Cerebral Palsy is caused by damage to the motor systems
of the brain affecting the child’s ability to perform basic functions such as swallowing and speaking. The word cerebral
refers to the brain and palsy refers to a movement disorder. Damage occurs before, during or shortly after birth. When CP
occurs before or during birth, it is called congenital. When it occurs after birth it is called acquired. Body movement and
muscle coordination is affected. Problems do not occur with the nerves or muscles but occur in the brain’s ability to
control movement and posture adequately by sending the wrong messages to the muscles. CP results in poor coordination, poor
balance, abnormal movement patterns or a combination of these. It is not a communicable disease, inherited or the primary
cause of death. The prevalence of CP is 1.4% to 2.7% of live births.
The cause of congenital Cerebral Palsy, in most cases,
is unknown. Some of the factors that may cause its’ development include: infections during pregnancy (rubella, cytomegalovirus,
toxoplasmosis), jaundice, severe oxygen shortage in the brain, trauma caused by a difficult birth, Rh factor, bleeding in
the brain and low birth weight. Children born with a low birth weight of less than 3 pounds 3 ounces account for at least
half of the reported cases of CP. Also, multiple births account for a greater incidence as compared with single births. Other
causes include asphyxia during labor and delivery and toxicity.
Several risk factors concerning the mother are identified
as being a risk factor for the development of prenatal CP. These factors include: thyroid disorder, previous miscarriage,
mental retardation, bleeding in the third trimester, high blood pressure, seizure disorder and alcohol or drug abuse. Other
causes include genetic or chromosome abnormalities, exposure to radiation, infections, congenital malformations, and kidney
and urinary tract infections in the mother that can lead to brain damage in the fetus.
Perinatal causes include severe brain hemorrhage resulting
in neurological damage. Also, insufficient oxygen and blood flow during birth which could be the result of aspirating the
first bowel movement during labor and delivery or having the umbilical cord wrapped around the neck. A child who does not
cry in the first five minutes of delivery or who has been on a ventilator for over 4 weeks may be at risk. During delivery
of a full term baby, damage to the brain would result in damage to the basal ganglia resulting in uncoordinated and uncontrolled
muscle movements. Also, untreated low blood sugar in the newborn can cause brain damage that leads to CP.
A small percentage of babies (10-20% of reported cases)
develop CP after birth. Acquired CP can result from brain infections such as meningitis or encephalitis, lack of oxygen to
the brain or brain trauma from a car accident, fall, or child abuse.
Cerebral Palsy can be classified in two ways: by site of
lesion and by identification of the affected extremities. When classifying by site of lesion, the terms spastic, athetoid,
ataxic and mixed are used. When classified by the extremities that are affected, the terms hemiplegia, diplegia, triplegia
and quadriplegia are used. From this dual model, the doctor would be able to classify CP based on both the site of lesion
and the extremities that are affected. The location and extend of the brain injury would determine the severity from mild
When classifying Cerebral Palsy by affected extremities,
the following terms are used:
Hemiplegia-one arm and one leg on the
same side are affected.
Diplegia-both legs are involved. The arms
are not affected.
Triplegia-three limbs are affected.
Quadriplegia-both arms and legs are affected.
Spastic Cerebral Palsy occurs when there is damage to the
pyramidal system of the brain. It is the most common form of CP and represents between 70%-80% of the reported cases. Children
with Spastic CP exhibit hypertonic muscle tone which affects control of their voluntary movements since their muscles are
rigid and permanently contracted. Attempts to perform a motor activity cause increased tension in the muscles. Breathing is
characterized by shallow inspirations and forced expirations. Damage to the cerebral cortex is usually the cause.
The major types of spastic involvement are:
Spastic Hemiplegia-involves the arm
and leg on one side of the body. Speech is usually OK. The child may have a developmental delay.
Spastic Paraplegia-involves the legs
only. This is very rare. The child may have problems with breath support.
Spastic Quadriplegia-all four limbs
are equally affected. The child may have articulation problems and/or dysphonia. Abnormal breathing patterns are caused by
weak muscles of the chest wall.
Spastic Diplegia-all four limbs are
affected. The lower limbs are affected more. The child may experience dysprosody with articulation problems.
Athetoid Cerebral Palsy is the least common
type affecting 5 to 10 percent of reported cases. It occurs from damage to the extrapyramidal system or damage to the basal
ganglia and causes mixed muscle tone-hypo or hypertonic which impairs the child’s ability to control involuntary movements
and causes slow, writhing movements. This loss of muscle control makes it difficult for the child to walk and grasp objects.
The muscles of the face may also be affected causing drooling, grimaces or odd expressions. Abnormal infantile reflexes are
common. Speech defects are variable and include different degrees of articulation deficits, phonation and prosody involving
stress and rhythm. Breathing patterns may be irregular and uncontrolled patterns with sudden bursts of air during inspiration
Ataxic CP affects 5 to 10% of the CP population.
The cerebellum is damaged which affects coordination resulting in unsteady, shaky movements or tremors. The hypotonia has
a negative impact on the ability to control muscles required to walk, write and dress themselves because of problems with
balance, coordination, and depth perception. Damage to the cerebellum causes this type of CP. About half of Ataxic CP children
have breathing problems characterized by irregular rate, rhythm and depth of tidal breathing resulting in difficulties with
loudness control and the rate of speech. Speech problems are mainly articulation and dysrhythmia.
Mixed CP is a combination of 2 or more
of spastic, athetoid and ataxic CP. This classification results in a mixture of hypertonicity and hypotonicity and is seen
in approximately 11% of the CP cases.
Using both systems for describing the disease, the doctor
is able to classify CP based on the site of the lesion and the affected extremities. CP can affect the child’s motor
skills from mild to severe. The location and extent of the brain injury determine the severity of CP. The effects can include
extreme weakness, seizures, paralysis, lack of coordination, sensory impairments and reduced control of the arms and legs.
It can affect the school age child in class by having trouble writing, drawing and cutting with scissors. The child may have
difficulty with receptive and expressive language. Articulation difficulties may result from lack of breath control, movement
of the vocal cords, lips, tongue and palate.
Diagnosing Cerebral Palsy requires observation over a
period of time. Diagnosis is usually made within the first three years of life and is accomplished by completing tasks for
motor skills and reflexes, looking into medical history and performing a variety of formal and informal assessments. Three
areas observed are: the acquisition of developmental milestones, muscle tone and muscle function. Usually parents will
begin to notice that their child’s motor skills are different from other children around the 6 month age. Concern of
CP continues to grow as the milestones become more evident that they are delayed. Abnormal muscle tone, movements that are
not typical for the age of the child and continued infantile reflexes are red flags for the disease. Some of the areas that
would signal a diagnosis would be muscle tone that changes from floppy to stiff, one side of the body moves better than the
other, poor tongue and lip control, and reflexes like the asymmetric tonic neck reflex that lasts beyond the 6 month stage
or the Babinski reflex that lasts longer than a year. Also, early signs of CP include the following: poor head
control after 3 month of age, increased irritability, feeding problems (problems sucking and swallowing), continuous fisting
of the hands, scissoring of the legs, pointing of the toes, tremors, seizures, an exaggerated startle reflex, and a
weak or shrill cry. The body can be either very relaxed and floppy or very stiff. When held, babies may arch their backs and
extend their arms and legs.
Since CP is a motor disorder that affects muscle control
and not the direct cause of cognitive, visual, hearing or attention impairments, it is important to understand the effect
that CP has on fine motor functions. It’s important to note that involvement varies with each individual as the disease
affects each person differently. Motor impairments range from a slight distorted gait to wheelchair bound. The rigidity of
the muscles can cause the feet to turn in or the legs to cross while walking. The child may also take large, uncontrolled
steps. If needed, the child may be fitted for an AFO brace to stabilize the ankle and calf. CP children often suffer from
dislocated hips and tight hamstring calf and ankle muscles. Medical and surgical treatments can help relieve the tight tone.
Botox can be used to relax the tight muscles to allow for an increase in motion. Surgically clipping a muscle can be
done to improve mobility. Oftentimes the fine motor skills make it difficult for CP children to dress themselves and feed
themselves. Using scissors and writing may be a challenge. It’s common for a CP child’s wrists to be stuck in
a downward position. Hand and wrist splints can be used for proper positioning of the fingers and wrist.
Difficulties with jaw control and mobility with tongue,
lips and cheeks can complicate feeding for the CP child due to high or low muscle tone. Forward thrusting of the tongue due
to decreased tongue strength pushes the food forward and limits the laterization of the bolus to the teeth. Because of this,
a sucking pattern is developed where the tongue mashes the bolus against the hard palate and the food is swallowed without
being chewed. Also, an open mouth position is common in CP children resulting in bolus leakage and drooling. If the
muscles of the larynx and epiglottis are weak, there is not sufficient protection of the airway during swallowing. But, if
there is high muscle tone, the pharynx is constricted and swallowing is difficult. Sometimes these swallowing issues make
if necessary to pursue alternate feeding methods such as the use of the nasogastric tube or the gastorstomy tube so proper
nourishment can be achieved.
In addition to swallowing problems, high muscle tone and
extra movements cause the CP child to burn a large amount of calories and develop low weight. If the child displays sensory
defensiveness, the child may not take nourishment by mouth which could lead to weight loss.
Abnormal neurological control
- Lack selective control of muscle activity and anticipatory
- Cough and airway clearance difficulties
- Respiratory muscle weakness
Sucking and swallowing problems in the first 12 months of life are
common and a high percentage require nonoral feedings on at least one occasion. Swallowing is a complex process that
involves the sequence of intricate timed maneuvers by a large number of muscles. Muscle weakness creates a disturbance
in the coordination of this sequence and often leads to swallowing difficulties. Individuals with spastic quadriplegic
cerebral palsy are most likely to be affected; however, dysphagia may be present in any of the cerebral palsy types.
Both the oral and pharyngeal phases of swallowing may be affected.
In the oral phase, the failure of proper bolus formation may impede swallowing. In the pharyngeal phase, esophageal
peristalsis, glottic closure and the coordination of swallowing and breathing may lead to aspiration of solids and liquids
during feeding. There may also be aspiration of secretions into the airway due to inadequate protective reflexes.
Coughing is also a complex action which requires the strong contraction of the abdominal and intercostal muscles, and precise
coordination of these muscles in conjunction with the glottic muscles. In addition, individuals with cerebral palsy
appear to have a diminished sensitivity to cough. It has been speculated that this may occur due to the result of desensitization
of airway irritant receptors from chronic aspiration. In addition, individuals with cerebral palsy often lead sedentary
lifestyles. Exercise is known to produce deep breathing which aids in the clearance of secretions and opens up underventilated
lung regions. Lack of exercise makes those with cerebral palsy prone to infection and hypoxemia. (Solomon, 1998)
About 40% of people with CP have visual impairment as well.
The causes would relate to prematurity and a lack of oxygen to the brain which results in damage to the retina, optic nerve
or occipital lobe. These impairments affect motor function and perceptual skills. If their balance is altered, this could
cause delays in achieving motor milestones such as crawling and walking. Children with hemiplegia commonly have a loss of
vision in a section of their visual field which affects depth perception. Cortical blindness is caused by damage to the brain
that prohibits the conversion of visual stimuli into a visual image. The eye and optic nerve are functioning properly, but
they are not receiving the visual messages from the brain. Optic atrophy is damage to the optic nerve that prohibits the brain
from receiving visual stimuli and transferring it into a visual image.
Approximately 15% of children with CP have a hearing impairment
caused by bleeding in the brain or a lack of oxygen to the brain. The severity ranges from slight to profound and can have
a negative effect of the child’s speech and language acquisition. It can also have an effect on their auditory processing
skills such as short term memory, sequencing and organizing skills.
Children with CP often have sensory problems which affect
their proprioception causing them to lean to one side when sitting or not be aware of their postures. Also, they may be tactile
defensive with new textures resulting in the child to become overloaded easily when introduced to textures, sounds and other
Due to brain damage, some form of mental retardation is
found in approximately two thirds of people with CP. This can range from mild to severe. Since physical impairments make it
difficult to assess the person with CP, the scores obtained from formal measures may not be an accurate picture of the person.
Since CP is a motor disorder, many of the children who suffer from CP are impaired only by their motor impairment and are
able to succeed in the cognitive demands of their daily life.
Delayed growth can be caused by swallowing difficulties.
Since it takes a long time for someone with CP to finish a meal, little food has been actually ingested. Also, poor lip closure
and tongue thrust also contribute to loss of food making it difficult for the child to receive enough calories to grow normally.
Also, muscles that are hypertonic or hypotonic can affect the growth of a child with CP.
Speech characteristics vary from child to child and can
range from severely impaired to no impairment at all. Speech dysfunctions include respiratory, phonatory, articulatory, prosodic
and velopharyngeal inadequacies. Articulation errors may be present due to hypotonicity or hypertonicity of the speech
muscles. The motor speech disorders, if any, would be dysarthria and/or apraxia. Respiration is often compromised by immature
lungs which may cause asthma, aspiration pneumonia, sleep apnea and chronic obstructive pulmonary disease. The lungs may be
healthy but the use of them may be compromised due to muscle control and/or weakness. Voice may be breathy or weak and the
child may speak with low volume and monotone. Children with spastic diplegia and spastic quadriplegics are more likely to
have speech disorders than are hemiplegics or paraplegics. Motor difficulties result in dysarthria. CP children initiate speech
using higher lung volumes and use more air during speech due to reduced vital capacities and difficulty with neuromuscular
control. (Solomon, 1998)
A team approach is recommended for the evaluation of a
child suspected of having CP. Some of the professionals involved in the assessment would include an orthopedist, developmental
pediatrician, physical and occupational therapist, speech-language pathologist, social worker, psychologist, social worker
and a special educator. The family is most important in the child’s management of intervention strategies because it
is the family who will follow through on the therapy recommendations offered by the specialists involved.
The speech and language assessment will include formal
testing and informal testing. The formal testing will give a standardized score in the areas of receptive/expressive language,
articulation, vocabulary, pragmatics, oral motor skills, auditory comprehension and memory skills. Areas tested will be determined
by the age and abilities of the child. For those children who suffer from impulsivity, attention difficulties, behavior issues,
cognitive impairment or physical limitations may require special modifications such as an AAC device, word processor, quiet
room, smaller sessions, repetition of directions, redirection to task, enlarged pictures and use of eye gaze. Untimed testing
may be required for children with physical limitations or problems with processing. Test results will help with strengths
and weaknesses and formulation of goals but they may not be a true picture of what the child can do in the classroom. Informal
testing needs to be performed to gain a truer picture of the child in the classroom setting of environmental setting.
Informal testing includes interviews and observations.
The interviews provide an insight in to the child’s functioning in their natural environment that formal testing can’t
identify. A parent interview is essential as well as a teacher interview. The teacher can give helpful information for providing
modifications required for the child as well as the child’s strengths and weaknesses. Behavioral observations by the
SLP will give valuable information about how well the child communicates and understands and the degree of cueing and compensation
required to function in their environment. It is recommended that several observations be made on different days to give a
more balanced picture of the child’s functioning.
Speech disorders may include developmental articulation
errors and motor speech disorders (dysarthria and apraxia). Traditional articulation therapy can be used for articulation
errors. If motor skills are compromised, oral motor exercises would benefit to increase awareness of the tongue and articulators
and increase strength. Children with CP often demonstrate deficits in vocabulary skills
If swallowing or feeding issues are suspected, a swallow
study should be preformed. The SLP should coordinate intervention techniques and strategies with the physician and caregivers
if a swallowing problem is present.
Careful observation of the patient should be done to assess
the respiratory mechanism and respiratory support. A determination should be made about the respiratory pattern used: clavicular,
thoracic or diaphragmatic-abdominal breathing. To measure maximum phonation time, the patient should be able to produce an
adequate amount of air and be able to sustain phonation long enough to communicate effectively. By measuring the maximum phonation
time, respiratory and glottal closure can be assessed. Elementary children should be able to sustain vowels for approximately
10 seconds. Reduced vital capacities result in inadequate support for phonation and articulation. Breathing may be rapid and/or
irregular with lack of thoracic movement. (Solomon, 1998)
In making a voice evaluation, it’s important to remember
that laryngeal dysfunction is responsible for harsh voices, short phrasing and prosodic abnormalities. General hypotonicity
results in strained vocal quality, hard glottal onset and reduced intensity.
Articulation deficiencies affect production of fricatives,
affricatives, laborious and slow rate of speech. Muscle weakness, instability and problems finding target points of articulation
contribute to articulation errors and abnormal prosody. Abnormal jaw movements during speaking and tongue movements are restricted
Velopharyngeal inadequacy results in hypernasality. The
child should be encouraged to speak with a greater degree of oral opening and to use a more posterior placement of the tongue,
if able. If hypernasality persists as the child matures, other treatment options can be explored, such as a palatal lift.
Phonological difficulties include voicing difficulties,
consonant cluster reduction, final consonant deletion, vowelization of /l/ and /r/.
The first step in therapy would be to satisfy the pre-speech
requisites such as head control, coordination of respiration, coordination of breathing and phonation and posture control.
After these objectives have been met, vocal play and babbling practice would start for the very young. For the older child,
work on coordinating respiration, phonation, resonation and articulation. When the child is able to inhibit abnormal reflexes
and perform movements for speech, artic training can begin. Traditional articulation therapy would consist of increasing speed,
range and accuracy of the tongue, lips and jaw. Begin with oral exercises, then placement exercises. Select target phonemes
according to stimulability of sounds and the developmental stage of the child. Choose stimulable, visible and developmentally
appropriate sounds first.
Consonants produced correctly in prevocalic position
Distortions before substitutions.
Motor involved misarticulations should be delayed.
Work on voice/voiceless contrasts. Children with CP substitute
voiced for voiceless consonants.
Strengthen inspiration and expiration muscles for breath
Practice diaphragmatic breathing, blowing, and abdominal
strengthening by use of sit-ups for muscle weakness.
For spasticity, combine strengthening with relaxation,
muscle lengthening and facilitation of normal movement patterns.
Some CP children will not have normal artic. Work on
Practice phonating while performing laryngeal adduction
exercises such as bearing down, squeezing palms together, pulling up on the chair with hands.
If verbal communication can’t be achieved due to
physical handicaps, an AAC device may be introduced. Cognitive abilities will need to be considered and motor abilities need
to be taken in to consideration. Proper symbols must be found for the AAC device according to the child’s cognitive
ability, visual acuity and environment.
The SLP works to improve the child’s vocabulary skills
by providing a variety of experiences through the use of thematic units, reading books and hands-on experiences. Oftentimes,
the child has limited experiences due to their physical limitations and lack of social interaction. When poor vocabulary skills
are due to neurological deficits instead of lack of experience, the SLP must provide the child with compensatory strategies.
The SLP works with the child’s teacher and family to ensure that the child progresses and generalizes strategies to
the classroom and home environment. (Solomon, 1998)
Poor oral motor skills have a negative impact on the child/s
ability to speak, eat and manage drooling. An individualized treatment plan should be established by the SLP consisting of
an oral motor stimulation program involving deep pressure and stroking of the lips, tongue, cheeks and gums. The deep pressure
helps to improve muscle tone and the stroking provides sensory input and helps to alleviate oral defensiveness. The SLP works
in partnership with the occupational therapist to develop a feeding program for the child. Pureed foods may be recommended
or adaptive feeding equipment, such as a special spoon or bowl, may be introduced to assist the child in feeding himself or
Since the effects of CP vary from one child to another,
careful and thorough assessment should be performed and an intervention program should be developed based on the specific
strength and needs of the child. Since cerebral palsy can have a severe effect on the child’s communication skills,
impact can be realized in the child’s socialization, academics and vocation goals. It is important to begin assessment
as early as possible to prepare the child for the future. A multidisciplinary team including the parents is most effective
for meeting the child’s needs. Consultation among the professionals is essential to ensure the best treatment possible.
Due to the continued development of devices and medical knowledge and multiple impairments that can co-occur with the disease,
assessment and intervention must be an on-going process.