benign/.
Cohen, S. M. (1998, March/ April). Congenital hypotonia is not benign: early recognition and intervention is the key to recovery. Journal of Maternal Child Nursing, 23:2, 93-98.
Haber, J.S. (1991, January). Early diagnosis and referral of children with developmental disabilities. American family Physicians 43(1), 132-140.
Handley, E., & Spencer, P. (1986). Project Bridge- decision making for early services: a team approach. Evanston, IL: American Academy of Pediatrics.
Kramer, S., McGonigel, M.J. & Kaufman, R.K. (1991).Developing the IFSP: outcomes, strategies, activities and services. In McGonigel, M.J., Kaufman, R.K. & Johnson, B.H. (Eds.), Guidelines and recommended practices for the Individualized Family service Plan (2nd ed., pp.57-66). Bethesda, MD: Association for the Care of Children’s Health.
Leviton, A., Mueller, M., & Kaufman, C. (1991). The family centered consultation model: practical applications for professionals. Infants and Young Children, 4(3), 1-8.
Lynch, E.W. & Hanson, M.J. (Eds.). (1992). Developing cross cultural competencies: a guide for working with young children and their families. Baltimore: Paul H. Brookes Publishing Co.
McGonigel, M.J., Kaufman, P.K., & Johnson, B.H. (Eds.). (1991). Guidelines and recommended practices for the individualized family service plan (2nd ed.). Bethesda, MD: Association for the Care of Children’s Health.
Trachtenberg, S. W., & Batshaw, M. L. (1997). Caring and coping: the family of a child with disabilities. In Batshaw, M. L. (Ed.), Children with Disabilities (4th ed., pp. 743-756). Baltimore, Maryland: Paul H. Brookes Publishing Co., Inc.


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