Is there a link between communication and motor skills in 2 year-olds with CP?

This is the question Andrea Coleman and colleagues posed, and explored, in a recent study published in Archives of Physical Medicine and Rehabilitation. Whilst this is not the first time that this link is the focus of an investigation, Coleman and colleagues add a new dimension: Assessing very young children and using a standardised language assessment.

Their main aim was to explore the communication skills of 24-months old children with CP to identify those who might benefit from early intervention. At the same time, they were interested in exploring the relationship to general motor skills as well as risk factors for communication problems.

124 two-year old children with CP living in Australia were recruited to the study over a period of 4.5 years. Parents were asked to fill in a questionnaire about their children’s communicative development. This infant toddler checklist covered aspects of social communication such as gestures and gaze, expressive language as well as symbolic play. Two physiotherapists judged the children’s motor skills, and medical notes were consulted to obtain further information on children’s health.

Findings showed that 15% of the children did not yet use words or gesture to communicate; a further 10% employed gestures only. Another 23% used single words and 52% used two word combinations. The study also revealed that - based on the assessment - 62% of children were found to have communication problems that would meet the criteria for further, more extensive language assessment. This percentage is in stark contrast to the reported norms for typically developing children (20%) who were assessed using the same checklist. The authors conclude that children with CP do have higher communication needs than their typically developing peers, and would benefit from an early communication screening.

With regard to the question posed above, Coleman and colleagues found that communication problems were strongly associated with motor skills: Children with more severe motor problems were more likely to have delayed communication development, whereas children with mild motor impairment were less likely to have problems with verbal communication. At the same time, the authors found that poorer communication was more likely in children who were either born full-term or suffered from seizures. Overall, the study highlights the need to monitor language development in children with CP from an early age to identify those who will benefit from intervention...This, though, poses another series of questions: Where are we in terms of intervention? Where do we want to go, and how are we going to get there???

Coleman, A., Weir, K. A., Ware, R. S. & Boyd, R. N. (2013). Relationship between Communication Skills and Gross Motor Function in Preschool-Aged Children With Cerebral Palsy. Archives of Physical Medicine and Rehabilitation, 94, 2210-2217.

Viking Speech Scale

In my previous blog I have introduced a classification system for young children with CP that was developed to estimate their speech and language development over time. This blog presents another attempt at classifying speech performance in children with CP: The Viking Speech Scale (VSS).

The VSS was developed by an international team around Lindsay Pennington for use in CP surveillance registers to complement information on gross motor performance and manual abilities. Information on speech would help clinicians and researchers to obtain a clearer picture of presence and severity of motor problems that affect communication.

The VSS is intends to be a global measure of speech that captures how speech is produced in daily life. A combination of perceptual characteristics and intelligibility was used as a basis for the scale which comprises 4 levels:

   1. Speech is not affected by motor disorder

   2. Speech is imprecise but understandable to unfamiliar listeners out of context. Loudness
       is adequate; voice may be breathy and harsh; articulation is imprecise but difficulties do
       not affect intelligibility.

   3. Speech is unclear and not usually understandable out of context. Speech can be too loud
       or too quiet; speech can be hypernasal; voice may be harsh; breath control is difficult;
       pitch may change suddenly; only a small range of consonants can be produced.

   4. No understandable speech

The scale was tested using speech samples of 139 children with CP. Their speech was rated by parents and a range of health professionals including speech and language therapists through direct observation or case notes. Feedback was positive and the scale considered being a helpful tool to summarise speech performance of children with CP for clinical reports and research.

Speech and language skills in 4-year old with CP

In my last blog I outlined the results of a study that assessed speech and language performances in 2-year old children with CP. Today’s blog is a continuation of this theme – looking at the speech and language abilities of 4-year olds with CP to find out whether their performances can be classified into groups as well. According to Katherine Hustad, Kristin Gorton and Jimin Lee - the authors of the paper - longitudinal results will help to predict outcomes, and change those outcomes through intervention.

The speech and language classification system employed in the study was developed using existing knowledge as to the nature of CP. Four groups were identified:

1. Children without speech and language problems

2. Children with speech problems, but intact language abilities

3. Children with speech problems and language problems

4. Children who are unable to produce functional speech

Speech and language data from 34 children with CP were collected. The authors measured vowel space, speech rate and language comprehension. They also asked parents to rate the intelligibility of their child’s speech. They then employed statistical procedures to see whether the children’s performances would align with the groups suggested above.

Findings show that children were assigned to the groups mainly based on the results of the speech measures - i.e. speech rate and vowel space. Specifically, it was found that children with speech impairment had a slower speech rate and a smaller vowel space than children without speech problems. Of the two measures speech rate was found to be the stronger indicator for group membership. This makes sense as speech rate performance reflects the integration of all four subsystems (breathing, phonation, velo-pharyngeal function and articulation), whereas vowel space primarily relates to articulation. Language comprehension scores and intelligibility ratings were found to be less predictive of group membership. These findings suggest that speech abilities are the primary determinant for communication profiles in children with CP.

Speech and language skills in 2-year-olds with CP

Children with cerebral palsy are more likely to develop speech and language problems than their peers. In an effort to identify those who may benefit from speech and language therapy to boost communication abilities from an early age, Katherine Hustad and colleagues examined the speech and language skills of 27 toddlers with CP aged 24 to 30 months. The aim of their study was to find out whether children as young as two could be classified into groups on the basis of their speech and language skills.

 

The children’s skills were examined based on parent-child-interaction, parental questionnaires and a language comprehension test. In particular, the authors looked at receptive and expressive skills - reflected in e.g. number of words produced and average length of utterances.

Three groups could be identified:

1.Children who were not yet talking (44%). Children in this group had an active vocabulary of  about three words and primarily used vocalisations to communicate.

2.Children who were emerging talkers (41%). Children in this group used on average 40 words and had begun to combine words.

3.Children who were established talkers (15%). Children in this group showed speech and language skills in line with age expectations.

Group membership was primarily determined by the children’s vocabulary size and ability to combine words. By contrast, receptive abilities did not turn out to be a good indicator for speech and language development as results varied considerably across groups. The study also found that the children’s speech and language abilities were not related to gross motor function. This is important and shows that no conclusion regarding communication skills should be drawn on the basis of gross motor abilities. Overall, the study shows that speech and language delays in children with cerebral palsy can be identified by 2 years of age.

 

Hustad, K., Allison, K., McFadd, E. & A. Riehle, K. (2013). Speech and language development in 2-year-old children with cerebral palsy. Developmental Neurorehabilitation, Early Online.

Can visual feedback help to improve articulation disorders that are resistant to conventional speech therapy?

Speech and language therapy usually relies on auditory feedback (listening to the sounds, words and sentences client and therapist produce) to change speech patterns. A team of Swedish researchers around Ann Nordberg wanted to find out whether visual feedback could help children with CP and dysarthria to change articulation patterns that were resistant to conventional therapy.

The visual feedback technique they used is called electropalatography (EPG). EPG allows to record when and where the tongue makes contact with the roof of the mouth, the hard palate, during speech. An artificial palate with electrodes - which looks a bit like a dental brace - records the tongue movements. That means the client gets direct feedback where the tongue is and can try and change its position to produce a sound that is closer to the desired sound. Using EPG the authors examined how children with CP produce dental and alveolar targets sounds (t, d, n and s) in different positions in single words before and after therapy.

Five children (mean age 9.4 years) with CP and mild or severe dysarthria took part in the study. The majority of them practiced at home for 15 minutes a day for 5 days a week over a period of 8 weeks. Weekly EPG exercises included the production of target sounds in syllables, words and short sentences. Speech materials to monitor progress consisted of 70 pictures from a Swedish Articulation Test.

A detailed analysis of the EPG patterns revealed that before therapy the children had unusual articulation patterns such as producing sounds far back in the mouth (retracted articulation). After therapy, EPG analysis and perceptual evaluation revealed that the tongue made more precise contact in dental and alveolar positions leading to an improvement in articulation. This improvement was observed for sounds in word-initial and -medial positions but not in word-final positions. Overall, the authors conclude that EPG can be valuable for the description of articulation patterns in CP and to document changes after speech therapy. Due to the instrumental nature of the intervention EPG may not be readily available everywhere as a therapy approach, but seems worthwhile pursuing for children who have not responded to conventional articulation therapy.


Nordberg, A., Carlsson, G. & Lohmander, A. (2011). Electropalatography in the description and treatment of speech disorders in five children with cerebral palsy. Clinical Linguistics & Phonetics, 25(10), 831-852

LSVT Loud versus systems approach

As indicated in earlier blogs there is a desperate need for intervention research in developmental dysarthria to find out which interventions lead to meaningful changes in speech, and if so why.

Hot off the press is an article by Erika Levy and colleagues that compares the effects of two interventions:  LSVT Loud and speech subsystems approach (what they termed traditional approach). Levy and colleagues recruited three girls with spastic type CP (aged 3-9 years) with mild to moderate dysarthria. The allocation to intervention was somewhat arbitrary with those girls who could commit to therapy 4 days a week getting LSVT Loud, whereas one girl received therapy following the traditional approach twice a week. LSVT focused on increasing loudness; the traditional approach targeted posture, speech clarity and breath control.

Changes - measured by means of caregiver questionnaires, articulation tests and listener perception tests of single words and spontaneous speech – were positive: caregivers reported a positive impact of therapy on speech, articulation tests showed greater articulatory precision, and listeners preferred the post-therapy speech samples. Interestingly, LSVT seemed to increase speech function and loudness, whereas the traditional approach resulted in better speech but had no effect on loudness.

Although overall results suggest an improvement in speech function, individual performances show a highly variable picture. For instance, in terms of loudness one girl undergoing LSVT treatment improved at word level, whereas the other one showed improvements in spontaneous speech. This is not the only reason why the results of the study should be interpreted carefully:

• The interventions were administered by different therapists/students
• It is unclear whether the frequency of intervention had an effect
• The allocation to intervention was arbitrary
• Relation of the findings to intelligibility were not examined
• Results were not tested for statistical significance

The study is a step into the right direction, and raises one important issue: How can we predict which intervention approach is the best for a particular child?

Levy, E. S., Ramig, L. O. & Camarata, S. (2012) The Effects of Two Speech Interventions on Speech Function in Pediatric Dysarthria. Journal of Medical Speech-Language Pathology, 20(4), 82-87.

treatment effectiveness

Although a number of articles describing treatment approaches for developmental dysarthria were published over the years, to date only few studies were conducted to test whether dysarthria intervention in children with CP is actually effective.

A series of therapy studies conducted by Lindsay Pennington’s research group in Newcastle addressed this research gap. Pennington, Smallman and Farrier (2006) started off with a small scale intervention study in which six children with CP received individual dysarthria therapy targeting breath support and volume across utterances. Improvement was measured by means of intelligibility of single words and connected speech. Four of the six children were more intelligible directly after therapy, although improvement was only maintained in one speaker seven weeks later.

This study was followed by a more extensive investigation in 2010. Pennington and colleagues wanted to find out whether a systems approach targeting breath support, phonation and speech rate can increase the speech intelligibility of older children with CP. Sixteen children with moderate to severe dysarthria aged 12 to 18 years attended three therapy sessions per week over a period of six weeks. As in the previous study, improvement was measured in terms of intelligibility in single words and connected speech across four time points (6 and 1 week pre-therapy, and 1 and 6 weeks post-therapy). The intervention was found to increase speech intelligibility for familiar and unfamiliar listeners for both measures. Importantly, changes were maintained after 6 weeks, indicating acquisition of stable motor patterns.

A recent study by the same lead author examined intensive dysarthria therapy for younger children with CP. Just as the previous study, the intervention targeted breath support, phonation and speech rate. Fifteen children were recruited aged 5 to 11 years. The therapy success was measured in terms of intelligibility and participation in conversational interactions across five points: 6 and 1 week pre-therapy and 1, 6 and 12 weeks post-therapy. Overall, gains in intelligibility and participation in interaction were observed, although scores in the latter did not correlate with changes in the former. This finding shows that some children interacted more following therapy - perhaps due to increased confidence - irrespective of how much their speech intelligibility improved.

Pennington, L., Smallman, C., & Farrier, F. (2006). Intensive dysarthria therapy for older children with cerebral palsy: Findings from six cases. Child Language Teaching & Therapy, 22, 255–273.

Pennington, L., Miller, N., Robson, S. & Steen, N. (2010). Intensive speech and language therapy for older children with cerebral palsy: a systems approach. Developmental Medicine & Child Neurology, 52, 337–344.

Pennington, L., Roelant, E., Thompson, V., Robson, S., Steen, N. & Miller, N. (2013). Intensive dysarthria therapy for younger children with cerebral palsy. Developmental Medicine & Child Neurology, 55, 464–71.

LSVT LOUD

LSVT LOUD (Lee Silverman Voice Treatment) is a treatment approach that was originally developed for people with Parkinson’s disease to raise their voice and be heard more clearly. Cynthia Fox and Carol Boliek took this intensive voice treatment approach as a starting point to work on the breathing and phonation patterns in children with CP. Improving breathing for speech is important as is lays the foundation to work on other speech subsystems such as articulation.

Four children with dysarthria due to spastic CP were recruited for the therapy study. The children had 16 therapy sessions overall (4 sessions a week for 4 consecutive days), and were given exercises to practice at home. Improvement in vocal functioning was measured using a combination of perceptual evaluation and acoustic measures. Seven speech and language therapists were asked to listen to speech samples recorded prior to therapy, directly after therapy and six weeks after the end of the treatment, and to judge which one they preferred.

Results were somewhat mixed. Although the therapists judged that the speech of the children - for features such as loudness and voice quality - improved directly after the intensive treatment, the improvement could not be maintained. In addition, acoustic measures taken prior to and after therapy did not suggest significant improvement in the children’s voices.
 

At the same time though, parents reported that after the treatment their children spoke with less effort and their voices sounded less strangled. This raises the question whether the perceptual and acoustic measures employed in this study were simply not suited to capture the actual improvements in the children’s voices. This observation leaves us with two questions: 1.) How can we best measure decreased effort? And 2.) What exactly is the basis of listener perception?

 

Any ideas?

Fox, C. M. & Boliek, C. A. (2012). Intensive Voice Treatment (LSVT LOUD) for Children with Spastic Cerebral Palsy and dysarthria. Journal of Speech, Language, and Hearing Research, 55, 930-945.

PROMPT

Improving intelligibility is the common goal of most intervention studies in dysarthria. Therapy approaches differ, though, regarding how to achieve this improvement. While it is well-known that modification to breathing can lead to gains in intelligibility, the benefit of improving timing and coordination of oro-facial movements during speech is underresearched, according to a team of researchers in Australia. Roslyn Ward and colleagues therefore intended to examine the effectiveness of a motor-speech intervention programme to improve intelligibility in CP. They did this by evaluating changes of lips and jaw movements in six children with moderate to severe dysarthria due to CP before, during and after participation in PROMPT.

PROMPT stands for Prompts for Restructuring Oral-Muscular Phonetic Targets. It is a specifically designed treatment approach that employs tactile-kinaesthetic-proprioceptive (...that is our sense of position) information to jaw, lips and tongue to guide the child’s speech movements.

Children participated in two blocks of intervention, each lasting 10 weeks (one 45-minute session per week). For each child a specific protocol was designed which identified intervention priorities for each child in terms of jaw, lip or lingual control. Speech intelligibility and kinematic movements were assessed prior to intervention, after each intervention block and 8 weeks after the end of the intervention. Findings were compared to the speech of 12 typically developing peers.

Results were promising as they showed significant changes in jaw and lip movements for all children with CP. For instance, they showed improvements in jaw stability as well as a decrease in lip rounding, rendering their movements after intervention more similar to those of their peers. These changes in kinematic control were accompanied by considerable gains in intelligibility for all children. Most importantly, the changes in intelligibility were maintained 8 weeks post-treatment.

Despite the successful intervention, it is important to highlight that other approaches that do not provide sensory information such as the LSVT® (Lee Silverman Voice Treatment) to name but one have also improved jaw movements in children with CP. This implies that the exact contribution of the tactile input remains somewhat unclear and further research is needed to find out which patients might benefit most from the motor based approach. It should also be considered that the children’s age ranged from 3 to 11, i.e. they were at different stages in their speech acquisition process.

 

Ward, R., Strauss, G. & Leitão, S. (2013). Kinematic changes in jaw and lip control of children with cerebral palsy following participation in a motor-speech (PROMPT) intervention. International Journal of Speech-Language Pathology, 15(2), 136-155.

Cerebral palsy and communication – Setting the scene

I thought it would be best to briefly outline the communication disorders that are common in children with CP before diving straight into the latest research work. Lindsay Pennington provides a great overview in her 2008 paper (Paediatrics and Child Health). In my explanations, I mainly refer to her paper.

Communication difficulties are frequently associated with CP: It is estimated that about 50% of children with CP have some form of communication disorder. In most children speech is affected, but language and more general aspects of communication can be compromised as well. Due to the oro-motor problems, feeding difficulties, swallowing problems and drooling are common, too.

The most frequent speech impairment observed in CP is developmental dysarthria. Arising from the motor impairment, it can reduce the functioning and control of the different components required to produce speech i.e. respiration, phonation, nasality and articulation. Depending on the component(s) affected, children’s breathing may be shallow and irregular, and their voice may sound harsh. In addition, the speech sounds they produce may be poorly articulated. Speech problems are associated with all types of CP, but difficulties are more likely to be seen in children with dyskinetic (involuntary movements) than spastic (hypertonic, i.e. stiff muscles) types of CP.

Speech disorders can impact on children’s ability to produce spoken language. Depending on the severity, children may only use vocalisations, produce one word utterances, or very short phrases. This may restrict the range of grammatical structures they can use. Furthermore, delayed language development can derive from the cognitive issues associated with CP, but also be the result of limited interaction with the children’s environment.

In addition to the production of speech, nonverbal communication including facial expression, gestures and body movements may be affected as well. Children with CP often exhibit a delayed development of pragmatic skills and functional aspects of communication. Research suggests that this may be partly due to the fact that conversation with familiar partners follows restricted patterns, showing high levels of partner control. As a result, children with CP are often passive communicators; i.e. they initiate less interaction, they are less responsive and less independent communicators.

Early intervention therefore often targets situations in which the children are required to initiate communication.

…More about intervention approaches will follow here soon…watch this space…

Reference: Pennington, L. (2008). Cerebral palsy and communication. Paediatrics and Child Health 18(9), 405-409.