How are speech and language therapists (SLTs) managing the communication needs of young people with CP: Findings from a recent UK survey

Speech and language therapy for children with CP aims to support the development of effective communication skills. Many clinicians will agree that reducing the speech impairment and improving speech intelligibility will support the child to be part of family, school and community life. However, there is likely to be less consensus regarding how this can be achieved. Rose Watson and Lindsay Pennington think that practices may vary due to differences in health and social care resources as well as uncertainty about which intervention is indeed effective. 

To explore this, they conducted a UK wide online survey asking SLTs about their assessment and intervention practices for communication problems in children and young people with CP, i.e. which problems are commonly addressed, which areas are assessed and how, and which areas are treated and how. The survey was advertised via NHS and RCSLT channels as well as associated social media. Over the course of two months about 300 SLTs replied, of which 265 responses were analysed.

Assessment practices

The responses showed that a wide range of published standardised tests is used to assess including oro-motor function, receptive and expressive language and speech. This shows that children’s communication skills are thoroughly assessed. SLTs also made an effort to individualise assessments where needed. For example, they enlarged pictures or cut them up for children with sensory and/or motor problems. On the other hand, the survey found that non-standardised tests were used as well, which means results cannot be compared to norms. Also, communication skills were sometimes assessed by observation only, which can underestimate children’s abilities.

Intervention practices

Swallowing and receptive language skills were listed by SLTs as the main areas of intervention. Assisted communication, also referred to as AAC, was another intervention priority for them to achieve the aim of communication participation. Again, SLTs used a number of intervention techniques, which is not surprising given the wide and varied range of communication difficulties in children with CP. However, the authors also noted that some of the techniques used are not supported by the literature. This means that in previous studies these techniques were not found to improve communication much.

Overall, the findings show that there is indeed a wide variation in the assessment and intervention of communication difficulties in children with CP. This variation makes it difficult to compare practices across different services. The authors conclude that a set of agreed clinical measures would be a good starting point to inform service development and identify research priorities to move evidence-based practice forward.

Watson, R. M. & Pennington, L. (2015). Assessment and management of the communication difficulties of children with cerebral palsy: a UK survey of SLT practice. International Journal of Language and Communication Disorders, 50(2), 241-259.

Does speech therapy change voice quality in children with CP?

Speech therapy focusing on aspects such as breath control and speech tempo has shown to improve voice quality and articulation. These changes can boost intelligibility, i.e. how well speakers are understood by listeners. Nick Miller and colleagues therefore expected that work on breathing should help improve intelligibility. Whether this is indeed the case was tested in a study published in 2013. Specifically, the authors explored whether perceived voice quality is altered following a speech therapy focusing on respiration and phonation.

 

The study used single word and connected speech data of 16 children with CP (mean age was 14) collected before and after a six-week block of speech therapy. 16 SLTs took part in the perception study. They were asked to rate the voice quality of the speech files using the GRBAS scale. This is an evaluation scale that perceptually rates the voice quality for 5 parameters:  

     

 - Grade (degree of voice abnormality)
 - Roughness (steadiness of vocal cord function)

 -  Breathiness (extend of air leakage)

 -  Asthenia (weakness)

 -  Strain (tension)

Each parameter is assigned a value on a 4-point scale, where 0 is normal and 3 is severe. The SLTs were specialists in voice problems and knew how to use the scale. They rated the speech files assigned to them without knowing whether it was a recording made before or after therapy.

Findings showed that the children with CP had voice problems - before and after therapy. They also showed that the perceived changes in voice quality were small, which means that the children’s voice did not change much as a result of the therapy. This in turn means that voice changes were not the reason for the improvements seen for intelligibility. And indeed, only asthenia, i.e. weakness of the voice, was found to have some importance for intelligibility. Overall, other aspects such as tempo and speech melody will need exploring to explain the improvements in intelligibility observed after therapy.

Miller, N., Pennington, L., Robson, S., Roelant, E., Steen, N., Lombardo, E. (2013). Changes in Voice Quality after Speech-Language Therapy Intervention in Older Children with Cerebral Palsy, Folia Phoniatrica et Logopaedica, 65(4), 200-207.

Therapy outcome measures for children with dysarthria

A recent discussion with a parent and a speech and language therapist about how best to measure whether therapy has had an effect made me choose this article for this month’s blog post. 

I am not telling you anything new when I say that speech therapy can have a positive impact on a person’s communication and wellbeing. However, services are under increasing pressure to prove that their therapies are effective – from a clinical as well as cost-effective point of view. According to Pamela Enderby, one of the leading researchers on speech and language therapy and health interventions in the UK, outcome measures are important for evaluating and improving clinical services as they can measure communication changes in individuals, but also allow for comparison across services.  

Outcomes measures try to establish whether an individual has benefitted from therapy. There are several reasons why this is this difficult to find out for an area such speech and language therapy: 1) there are a wide range of therapy options for a child with dysarthria depending on the communication problem; 2) it is one thing to measure improvement in speech e.g. intelligibility, but how do you measure wellbeing, improved coping skills or increased confidence, which can all contribute to improved communication?

According to Enderby, Therapy Outcomes Measures or TOM (Enderby et al., 2006) can capture these more holistic aspects of therapy. TOM allows clinicians to describe the abilities of a child for impairment, communication activity, participation and wellbeing before and after therapy. The four features are rated on an 11 point scale (0 – severe to 5 – normal for age and sex) using the usual assessment procedures. I see TOMs strengths in the fact that they are a set of scales which are based on the International Classification of Functioning, Disability and Health framework (WHO). It is a quick tool that has proved reliable for a range studies, and can be applied irrespective of the various assessment procedures that exist in services. 

On the other hand, I think that in some cases a qualitative analysis of the data would be helpful to better understand results. For instance, no change in the rating could be considered a positive outcome in cases where the dysarthria is due to progressive disorders. Also, training may be needed to ensure consistency in the use of the scale. Being a member of review panels, I know how differently the same work can be viewed, with some judges, for instance, never exhausting the full scoring range available to them. After all, judging is the act or process of forming an opinion or making a decision after careful thought, i.e. it has a subjective element to it. This, however, should not stop us in our endeavour to improve the quality of the services we offer.

Enderby, P. (2014). Use of extended therapy outcome measure for children with dysarthria. International Journal of Speech-Language Pathology, 16(4), 436-444.

How does communication and social interaction develop in school-aged children with CP over time?

This was the central question Petra van Schie and colleagues addressed in their article published in Research in Developmental Disabilities. According to the authors communication becomes more important as children grow older, and they were keen to find out how cerebral palsy affects the development of communication and social interaction.

Over a period of 3 years, van Schie and colleagues monitored the development of 108 children with CP in the Netherlands. The children joined the study when they were about 6 years of age. Information on their communication was collected each year through an extensive parental questionnaire (the Vineland Adaptive Behaviour Scales).

Findings showed that more than half of the children (58%) had problems with communication and social interaction because of CP. This was particularly true for those children with a history of epilepsy, and – not surprisingly - speech problems. The results also showed that children who could not walk had greater problems with social interaction than those children who could walk or had walking aids. This shows that there is a link between motor abilities and communication, which mirrors findings from previous studies discussed here in this blog. However, even children in the latter group, i.e. who could walk, were not always successfully interacting with others. The authors thus conclude that a wide range of children with CP would benefit from intervention to support communication and social development.

This study highlights again how important intervention is to support communication development in children with CP…and how desperately needed intervention and intervention studies are to monitor progress…

Reference: van Schie et al. (2013). Development of social functioning and communication in school-aged (5-9) years children with cerebral palsy. Research in Developmental Disabilities, 34, 4485-4494.

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.

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.

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.