Cutting edge approaches for working with children with CP Katie Hustad, Ph.D., Rupal Patel, Ph.D., Ignatius Nip, Ph.D., Carol Boliek, Ph.D.
Overview of session Background on CP Speech and Language Profiles in children with CP Prosodic abilities in chidlren with CP Respiratory abilities in children with CP Articulation and oromotor control in children with CP Discussion
Cerebral Palsy First identified in 1860. Prevalence has been quite stable for many years Possibly increasing slightly with advances in medical treatment for infants and children. Current estimates 2-4 per 1000 live births
Definition of CP (Bax et al., 2005) Problems with development of movement and posture (motor control) Caused by disturbance or anomaly in early brain development Non-progressive in nature Problems with sensation, cognition, communication, perception, behavi or, and/or seizure disorder often co-occur
Speech and language in CP Many early studies in speech pathology focused on speech in CP Achilles, R. F. (1955). Communicative anomalies of individuals with cerebral palsy. Cerebral Palsy Review, 16(5), 15-24. Leith, W. R., & Steer, M. D. (1958). Comparison of judged speech characteristics of athetoids and spastics. Cerebral Palsy Review, 15-19. Rutherford, B. R. (1939). Frequency of articulation substitutions in children handicapped by cerebral palsy. Journal of Speech and Hearing Disorders, 4, 285-287. Wolfe, W. G. (1950). A comprehensive evaluation of fifty cases of cerebral palsy. Journal of Speech and Hearing Disorders, 15, 234-251.
Speech and language in CP Previous work: Emphasis on differentiation of speech features based on underlying motor pathology (i.e. athetoid vs. spastic) Perceptual features of speech in adults Some speech acoustic studies in adults Most all studies focused on those with only speech motor problems and normal cognitive abilities.
Cognitive abilities Intellectual disabilities 50% Learning disabilities 25% Normal 25% The co-occurrence and impact of cognitive or language deficits on speech production and speech development has never been studied in CP Cognitive involvement in CP TD LD ID
Communication abilities General communication problems (59%) The nature of specific problems is not well understood. Medical demographic studies use a broad definition of communication, so specifics are unknown Existing speech studies are very dated Little is known about language characteristics beyond case studies and small group studies.
In a nutshell Individuals with CP are extremely heterogeneous CP is really an umbrella term that alone tells very little except that the person has a developmental motor problem of some kind. One strategy to reduce the heterogeneity problem is to identify subgroups or clusters within the larger whole that have commonalities.
Identifying subgroups of children with different communication profiles will allow the potential for: prediction of outcomes changing outcomes Development of interventions tailored to different communication profile groups Improved quality of life
Aims of ongoing work Aim 1. Establish subgroups of children with CP on the basis of cross sectional communication (speech, language, and cognition) profiles. Aim 2. Quantify developmental changes in speech, language, and cognitive abilities and determine the stability of communication subgroup membership over time in children with CP. Aim 3. Identify the extent to which gross and fine motor classifications are associated with communication subgroup membership.
Ongoing longitudinal project Participants 110 children with a medical dx of cerebral palsy Under 60 months of age at enrollment Have hearing that is normal Seen for longitudinal visits at 6 month intervals to the age of 8 years; seen at 12 month intervals thereafter
Ongoing longitudinal project Data collection from children Speech production Language Multimodal communication Parent questionnaires Supporting documentation IEP, IFSP Medical reports
Data reduction Speech acoustics Intelligibility Standardized language scores Systematic Analysis of Language Transcripts Behavior coding
No clinical speech-motor involvement Age appropriate Language / Cognition Impaired Language / Cognition NSMI- LCT NSMI- LCI Children with CP Able to produce speech (speech-motor disorder) Mild speech-motor impairment Age appropriate Language / Cognition Impaired Language / Cognition Age appropriate Language / Cognition SMI-MILD- LCT SMI-MILD- LCI SMI-M/S- LCT Speech-motor involvement Moderate-severe speech-motor impairment Impaired Language / Cognition SMI-M/S- LCI Unable to produce speech (anarthria) Age appropriate Language / Cognition Impaired Language / Cognition ANAR-LCT ANAR-LCI
No clinical speech-motor involvement Age appropriate Language Impaired Language Group NSMI Children with CP Able to produce speech (speech-motor disorder) Mild Speech-motor impairment Moderate / severe Speech-motor impairment Age appropriate Language Impaired Language Group SMI-LCT Group SMI-LCI Speech-motor involvement Unable to produce speech (anarthria) Age appropriate Language Impaired Language Group ANAR
Speech and language profiles in children with CP (Hustad, Gorton, & Lee, 2010) Speech rate and vowel space made the greatest statistical contribution to differentiation among groups (93% of the variance). Language abilities accounted for only 5.6% of the variance among groups. Speech intelligibility accounted for only 1.4% of the variance and was not statistically significant.
Speech and language profiles Statistical classification accuracy into hypothesized groups varied between 79% and 97%. Inter-rater reliability of human classification was 94%.
Speech rate Speech Rate in syllables per minute 225 200 175 150 125 100 75 50 25 0 NSMI SMI-LCT SMI-LCI Profile Group
Vowel space 1200000 Vowel Space Area 1000000 800000 600000 400000 200000 0 NSMI SMI-LCT SMI-LCI Profile Group
Language Comprehension Language Comprehension Score 120 100 80 60 40 20 0 NSMI SMI-LCT SMI-LCI ANAR Profile Group
Intelligibility Ratings 7 Speech Intelligibility Rating 6 5 4 3 2 1 NSMI SMI-LCT SMI-LCI ANAR Profile Group
Speech & Language Profile Groups No Speech Motor Involvement N = 8 24% Speech motor Involvement Language typical N = 9 26% Speech motor Involvement Language delay N = 6 18% Speech motor Involvement Unable to speak N = 11 32%
2-3 year old children with CP: Preliminary findings 51 children with CP between 30-35 months Only 19 (37%) of these children were able to produce single words in imitation A typically developing comparison group had intelligibility of 58% (range 23 70%) Of the children with CP who could talk, intelligibility was 22% (range = 0 45%) 8 children with CP (16% of total sample) had intelligibility scores within the range observed for typical children. Vowel spaces smaller for children with CP Artic rate slower for children with CP By 54 months of age approximately 75% of children can repeat words in imitation (with varied intelligibility)
Take home points We need more research focused on communication development in children with CP We should consider language and cognitive factors in interreting findings related to speech production