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Speech and Communication in Cerebral Palsy Eastern Journal of Medicine 17 (2012) 171-177 Review Article Speech and communication in cerebral palsy Lindsay Pennington Institute of Health and Society, Newcastle University, England, UK Abstract. Children communicate using speech, vocalisation, facial expression, gesture and body movement. The motor disorders of cerebral palsy (CP) may affect the movements needed to produce any type of communication signal. Movements intended to be the same may vary in range, speed, strength and accuracy and as a result communication signals may be difficult to understand. Children’s communication development may also be affected by cognitive or sensory disturbances, which are also common in CP (1). This paper will describe the speech and communication difficulties often experienced by children with CP and will summarise the interventions that have been found to be clinically effective with this population of children. Key words: Cerebral palsy, speech, communication, language, children into sound (acoustic energy) in the process 1. Speech disorders known as phonation. The resonance of the vocal Motor speech disorders (dysarthria) are tract is determined by its shape, and is altered by associated with all types of CP-spastic, dyskinetic movements of the jaw, soft palate, lips and and ataxic. However, little is known about the tongue. For example, if the nasal cavity is not prevalence of dysarthria in CP. We know that it is closed off during speech, nasal resonance is more common in dyskinetic CP than spastic produced and speech sounds nasalised. forms (2, 3), and that estimates of the overall Articulation refers to the movements of the jaw, prevalence of dysarthria in children with CP are tongue and lips, which further shape acoustic around 50% (2, 4). However, exact prevalence energy to create vowels and consonants. When figures for the presence and severity of dysarthria describing the components of speech production are not currently available, as speech is not researchers and clinicians also talk about currently measured in CP surveillance registers. prosody, which refers to the rhythm, stress and Children with different types of CP share many intonation patterns of connected speech. Prosody speech characteristics and it is difficult for is created by changes in pitch, syllable duration clinicians to differentiate between the CP types and loudness, which in turn depend on respiratory when listening to speech recordings (5). The and laryngeal control. perceptual similarities may be due to the Movements for speech are rapid and demand developmental nature of the disorders or the considerable coordination and control. Dysarthria presence of mixed disorders. in children with CP often affects all processes - Speech production relies on several underlying respiration, phonation, resonance, articulation processes-respiration, phonation, resonance and and prosody. Children may have difficultly articulation. To produce speech respiration is controlling their breathing for speech. They may controlled so that exhaled air is forced from the have shallow breathing and may speak on short lungs through the vocal folds and into the oral bursts of air, which might make their voices and nasal cavities. At the larynx, the vocal folds quiet, especially in longer utterances (6). vibrate to turn air pressure (aerodynamic energy) Children may also have difficulty in coordinating exhalation with phonation. They may exhale and *Correspondence: Dr. Lindsay Pennington then start to speak when a significant proportion Institute of Health and Society of their breath has been exhaled. This may lead to Newcastle University them running out of breath and speaking on England, UK residual air. The vibration of their vocal folds Email: [email protected] may be slow or irregular, which can create low Tel: 00 44 191 282 1360 pitched, monotone and breathy voices (7). Children’s voices may sound harsh or vary 171 L. Pennington / Speech and communication rapidly in pitch. Reduced control of the soft production of loud, clear voice starts with the palate may lead to speech sounding nasalised, and production of isolated vowels and moves to reduced control of the tongue and lip muscles is words and phrases so that children can practice evident from reduced range of consonants and controlling their voice in functional speech. vowels that can be produced in speech (8-11). Children are taught to maintain sufficient breath Difficulties in controlling the vocal tract can support for words or phrases and to breathe at range from mild, with slight imprecision of appropriate points in phrases. For some children speech in words and phrases, to profound, with a this might be between each phrase in a sentence: complete inability to produce any intelligible “The man” “is feeding” “the dog”. Other speech. children may be able to produce longer utterances Children with CP and communication between breaths “The man is feeding” “the difficulties are at risk of lower quality of life and dog”. Therapy may also include modulating reduced participation (12-14). The aim of speech pitch, loudness and timing for prosody (20, 21). and language therapy is to help children to As this type of therapy aims to help children to communicate effectively and independently in all learn new motor behaviours it should follow situations, thereby increasing their access to motor learning principles: therapists should education and social life. For children with severe provide frequent feedback to facilitate the or profound disorders speech may not be production of the target behaviour and then fade effective as the main means of communication feedback once the target has been reached, in and alternative and augmentative communication order to aid retention; therapy should be given (AAC) systems should be implemented to enable intensively so that children can practise of target children to express themselves and their ideas behaviours frequently; targets should be clearly. For children with less severe disorders randomised in practice, rather single behaviours therapy may serve to increase the intelligibility of being practiced repetitively; and children should their speech. be given provided with knowledge of their results (22-25). 2. Speech intervention Therapy focusing on breathes support and voice Research has shown the different motor control production, which follows the motor learning needed to produce movements for sucking, principles above, has been associated with chewing and speech (15). Motor learning theory changes in the ICF levels of body function and also tells us that motor learning is task specific activity. Increased lung volume and greater (16). Therapy to improve speech production muscular effort (26) have been observed post should therefore focus on speech, rather than oral therapy. Changes to children's voices with exercises that use the same body structures. reduced fluctuations in pitch and increased As dysarthria affects all processes involved in volume have also been observed (27, 28). More speech production, from respiration to importantly clinically, however, is change to articulation, therapy needs to address each of children's speech intelligibility. For a group of these processes. Clinicians and researchers children with mild to severe disorder average recommend that intervention focuses on increases in intelligibility post therapy of 15% controlling respiratory effort and coordinating have been observed. For some children with more exhalation and phonation, as these processes severe disorders this represented a doubling in underpin the production of a robust acoustic the number of words that are understandable in signal (3,17,18). Treatment for articulation is single word and connected speech (21). The only advised when other aspects of speech above studies suggest that intervention focusing production have been/are being addressed, as on clear voice production is effective in changing imprecise “production of speech sounds (which is speech and intelligibility in clinical settings. It is the most common perceptual characteristic of now important that research includes measures of dysarthria) is not simply an oral articulatory change at the ICF participation level, and to problem, and is usually the result of laryngeal, investigate if the intervention has a positive velopharyngeal, respiratory and oral articulatory impact on children’s involvement in social and problems” (18). Thus, more precise articulation educational activities and facilitates everyday and improved intelligibility is achieved through interaction (29). developing control of breathing for speech, Following or in conjunction with therapy to increasing background effort and slowing speech maintain breath support and increase control of rate (3,18,19). the coordination of exhalation and phonation, Therapy to increase respiratory effort and intervention may also address nasality and coordination of exhalation and phonation for the articulation. Behavioural therapy for nasality has 172 Eastern Journal of Medicine 17 (2012) 171-177 Review Article been described in text books and includes motor people. Communication signals can be sent using exercises to raise the soft palate and close off the speech, vocalisation, facial expression, gesture nasal cavities (19). However, there is currently and whole body movements. Each of these modes insufficient evidence to evaluate the effectiveness of communication can be affected by the motor of this type of intervention (30). The fitting of disorders of CP as the
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