How well do children with severe cerebral palsy understand spoken language?

Thanks to a range of recent studies, we now know that receptive and expressive language can be affected in children with CP. We also know that language problems are more likely in children with severe mobility issues. What we do not really know at this stage is how well non-verbal children with severe CP can understand spoken language, and whether there are factors that can to some extent predict how well they will do.

Geytenbeek and colleagues tried to answer this question. In a recently published study, they tested the receptive language abilities of 87 Dutch children with severe CP who spoke fewer than 5 words. The children were between 1 and 6 years old. The authors used the C-BiLLT (which stands for computer-based instrument for low motor language testing), a test they have developed that considerably reduces the need for any motor action to respond to the test stimuli. Children can use a range of devices to respond including a touch screen, input switches, switch activators, their own electric wheelchair head support and/or eye gazing. The test contains 77 sentences, which become more difficult over the course of the test in terms of vocabulary and grammar. In the test situation, the test leader says the items out loud. At the same time, the items are presented visually on the computer. There are a number of practice items, which are included to make sure that the child can signal a choice between 2 objects. Only if they do well in this pre-test, they move on to the main test.

Results showed that 78% of children were able to complete the language test. The results also showed that type of CP mattered when it came to completing the test. Children with dyskinetic CP were much more likely to move on to the main test than children with spastic CP. In terms of response mode, 38% of children used the touch screen, 24% used their own wheelchair head support and about 20% used eyegazing. The latter 2 options were used more frequently by children with very severe mobility problems (GMFCS V).

What about the language performance? The authors found that receptive language abilities varied considerably in the group, even though children had similar levels of functional limitations. Children with dyskinetic CP performed better than children with spastic CP. For the former group half of the children showed similar language scores as children with typical development; for the latter group no such pattern was found showing that language delay is much more likely with spastic type CP.

Based on these findings the authors conclude that receptive language abilities in dyskinetic CP can be good, and therefore expressive as well as receptive language ability should be tested. This will also help to make sure that the right communication aids are chosen for each child and their individual abilities.

Geytenbeek, J., Vermeulen, J., Becher, J. & Oostrom, K. (2015). Comprehension of spoken language in non-speaking children with severe cerebral palsy: an explorative study on associations with motor type and disabilities. Developmental Medicine & Child Neurology, 57, 294–300.

Communication Function Classification System: the Farsi version for children with CP

The Communication Function Classification System, or short CFCS, is one of the scales that can be used by health care professionals to classify everyday communication abilities of their clients. The original version was developed for use with people with CP, but is now also used to describe communication in people with any speech and language impairment or developmental disabilities.

The CFCS has 5 levels to describe a person’s communication performance. The ability to send and receive messages is rated, taking into account whether the conversation partner is familiar or not. Level 1 describes a person who is an effective sender and receiver, whereas Level 5 describes a person who is rarely successful in communicating effectively even with familiar partners. 

The CFCS has been translated into various languages by now, and a recent addition to this growing list is the Iranian version. The research team around Zahra Soleymani led the development of the Farsi version. 

In a first step, the original version was translated by two experienced translators. Their individual translations were merged, and together with a speech and language therapist a working version was created. This version was then discussed with parents and other health professionals. It was decided that the version would benefit from some changes as not all terms used were known to the people consulted. For this reason, the authors added an introduction defining the terms used as well as explaining the advantages and benefits of the tool. A third translator then back-translated the adapted version, and based on this a final version was developed. 

In a second step, inter-rater as well as test-retest reliability was tested. For this, professionals and parents were asked to use the tool to rate the communication performance of 152 children. Other professionals and parents were further asked to use the test again after 2 weeks. It was then checked how similar judgements were between raters or between time points. Results show that reliability was excellent, meaning that the CFCS is a tool that can be used by health professionals in Iran to better understand clients’ communication abilities.

Soleymani, Z., Joveini, G. & Baghestani, A. R. (2015). The Communication Function Classification System: Cultural Adaptation, Validity and Reliability of the Farsi Version for Patients With Cerebral Palsy. Pediatric Neurology, 52, 333-337.

Coordination of lip and jaw movements in children with CP

Does reduced movement of lip and jaw contribute to difficulties understanding some children with CP? According to Ignatius Nip from San Diego State University, yes. Nip explores the development of speech from a kinematic perspective - that is the study of motion - and in this case the movement of jaw and lips. In his latest publication, he investigated how coordination between lips and jaw affect speech production and intelligibility in children with CP. As part of this study, he also intended to find out whether the complexity of an articulatory movement - there is a difference between repeating sentences and repeating the same syllable - plays a role as well.

To answer these questions Nip invited 12 children with spastic CP and 12 typically-developing kids into his lab. Reflective markers were put on the children’s faces to capture the movements of upper lip and jaw, lower lip and jaw and upper, and lower lips when repeating syllables and sentences. Temporal and spatial movement were measured, that is the timing of the movements as well as how well the movements fit together.

The study found that the children with CP had difficulties coordinating the movements between upper and lower lips. This is likely to affect sounds that are produced using both lips such as [b]. The timing for moving upper lip and jaw was also affected. With regard to the complexity of the speech movements the results showed that the coordination of lips and jaw was more precise for the sentences than for the syllables. In addition, there was a clear relation between effective movement coordination and intelligibility. That is, the children who showed signs of dysarthria – reflected in their intelligibility scores – were less successful in coordinating their movements. Children with CP and dysarthria do seem to move their lips and jaw differently than their typically-developing peers. This difference in articulatory movement is measurable and there is a chance that information on articulatory performance can be used to help describe dysarthria problems in children with CP…provided relevant resources are in place...

Nip, I.S.B (2015). Interarticulator coordination in children with and without cerebral palsy. Developmental Neurorehabilitation. Early online, 1-13.