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.

Activity and participation in children with CP

Research has shown that children with CP and speech problems can find it harder to engage with others in social situations than children with CP who do not have any speech difficulties. Cristina Mei and colleagues from Australia built on these findings trying to find out how speech problems can affect children’s day-to-day interactions in different communication settings such as home, school and community. 

Seventy-nine 5- to 6-year olds from Victoria, Australia, took part in the study. A range of scales were used by the first author to collect information on the presence of speech problems, and the severity of speech problems reflected in level of intelligibility and functional communication, i.e. how well children get their messages across: 

1. Viking Speech Scale (VSS) to judge presence of speech problems 
2. National Technical Institute for the Deaf (NTID) rating scale to rate intelligibility (using connected speech obtained during free-play between parent and child
3.  Functional Communication Classification System (FCCS) and Communication Function Classification System (CFCS) to measure functional communication

In addition, parents were asked to rate on a 1 to 10 point scale whether their children find it easy or difficult to participate in activities within home, school and community settings because of their ability to communicate.

Results revealed that 90% of children did show some speech problems. This is a high number compared to other studies, which found that between 30 to 70% of children with CP have some form of communication problem. The authors think that maybe only those parents who were concerned about their children’s speech were interested in participating. The analysis of the intelligibility scores also showed that over half of the children were highly intelligible. The authors also found that about 60% of children were good at getting their messages across. In addition, a clear link between speech skills and activity and participation was found with children with mild speech problems being more successful communicators in social situations than children with severe speech problems.

The study also revealed that participation was easiest in familiar environments such as home, and more difficult in school and community, although this was influenced by the severity of the speech problems. The good news is that children with mild problems were equally successful in participating in social interactions than children without speech problems. This means that mild speech problems did not have any negative effects on communication – at least for the children in this study. It can therefore be reasonably concluded that intervention to increase social participation is likely to be more important for children with moderate to severe speech problems.

Mei, C., Reilly, S., Reddihough, D., Mensah, F. & Morgan, A. (2014). Motor speech impairment, activity and participation in children with cerebral palsy. International Journal of Speech-Language Pathology, 16(4), 427-435.

Production of consonants in school-aged children with CP

Detailed descriptions of speech features in children with CP are a prerequisite for providing suitable interventions for children with speech impairments. However, as Ann Nordberg and colleagues point out in their most recent article: thorough descriptions of speech impairment in children with CP are rare - and even non-existent for those with ataxic dysarthria. The aim of their study was therefore to investigate the production of consonants produced by 19 school-aged Swedish-speaking children with CP in order to fill some of the blank spaces.

The children participating in the study were about 11 years old, and - according to medical records -had some form of speech impairment. In addition, 9 of the 19 children were known to have cognitive problems. The children were asked to name 59 pictures of the Swedish Articulation and Nasality Test (SVANTE), which covers the whole range of Swedish oral consonants prone to articulation deficits. Two speech and language therapists then phonetically analysed the consonants to obtain the percentage of correctly articulated consonants, and describe the error patterns. They also rated the severity of the speech impairment, whether the children sounded nasal and whether anything about their breathing, voice quality and prosody was noticeable.

Results showed that more than 50% of the children had severe difficulties with articulation resulting in a mean score of correct consonants that was well below that of typically developing children. The authors also found that children with spastic and dyskinetic dysarthria did better than the kids with ataxic dysarthria. Voicing errors were the most frequent type of errors followed by substitutions and omissions, which might be a result of poorly controlled phonation.

The authors further found that most of the children had mild dysarthria, and nasality – as opposed to previous reports – was not a common feature of the children’s speech. However, 13 children had problems related to breathing including having low energy, being breathless and not having enough air for speech production. The same number of children was also found to have unusual voice features such as high pitch levels, harsh voice and creaky voice. A further 6 of the 19 children were described as having deviant prosodic speech characteristics such as monotonous speech. The authors conclude that these features are equally important for the perception of dysarthria as the articulation deficit, and listeners may rely on the whole range of speech changes when making judgements about the presence and severity of dysarthria.


Nordberg, A., Miniscalco, C. & Lohmander, A. (2014). Consonant production and overall speech characteristics in school-aged children with cerebral palsy and speech impairment. International Journal of Speech-Language Pathology, 16(4), 386-395.

Ways to advance speech treatment research in developmental dysarthria

We all are aware that speech treatment in developmental motor speech disorders is an under-researched area. We also know how important it is to find out whether current treatments help children to communicate more successfully. However, one of the main challenges we are facing is the lack of detailed information on how the few treatment studies that were conducted were designed and carried out. This lack does not just affect research by making it more difficult to repeat treatments to confirm its success for other speakers. It also means that speech and language therapists, who want to apply the approaches described in the literature, have very little information that could assist them in understanding what made those approaches successful.

This issue was the starting point for Erika Levy’s most recent article published in the International Journal of Speech-Language Pathology. Unlike most articles, which usually focus on outcome and improvements in speech, it details how speech treatments were carried out in the Speech Production and Perception Lab at Teachers College, Columbia University. In her article, Levy focuses on two approaches that were successfully used in the past to improve speech function in children with CP and dysarthria:

-Speech Systems Approach

-Lee Silverman Voice Treatment

Both approaches featured in previous blog entries. The former aims at improving the functioning, coordination and control of breathing, phonation and articulation, whereas the latter focuses on producing loud and clear speech. For both approaches Levy describes treatment protocols which include specific information on preparation and progression of treatment sessions, session structure, the tasks that were used, and how children can be motivated to do these tasks repeatedly.

The article also describes how best to record speech, and how these speech samples could be used for acoustic analyses. It further refers to a range of games and apps that could be used to keep children engaged in the therapy process as well as provide feedback on their performance.

By providing treatment specifics and strategies Levy intends to reduce some barriers that exist when it comes to researching speech treatment in developmental dysarthria. I do hope that this article will trigger further clinical research with the ultimate aim of designing treatments that will help children to be successful communicators.

Levy, E. S. (2014). Implementing two treatment approaches to childhood dysarthria. International Journal of Speech-Language Pathology, Early Online, 1–11. 

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.

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.

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.