Individuals with cerebral palsy (CP) have sensorimotor and developmental issues that affect their daily lives by restricting their mobility, manipulation of objects, and/or communication.1 Within the framework of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF),2,3 the Gross Motor Function Classification System (GMFCS)4 and the Manual Ability Classification System (MACS) for children with CP5 make it possible to classify mobility and handling objects respectively, at the ICF activity/participation level.6 However, no analogous classification of functional communication has been available for use in CP practice and research. The lack of a communication classification tool that is quick, reliable, valid, and easy to use limits the comparison of descriptive CP epidemiology studies as well as the interpretation and generalizability of CP treatment studies.

Communication disorders can be described from several perspectives: body structure and function level, activity level, and participation level, as well as environmental and personal levels.2,3,7–13 Estimates of communication disorders in CP have varied from 31%14 to 88%.15 This wide range is partly a result of the lack of a consensus definition of communication disorders within CP research and practice. A recent study from a Norwegian CP registry reported that 51% of children with CP had speech problems as classified by ratings of ‘slightly indistinct’, ‘obviously indistinct’, ‘severely indistinct’, or ‘no speech’, including 19% who had ‘no speech’.16 This population-based estimate reporting indistinct or no speech may underestimate CP communication disorders as it may not capture other types of communication problems resulting from hearing or language impairments. However, reporting speech, language, and hearing difficulties simply suggests the range of associated impairments in CP, not the more pertinent daily-life issues of how well a child with CP communicates with family, friends, acquaintances, and strangers.13

The purpose of this study was to create and validate a communication function classification system (CFCS) for children with CP, for use by a wide variety of individuals interested in CP. This required a shift from the traditional focus on body structure and function (i.e. assessing components of speech, language, and hearing problems), to a focus on activity/participation, specifically the way in which to classify a person’s communication capacity within real-life situations.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.2011.03996.x

Developing and validating the Communication Function Classification System for individuals with cerebral palsy

OBJECTIVE: To summarize evidence on the rates of co-occurring impairments, diseases, and functional limitations with cerebral palsy into succinct clinical messages. METHODS: A search was conducted of the databases PubMed, Medline, CINAHL, and PsycINFO, and the results were supplemented with hand searches. Two independent reviewers determined whether retrieved abstracts met the following inclusion criteria: human subjects; >90% were children or adults with cerebral palsy; published after 1999; and population-based data. Articles were appraised, analyzing design, participants, level of evidence, rates of impairments, and functional implications. Methodologic quality was rated by using a standardized checklist. RESULTS: A total of 1366 papers were identified in the search; 82 were appraised and 30 were included in the meta-analyses. High-level evidence existed, as rated on the Oxford 2011 Levels of Evidence: 97% of prevalence studies were level 1. The data were of a moderate to high quality grade (with the exception of sleep disorders), allowing plain English clinical messages to be developed. CONCLUSIONS: Among children with cerebral palsy, 3 in 4 were in pain; 1 in 2 had an intellectual disability; 1 in 3 could not walk; 1 in 3 had a hip displacement; 1 in 4 could not talk; 1 in 4 had epilepsy; 1 in 4 had a behavior disorder; 1 in 4 had bladder control problems; 1 in 5 had a sleep disorder; 1 in 5 dribbled; 1 in 10 were blind; 1 in 15 were tube-fed; and 1 in 25 were deaf.

Clinical prognostic messages from a systematic review on cerebral palsy.

Cerebral palsy (CP) is the most severe physical disability within the spectrum of developmental delay. CP is an umbrella term describing a group of motor disorders, accompanied by many associated impairments. The disability is a result of injuries to the developing brain occurring any time from the first trimester of pregnancy through to early childhood. However, for the great majority, their full etiological causal pathway remains unclear. It is important to discriminate as early as possible between: (a) mild or nonspecific motor delay, (b) developmental coordination disorder, (c) syndromes, (d) metabolic and progressive conditions, and (e) CP with its various motor types and distributions. The most promising predictive tool for CP is the general movements assessment, which assesses the quality of spontaneous movements of infants in the first 4 months of life. We propose a change in diagnostic practice. We recommend a shift away from referral for intervention following a formal (most often late) description of CP, to one of referral for intervention which occurs immediately once an infant is considered "at risk" of CP.

Cerebral palsy--don't delay.

Aim The aim of this study was to describe speech, expressive language, and verbal cognition of children with cerebral palsy (CP).



Method  A population study included 152 Icelandic children with congenital CP (74 males, 78 females; mean age 5y 5mo, range 4y–6y 6mo). Children who spoke in sentences, phrases, or one-word utterances were categorized as verbal. Speech was classified as normal, mild dysarthria, or severe dysarthria. Cognition was reported as IQ (Wechsler Preschool and Primary Scale of Intelligence – Revised) or developmental quotient (DQ).



Results  Most children (81%) had spastic CP and bilateral symptoms (76%); 74 (49%) were at Gross Motor Function Classification System (GMFCS) level I, 27% at levels II and III, and 24% at levels IV and V (p<0.001). One hundred and twenty-eight children (84%) communicated verbally whereas 24 were nonverbal. Nonverbal status and severe dysarthria were associated with greater motor impairment (GMFCS; p<0.001). Twenty-five children (16%) had severe dysarthria. Most (88%) of the nonverbal children had multiple disabilities compared with 18% of the verbal group (p<0.001). Median (interquartile range) verbal IQ was 93 (73–104) and performance IQ 77 (61–94; p<0.001). Sixty-eight children (45%) had normal verbal cognition and almost a quarter of the children with severe dysarthria had a full-scale IQ/DQ of 70.



Interpretation  Most children with CP express sentences and almost half of them have normal verbal IQ. Nonverbal status frequently indicates multiple impairments whereas severe dysarthria may be associated with normal cognition.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.2010.03790.x

Speech, expressive language, and verbal cognition of preschool children with cerebral palsy in Iceland.

https://eprints.ncl.ac.uk/file_store/production/196599/3A87471B-CEE2-4227-A310-FE28A6117EAC.pdf

Development of The Viking Speech Scale to classify the speech of children with cerebral palsy

This study describes the prevalence of speech problems and the use of augmentative and alternative communication (AAC) in children with cerebral palsy (CP) in Norway. Information on the co...

Prevalence of Speech Problems and the Use of Augmentative and Alternative Communication in Children With Cerebral Palsy: A Registry-Based Study in Norway

This scale has been developed to classify children’s speech production. The ease with which children can make themselves understood using other methods of communication is scored using different scales.
Speech production relies on the control and coordination of several body functions, including breathing and breath control, phonation (vibration of the vocal cords when speaking which creates the voice) and movement of the lips and tongue for articulation. Motor disorders in cerebral palsy can affect individual functions, giving rise to different speech patterns (e.g. reduction in breath control can lead to difficulties controlling the loudness of speech; impaired movements of the vocal cords is associated with breathy or harsh voice; impaired articulation is evident inability to produce some consonants etc). The extent to which each of the individual functions is affected will vary greatly from child to child. We know that the speech functions are adequate if words are perceived correctly by listeners. Although intelligibility is strictly a measure of activity (communicating a message) it relates directly to speech function and can help differentiate levels of impairment.

Tone R. Mjøen

Papers

Development of The Viking Speech Scale to classify the speech of children with cerebral palsy

Prevalence of Speech Problems and the Use of Augmentative and Alternative Communication in Children With Cerebral Palsy: A Registry-Based Study in Norway

Viking speech scale