A quick course on cerebral palsy

Join me in my rabbit hole for a moment, SLP friends. Bring coffee. Last month, Developmental Medicine & Child Neurology had a whole issue on cerebral palsy (CP).

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Our search takes us back to 2017, when a HUGE group of researchers lead by Iona Novak described diagnosis and treatment options based on their systematic review (note: this research team also included SLPs and people with CP/parents of people with CP as authors, so we have the FULL EBP triangle going on here!). Cerebral palsy is a huge umbrella diagnosis; but in general, CP is defined as a non-progressive disorder of posture and movement related to an injury or some problem in the developing brain. It can be diagnosed between 1 and 2 years, and sometimes a provisional diagnosis is given until CP can be confirmed or ruled-out after a period of development, around 5 years. For a diagnosis of CP, a child has to demonstrate motor dysfunction and either abnormal neuroimaging or a risky clinical history (genetics, stroke, maternal health risks, etc.). Table 1 in Novak et al. will give you a thorough overview of identification and diagnosis.

Last month, Msall published a commentary on a recent paper by Boychuck et al., who surveyed international experts on CP to compile a list of red flags clinicians should keep in mind (see Table 3 or read the Msall’s one-page commentary for more information):

  • Children should be referred for evaluation if they demonstrate things like:

    • Holding hands in fists, asymmetry, or head lag after 4 months

    • Tightness in legs between 6–12 months

    • Requiring support to sit after 9 months

    • Hand preference before 12 months

  • Children should be referred for monitoring if they demonstrate:

    • A persistent startle after 6 months

    • Consistent toe-walking or asymmetric walking after 12 months

  • Children should be referred to SLPs any time there are feeding or communication delays or concerns

    • Speyer et al. reported a high prevalence of feeding (53.5%), drooling (44%), and swallowing (50.3%) problems in children with CP.

Thinking about the diagnostic process and transition to treatment, EI SLPs should be pretty well-versed in interacting with parents, but it’s always nice to have a reminder of parent priorities as they begin to plan for their child’s interventions. Byrne et al. conducted focus groups of parents and providers and found that overall, parents of children with CP want:

  • Honesty and directness from providers, with information specific to their child (not just a general prognosis)

  • Explanations of the assessments and tools used to make the diagnosis (including the names of the assessments)

  • Written material (it helps to be able to refer back)

  • Support from providers and assistance in securing services 

In terms of treatment in CP, EI is critical for development. We have to help build those brain connections and take advantage of early neuroplasticity. While CP is a motor disorder (so you will probably need involvement from PT and OT in some capacity), many children with CP have feeding and communication difficulties, so SLPs are likely to be involved on intervention teams. For communication, Novak et al. recommended supporting parent–child interaction, and considering AAC. If feeding is a concern, the team should assess swallowing safety because pneumonia is particularly risky for people with CP. For those of you providing family-centered services in natural environments, you’re already on the right track for service delivery for this population. McCoy et al. measured gross motor outcomes in children with CP, but their message is powerful for all EI providers. The number of therapy visits (including PT, OT, AND Speech) did not predict outcomes, but family-centered services and the focus of sessions (e.g., incorporating overall health and well-being and engaging in structured play activities) did. So keep coaching those parents on how to implement interventions in enjoyable and contextualized settings.

 

Boychuck, Z., Andersen, J., Bussieres, A., Fehlings, D., Kirton, A., Li, P., …, & Majnemer, A. (2019). International expert recommendations of clinical features to prompt referral for diagnostic assessment of cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14252.

Byrne, R., Duncan, A., Pickar, T., Burkhardt, S., Boyd, R., Neel, M. L., & Maitre, N. L. (2019). Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy. Child: Care, Health, and Development. doi: 10.1111/cch.12707.

McCoy, S. W., Palisano, R., Avery, L., Jeffries, L., Fiss, A. L., Chiarello, L., & Hanna, S. (2019). Physical, occupational, and speech therapy for children with cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14325.

Msall, M. E. (2019). Establishing community pathways for the early recognition of cerebral palsy: Red flags, enablement, and family support. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14314.

Novak, I., Morgan, C., Adde, L., Blackman, J., Boyd, R. N., Hernandez-Brunstrom, J., …, & Badawi, N. (2017). Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment. JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1689.

Speyer, R., Cordier, R., Kim, J., Cocks, N., Michou, E., Wilkes-Gillan, S. (2019). Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: A systematic review and meta-analyses. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14316.

Spanish and English in the classroom: Does it matter?

In this study of nearly 2000 dual-language learners (almost all Latinx) ages 18 months to age 5, in Educare/Head Start programs across the U.S., the researchers asked—does classroom language matter? 

Children were observed in each of three classroom categories:

  • English w/ No Spanish

  • English w/ Some Spanish

  • English & Spanish

The researchers found that all three classrooms supported English growth, but the English + Spanish classroom best supported Spanish growth. So to support Spanish growth, we may need more balanced bilingual instruction.

The authors further state, “… DLL children learn English at equal (and advanced) rates regardless of L2 classroom exposure, when in high-quality classrooms”, and thus “… Spanish use in the classroom at varying levels does not impede English acquisition.”

Surprising to most Informed SLPs? Probably not. But this is a great article to share with others if you’re trying to explain the impact of dual language instruction.

 

Raikes, H. H., White, L., Green, S., Burchinal, M., Kainz, K., Horm, D., ... Esteraich, J. (2019). Use of the home language in preschool classrooms and first- and second-language development among dual-language learners. Early Childhood Research Quarterly. doi:10.1016/j.ecresq.2018.06.012.

Culturally congruent interventions for Latino families

When working with families from diverse backgrounds, it is imperative to make sure that our interventions are consistent with the family’s culture and values. Guiberson & Ferris studied caregiver interaction style in Latino families to identify interventions that would be culturally appropriate for the Latino population.  

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European–American families tend to use an independent style of interaction with their children: emphasizing the child’s individuality, following the child’s lead, and allowing the child to explore toys in different ways. This study found that the majority (75%) of Latino families interacted with their children using a more interdependent style. An interdependent interaction style emphasizes the child’s relationships and belonging to the family and cultural group. Caregivers who use an interdependent interaction style are more likely to direct the child’s attention, teach explicitly, show children how to play with toys, and use more commands and directives in their language.

Considering how Latino families tend to interact with their children, EI approaches that emphasize following a child’s lead may not be culturally appropriate for all Latino families. When working with families who use an interdependent interaction style, consider using the following interventions: 

  • Explicit teaching combined with attention directions

  • Modeling

  • Focused stimulation

  • Dialogic reading

Because these interventions give the caregiver more of an authoritative role in the interaction, they may feel more natural for Latino parents and therefore be more likely to be implemented. Latino mothers reported feeling more comfortable with a didactic style in which the parent gives commands, directs the child’s behavior, and explicitly teaches children how to complete tasks.

Check out the original article for more in-depth descriptions of these interventions and information on Latino caregiver preferred activities.  

 

Guiberson, M. M., & Ferris, K. P. (2018). Identifying culturally consistent early interventions for Latino caregivers. Communication Disorders Quarterly. Advance online publication. doi: 10.1177/1525740118793858.

Throwback Pub (2012): Training parents to support children with developmental language disorder

As SLPs working in EI, we know that developmental language disorder presents risk for later academic skills. We also know that parent-implemented language interventions can be effective (see Roberts & Kaiser, 2011, for a meta-analysis of parent-implemented language interventions). This study examined whether parent-implemented Enhanced Milieu Teaching (EMT) would impact receptive and expressive language growth in children with language disorder (with cognitive standard score > 80 and no other primary diagnoses; see article for full inclusion/exclusion criteria).

The researchers examined three groups of 24–42-month old children:

  • Typical language

  • Language disorder w/ no treatment, or a “wait-and-see” approach

  • Language disorder w/ parent-implemented Enhanced Milieu Teaching

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Families treatment group participated in parent training in 28 sessions (workshops, clinic, and home visits) over a three-month period. EMT strategies were trained in four phases: 1) setting a communicative context, 2) modeling and expanding communication, 3) time delay strategies, and 4) prompting strategies (see Table 5 for examples and description). During training at the clinic, therapists and parents practiced strategies using a specific set of toys. Home visits also included integrating strategies into functional family routines such as snack. All children were assessed with monthly language samples (MLU, total words, different words) plus the Preschool Language Scale, Fourth Edition (PLS-4), at the beginning and end of the study.

So what happened? Parent-implemented EMT was effective for improving language outcomes for children with LI, and parents in the treatment group used significantly more strategies than either other group! Parent use of strategies for typically-developing children and those with language disorder undergoing “wait and see” were about the same.

Children whose parents used EMT

  • significantly improved their PLS-4 Total and Expressive Communication scores and gained an average of 50 more words than untreated children with language disorder

  • gained an average of 15 more words per month compared to untreated children with language disorder

  • grew at about the same rate as children with typical language

Fantastic, right? But what about the kids with language disorder undergoing a “wait and see” approach? They showed significantly slower growth. Not only did those “wait and see” kids start out with lower language abilities, it looks like “waiting and seeing” might just hold them at a disadvantage when compared to those who have access to intervention. The authors stated, “Children in the LI-control group did not catch up but fell farther behind their peers with TL.”

How about a little extra info? The authors also looked at which child characteristics predicted language growth and outcomes. They examined risk at birth (e.g., a NICU stay), cognitive skills, and receptive skills (based on the Bayley-III scores). Risk at birth and cognitive skills were not predictive of expressive language analyses performed. However, “Receptive language at the start of the study predicted growth in language for all three groups of children after controlling for differences in IQ.”

The authors note that more research is needed to determine long-term outcomes. For example, how would these children progress over a period of 12 months? What kind of gains would come from 28 hours of traditional therapy in 3 months? Overall, parent-implemented EMT looks to be a promising model to add to our intervention options for young children with developmental language disorder.

Note: For our bilingual SLPs, see Peredo, Zelaya, & Kaiser, 2017 for a study on adapting parent-implemented EMT for Spanish-speaking families.

 

Roberts, M. Y., & Kaiser, A. P. (2012). Assessing the effects of a parent-implemented language intervention for children with language impairments using empirical benchmarks: A pilot study. Journal of Speech, Language, and Hearing Research55(6), 1655-1670.