speech and language abilities in children with ......speech and language abilities in children with...

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SPEECH AND LANGUAGE ABILITIES IN CHILDREN WITH CEREBRAL PALSY IN

ELEMENTARY SCHOOL

Ivana Terzic, Nadica Jovanovic, Mile Vukovic and Goran Nedovic

University of Belgrade Faculty of Special Education and Rehabilitation, Serbia

DOI: 10.2298/MICP2012055T

SUMMARY

Cerebral palsy (CP) is a heterogeneous set of pathological symptoms that manifests clinically as a motor impairment and motion inability, followed by intellectual, sensory, speech and language, emotional, behavioral and other disorders. Impairments associated with cerebral palsy differ from child to child in their severity and consequent effect on communication development. Children may have mild or severe speech, language, and/or communication disorders. Objective of this study was to determine the speech and language abilities of children in elementary school who had a cerebral palsy as a primary impairment. The presence of associated disorders was explored as well as their possible relation to additional speech and language deficits, difficulties in reading and writing, as well as to success in managing the school curriculum. The sample consisted of 12 elementary school students with cerebral palsy as a primary disorder, while most, but not all children, have associated problems such as intellectual disability, attention and memory deficits, visual impairment, seizures and others. The sample consists of two students from I, III, IV, V, and VIII grade and one student from VI and VII grade, including 7 male and 5 female students. Results were presented as case studies, with a qualitative description of the abilities of each student, taking into account the impact of primary damage (CP) and associated disorders, particularly intellectual disability,

Ivana Terzic et all.

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on speech and language abilities of individuals. Results are shown separately, for students who predominantly use nonverbal communication and for students who use verbal communication. KEY WORDS: cerebral palsy, speech and language abilities, associated disorders

INTRODUCTION

Cerebral palsy (CP) is the most common childhood physical disability. It is described as a group of disorders that is attributed to non-progressive disturbances that may occur in the developing foetal or early infant brain before the first year of life (Rosenbaum et al., 2007). Cerebral palsy can be defined as a disorder of aberrant control of movement and posture, appearing early in life secondary to a CNS lesion or dysfunction that is not the result of a recognized progressive or degenerative brain disease (Nelson & Ellenberg, 1978). The term ,,cerebral” refers to the brain and changes of its structure and function, while „paralysis” indicates a disorder of movement and posture. The term is comprehensive and indicates wide clinical expression that can affect the child's ability to walk, posture and balance. Definition and diagnosis of cerebral palsy are still the subject of scientific discussion. The term „central motor deficit“ is proposed as it is believed that it’s more understandable. Abnormalities in the brain may occur before, during or after the natal period, and always include motor deficit. Cerebral palsy is a syndrome with many etiologies. The etiology of CP is very diverse and multifactorial. Some of many causes of CP are congenital, genetic diseases, brain malformations, inflammatory, infections, traumatic, metabolic and anoxic injury to the developing brain. Most of the cases are due to prenatal injury with less than 10% being due to significant birth trauma or asphyxia (MacLennan, 1999). The most important risk factor seems to be prematurity and low birth weight with risk of CP increasing with decreasing gestational age and birth weight. Cerebral palsy is defined as an “umbrella term covering a group of non-progressive, but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development” (Mutch, Alberman, Hagberg, Kodama & Perat, 1992). Observation of slow motor development, abnormal muscle tone, and unusual posture are common initial clues to the diagnosis of cerebral palsy (Krigger, 2006). Also, there are mobility problems, mild tension or muscle weakness, inability to sit and upright posture without support,

SPEECH AND LANGUAGE ABILITIES IN CHILDREN WITH CEREBRAL PALSY IN ELEMENTARY SCHOOL

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the use of only one side of the body, paresis or paralysis i.e. plegia of one, two, three or all four extremities, as well as difficulty of swallowing, chewing and eating. Motor development of the child is not in line with the expected relative to chronological age, but since the damage is not progressive there is no loss of certain functions. Even though the primary lesion, anomaly or injury are static, the clinical pattern of presentation may change with time due to growth and developmental plasticity and maturation of the central nervous system. Associated disorders are numerous and related to deficits in sensory perception and integration, cognition, communication, behavior, emotional and social development. Problems of sensory integration are manifested by decreased or increased sensitivity to stimuli, difficulty in perception of shape and space, difficulty in performing of fine manipulative movements, the attention deficit disorder and developmental disorders of speech and language (Bratovcic, Mujanovic & Saric, 2011). Cerebral palsy is a heterogeneous set of pathological symptoms. That is the reason why is nowadays often used the term „multiple disabilities“. Multiple disabilities imply the presence of two or more disability in one person.

Associated disorders Children with physical disabilities are most heterogeneous category of disabled children. Within this group there is a wide range of conditions and diseases of different etiologies and different degrees of physical disability (Dragojevic, 2010). Children with cerebral palsy are a subgroup within the broader population of physically handicapped children. The term CP is descriptive and can refer to a different etiology and clinical features. Motor impairment and motion inability are common characteristic of people with CP, but there is no single profile of their skills primarily because of the great heterogeneity of this kind of disability, and also because of the many factors that influence this kind of functioning. In addition to the numerous and complex disorder that can occur in the area of motor functioning, in most cases motor impairment is associated with the number of problems and that points out that cerebral palsy is a multiple disorder often accompanied by different degrees of intellectual disability, disorders of attention, memory and concentration, speech and language disorders, seizures, sensory disturbances, behavioral disorders. The incidence of intellectual disability (52%), epilepsy (45%), ophthalmologic defects (28%), speech and language disorders (38%), and hearing impairment (12%) are quite significant (Ashwal et al., 2004). Associated conditions such as intellectual disability or epilepsy are often equal in severity to their motor impairment. The heterogeneity of symptoms may be such that even in two children with the same type and form of CP can be observed differences in motor,


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cognitive, speech and language functioning that even expert may think that those are two different forms (Falkman, 2005). However, individuals with cerebral palsy have similar needs for rehabilitation, education, social and medical services. Cerebral palsy and associated disorders are an obstacle to the individual which sometimes limits the achievement of basic needs, mobility, education and employment.

Intellectual disability and cognitive skills Cognitive and neuropsychological functions in children with CP are commonly impaired. Cognitive impairments are common within these children, and their prevalence depends on the type of CP and increases with the presence of epilepsy (Odding, Roebroeck & Stam, 2006). All levels of intellectual disability are present in half of this population, while about 5% have intelligence which is above average. The average intelligence is relatively uniform in all clinical conditions while intellectual disability is not uniformly present in different forms of CP. The percentage of children with cerebral palsy and intellectual disability varies depending on the type of cerebral palsy and can range from 10% in children with dyskinetic syndrome, and 100% in children with spastic tetraplegia (Saner, 1999, according to Falkman, 2005). Children with spastic quadriplegia have greater degrees of mental impairment than children with spastic hemiplegia (Fennell & Dikel, 2001). About 75% of children and adolescents with CP have significant disorders of higher cortical functioning (Wood, 2006). Children with different forms of CP may be difficult to assess because of the motor deficits and in some forms of CP the differences between performance and verbal intelligence test scores (Aram & Eisele, 1994). There are different data about how intellectual disability (ID) is common in people with cerebral palsy. Intellectual disability is common in CP in up to 60% of the cases (Sankar & Mundkur, 2005). Another study in India report ID in 72.5% of affected children (Singhi, Ray & Suri, 2002). Intellectual impairment occurs in about two thirds of patients with cerebral palsy (Krigger, 2006). The quality of memory in children with cerebral palsy depends on the type and degree of motor impairment and is conditioned by the existence of numerous interrelated factors. It is important to pay attention to the presence or absence of intellectual disability, maintained perceptual abilities, as well as the quality of attention. Attention disorders may be correlated with all clinical forms and intellectual levels, and are often associated with epilepsy. Sometimes in children with cerebral palsy, impulses, mainly irrelevant, are coming constantly from the periphery of the body, and that can cause problems in initiating and sustaining of attention (Rapaic, 1996). Learning difficulties are frequently present due to the existence of intellectual disability, deficits of attention, memory and concentration, sensory


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disorders, emotional and behavioral problems. In addition, specific intellectual dysfunction, difficulties in reading and writing, speech and language disorders, motor limitations, rapid fatigue and increased irritability significantly interferes with success and adaptation in school.

Visual and hearing impairments

Visual and hearing impairments occurs in children with cerebral palsy. Hearing impairment occurs in approximately 12% (Sankar & Mundkur, 2005), and visual impairments and disorders of ocular motility occurs in 28% in children with CP (Ashwal et al., 2004). In another study visual defects occur in 25- 39% of adult patients wit CP, and 8-18% of adults with cerebral palsy have hearing problems (Taylor, toward Krigger, 2006). Hearing impairment occur more commonly if the etiology of CP is related to very low birth weight, neonatal meningitis, or severe hypoxicischemic insults, and if children with CP have intellectual disability or abnormal neuroimaging studies. Disorders of visual perception may exist as isolated or as a part of symptoms in intellectual disability. Also, there is an increased presence of nystagmus, strabismus, refractive errors, amblyopia, hemianopia and optic atrophy in person with cererbral palsy.

Epilepsy Epilepsy is common in children with cerebral palsy. Epileptic seizures can manifest clinically diverse, and sometimes it is difficult to distinguish between seizures and involuntary movements in some form of CP. In children with intellectual disability, it is difficult to distinguish tonic, atonic and myoclonic attacks from dyskinesia and stereotypic movements (Dimitrijevic, 2007). In children with CP, epilepsy may occur from 35% to 62% with no difference among the types of CP, but it is most common among people with spastic quadriplegia (50% to 94%) (Sankar & Mundkur, 2005). The overall prevalence of childhood epilepsy is 3-10 per 1000 children. In the population of children with CP, prevalence of epilepsy is higher and ranges from 15-55% and the percentage increases further when there is presence of intellectual disability (71-94%) (Barkovich & Kjos, 1992).

Speech and language disorders Impairments associated with cerebral palsy differ from child to child in their severity and consequent effect on communication development, creating heterogeneity in the clinical population. Children with the same medical diagnosis vary widely in their speech and language development. They often have speech, language, and/or communication disorders (Aicardi & Bax, 1992). Although the exact prevalence of the communication disorders associated with CP is not known, it has been estimated that approximately 20% of children with a diagnosis of CP


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have severe communication impairment and are classified as non-verbal (Ratcliff & Little, 1996). Many more will have less severe speech and communication disorders as a consequence of their motor impairment, or disorders arising from speech, language, and cognitive processing deficits associated with CP. In other studies, data on the percentage of children with CP who have speech disorders vary from 67% (Anwar, et al., 2006) to over 80% (Odinga et al. 2006). These data suggest that speech, and language deficits are highly prevalent among children and people with CP, and greatly complicate the process of education and learning from the earliest period. Speech, language and communication impairment can be associated with any tipe of CP, irrespective of the nature of the central motor disorder in classical neurological terms (Pennington, Goldbard & Marshall, 2003). However, the severity of the motor impairment is an important variable in the communication development of children with CP. Many children with cerebral palsy experience communication difficulties because their motor impairments affect the range, speed, strength and consistency of movements needed to produce speech, gestures and facial expression (Pennington, Goldbart & Marshall, 2004). As well as the severity of motor disorder, disorders in cognitive functioning may also influence the communicative development in children with CP (Heim, Jonker & Veen, 2009). If a child has a severe degree of intellectual disability alogia and dyslogia may occur. Speech disorders can occur in relation to the type of neuromotor failure. Complete absence of speech is as little present in all four types of neuromotor deficits; speech difficulties are specific to ataxia, athetosis and mixed form, while paresis is characterized by preserved speech. Speech difficulties may arise in relation to the number of affected limbs. Children with tetraplegia (four-limb paralysis) tend to have more complex communication needs and regardless of the type neuromotor deficit, most of them do not speak or have severe speech difficulties. In cases where only one limb is affected speech is usually preserved, and only few of them have speech difficulties. Articulation disorders and impaired speech are present in 38% children with CP, and oromotor problems with feeding difficulties, swallowing dysfunction and drooling are also present (Reilly, Skuse, & Poblete, 1996). Receptive and expressive language deficits are also present in children with cerebral palsy and usually associated with intellectual disability. It is important to distinguish between expressive and receptive language when assessing communication abilities of children with CP. Verbal comprehension is known to play a pivotal role in eary language development (Sevcik, 2006), and comprehension of words can develop even if a child is not speaking.


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The most common impairments are dysarthria and reduced speech intelligibility (30-90%), but anarthria also occurs. Dysarthria may severely compromise their intelligibility (Ansel & Kent, 1992). Individuals with CP and dysarthria have normal grammatical understanding but smaller receptive vocabularies compared to individuals with CP without dysarthria (Bishop, Brown & Robson, 1990). Developmental apraxia of speech can also occur and it is characterized by disorder in the selection and sequencing of articulatory movements, sometimes present oral apraxia, intact comprehension, sparse expression, and sometimes nonfocal neurological symptoms. Developmental dysarthria, which is a syndrome of disruptionin respiration, phonation, resonance and prosody, is expressed differently according to the type of cerebral palsy. Impaired mobility can cause limited interaction with individuals in the environment and children with cerebral palsy might not be able to develop the linguistic skills necessary to develop more complex speech patterns (Uvebrant & Carlsson, 1994). On the other hand, the language deficits in this population may be caused by intellectual disability, attention and memory deficits, perceptual and sensory deficits, and many other factors.

RESEARCH GOALS

Objective of this study was to determine the speech and language abilities of children in elementary school who had a cerebral palsy as a primary impairment. The presence of associated disorders was explored as well as their possible relation to additional speech and language deficits, difficulties in reading and writing, as well as to success in managing the school curriculum.

Sample The sample consisted of 12 students from elementary school “Milan Petrovic”, Novi Sad. All students have cerebral palsy as a primary disorder, while most, but not all children, have associated problems such as intellectual disability, attention and memory deficits, visual impairment, seizures and others. The sample consists of two students from I, III, IV, V, and VIII grade and one student from VI and VII grade, including 7 male and 5 female students (Table 1). It should be noted that one class consisted of 3 to 5 students. From the table with a sample, it can be observed that the age of students mostly is not appropriate for grade that they are in, namely, the students were older than the children of the same grade from the general population. It can be assumed that the reason is an intellectual disability that is associated disorder in ten students. Two students from


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the sample have average intellectual abilities and without other associated disorders. Three students from the sample have mild intellectual disability, four of them have moderate, and three of them have severe intellectual disability. Table 1. General data

Primary disorder

Associated disorders No. Grade Age Gender Intellectual

disability Visual impairment

1. I 7.5 M CP moderate / 2. I 7.5 F CP severe / 3. III 11.5 M CP moderate / 4. III 10.5 F CP severe / 5. IV 12 M CP / / 6. IV 13 M CP moderate mild 7. V 15 M CP moderate / 8. V 16.5 M CP severe / 9. VI 14 F CP / / 10. VII 13 M CP mild mild 11. VIII 15 F CP mild mild 12. VIII 15.5 F CP mild mild

We asked about potential hearing and/or visual impairment, which are common in persons with CP and may have a negative impact on the development of speech and language abilities. Hearing impairment was not present in any of the respondents while vision impairment, which was present in four patients, was corrected with glasses, due to which negative impact to speech and language abilities was ruled out. In addition, the sample consisted of students with cerebral palsy who use wheelchairs or are possible to walk with the appropriate aid (crutches, compliance or assistance from another person). All students have good arm motility, or possibly the presence of mild spasms.

METHODOLOGY

The study was conducted during March 2012. As already stated, aim of the study concerned the assessment of speech and language abilities in children with cerebral palsy at school age. Consent for testing was obtained from parents of 12 students. Six students who have had developed verbal communication were tested, while data about abilities of 6 students who do not speak were obtained from teachers-special educators and speech therapists that were in constant contact with the child. Results are shown separately, for students who predominantly use nonverbal communication and for students who use verbal communication.


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For assessment of speech and language skills we used special didactic material ,,Evaluation and impelling of motor-perceptual and speech abilities” (Krajnovic, Bacurin, Dobrojevic & Robotic, 2004). It is designed for children ages 3 to 8 years, but since it examines the speech and language skills that are often damaged or underdeveloped in children with cerebral palsy at all ages, in this case was used it for children from I to VIII grade (ages 7 and a half to 16 years). The didactic material consists of three parts which are accompanied by color images, A5 format. The material can be used as a whole, but in this study, first were used segments related to assessing and abetment of speech and language skills, as well as some segments that include evaluation and impelling of motor and perceptual abilities. As an auxiliary material, we used pictures that allowed additional visual stimuli which, along with auditory stimuli, facilitate the testing process. Assessment of motor and perceptual abilities in children with CP, from I to VIII grade, purported the assessment of orientation to their own body movements, more precisely assessment of eye-hand coordination and eye-foot-hand coordination. Assessing speech and language abilities of children with CP was related to the assessment of: - articulation, phonemes pronunciation (pronunciation of vowels and

consonants, the pronunciation of words in which the phonemes are in the initial, medial and final position);

- pronunciation of composite words (diminutives and augmentatives); - differentiation and naming of phonemes and letters in words

(phonemic discrimination); - analysis and synthesis of words; - complementing of sentences; - telling stories through series of three pictures. Due to the small and heterogeneous sample, as well as because of the nature of assessed abilities, statistical analysis would not give valid significance therefore the results were presented as case studies, with a qualitative description of the abilities of each student, taking into account the impact of primary damage (CP) and associated disorders, particularly intellectual disability, on speech and language abilities of individuals.

RESULTS

Orientation to own body Before evaluation of speech and language abilities in children with cerebral palsy, the part of didactic material, previously described, was


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used for evaluation of motor and perceptual abilities in the total sample (12 students) and was related to the assessment of orientation to own body, which is one of the important prerequisites for the development of speech and language skills as well as reading and writing skills. In this study, the orientation to own body was assessed by eye-hand and eye-foot-hand coordination. Eye-hand coordination was assessed by simply orders (e.g. “show the right hand”) and by more complex orders (e.g. “show the left eye with your right hand”). Eye-foot-hand coordination was also assessed by simple orders (e.g. “show the right leg”), as well as by complex orders (e.g. “show the right lag with your left hand”). Results are shown in the table 2 where the success of the child to properly orients to his own body is marked with a plus, (+), and failure in the orientation with a minus (-). It was also noted that if the student understands verbal instruction given by the examiner. Table 2. No.

Grade

ID

Eye-hand Eye-foot-hand Comprehension of instructions

Simple instructions

More complex instructions

Simple instructions

More complex instructions

1. I moderate

- - - - -

2. I severe - - - - - 3. III moder

ate + - + - +

4. III severe - - - - - 5. IV / + + + + + 6. IV moder

ate + - + - +

7. V moderate

+ - + - +

8. V severe - - - - - 9. VI / + + + + + 10.

VII mild + + + + +

11.

VIII mild + + + + +

12.

VIII mild + - + - +

The results shown in the table indicate that the four students (1,2,4,8.) did not understand the instruction for assessing of orientation to own body, therefore they were not successful in eye-hand and eye-foot-hand coordination. The degree of intellectual disability (severe and moderate) as well as attention deficits, as an associated disorders in all four students, may be important interfering factors in this case, not the motor deficits, because, as already noted, neither one of the students in our sample have the paralysis of upper extremities.


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Eight students from the sample understood the instructions for assessing of orientation to own body, whereby two students of average intelligence (5.,9.) and two with mild intellectual disability (10,11.) were successful in all tasks. The remaining four students, three with moderate (3,6,7.) and one with mild intellectual disabilities (12.), were successful in tasks with simple instructions given by the examiner, while they were unsuccessful in tasks with more complex instructions. These eight students did not exhibit significant attention deficits, suggesting that variances of performance in orientation to own body, observed between these two groups, are probably caused by the intellectual abilities of the individual.

Students who predominantly use nonverbal communication First, verbal and nonverbal skills will be presented, as well as comprehension abilities of six students in the sample who do not establish, or have very meager verbal communication, so it was not possible to use earlier described didactic materials. Data were obtained from teachers-special educators and speech therapists who were in constant contact with the child. The dominant form of communication for these children is non-verbal communication, which is mainly achieved with gaze, facial expression, gesture, using pictures and drawings. Some students use a few inarticulate speech sounds or incorrectly articulated words to point out to familiar persons, objects, phenomena and activities, and that is intelligible only to the people with whom the student is in daily contact (table 3). This group consists of those students who attend I, III and V grade. Data shown in the table indicate that of the six students, who predominantly use nonverbal communication, two students don’t verbalize a single word, while four students verbalize from 3 to 5, 10 or 15 of incomprehensible words. Among the results the presence of intellectual disability is pointed out because, in addition to the primary disability, can significantly affect speech and language abilities. Among these students three students have severe and three students have a moderate intellectual disability. In addition, their comprehension is limited as four students can understand only simple verbal orders, while two students do not understand and do not respond to verbal orders but only to certain sounds or images.


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Table 3. No. Grade Intellectual

disability Verbal communication

Non-verbal communication

Comprehen-sion

1.

I

moderate

3 words (mom, dad, (g)ive

inarticulate sounds, staring, pointing with a hand

understands the simple order

2.

I

severe

/

inarticulate sounds, no eye contact

cannot understand a simple order, respond only to some pictures and sounds

3.

III

moderate

10-15 unintelligible words

staring, gesture, pointing with a hand


4.

III

severe

/

inarticulate sounds, no eye contact

cannot understand a simple order, respond only to some pictures and sounds

5.

V

moderate

up to 5 unintelligible words

eye contact, the use of pictures, gesture, pointing with a hand


6.

V

severe

10-15 unintelligible words

eye contact, the use of pictures, gesture, pointing with a hand


Two students from this subsamples (2. and 4.) who do not understand even simple commands are the same ones who have not developed verbal communication and belong to a group of children with severe intellectual disability. In addition, it is important to emphasize that these children have associated and frequent seizures, which can greatly affect the functioning and the development of individual skills. It can be assumed that cerebral palsy, associated with a severe intellectual disability and seizures, can cause such a severe speech and language deficits of these students. Four students can understand only simple verbal commands, and they use few words which are incomprehensible


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to the wider environment. Among them there is one student with a severe, and three students with moderate intellectual disability.

Students who predominantly use verbal communication Six students within the sample were assessed with previously described didactic material for evaluation and impelling of motor-perceptual and language abilities. Assessing speech and language skills refers to an examination of speech development and the detection of possible speech and language disorders. It involves examination of: articulation, ability for phonemic discrimination, vocabulary and syntax abilities and the presence of speech disorders. It is necessary to determine whether speech and language skills are appropriate to the age of the child or whether they are below or above expectations in relation to age. Such an assessment is important to administer within children with cerebral palsy of all age, because the cerebral palsy is often associated with voice, speech and language disorders which can manifest as aphonia, rhinolalija, dyslalia, dysarthria, apraxia of speech, congenital motor aphasia and undeveloped speech / alogia. Sub-sample, that was evaluated, consisted of two students of IV and VIII, and one student of VI and VII grade who were capable for verbal communication. Two students had average intellectual abilities, three of them had mild and one student had moderate intellectual disability. Already from this data we can see that the intellectual abilities are very important for speech and language development since, compared with a group of students who predominantly use nonverbal communication, students in this subgroup have an average intellectual abilities or mild forms of intellectual disability.

Articulation and pronunciation of composite words Articulation involves the formation of speech sounds, and refers to the movement and position of the speech organs while pronouncing sounds. Assessment determines whether speech sound is pure, distinct and clear, or whether there is a distortion, omission or substitution. Assessment of articulation implies pronunciation testing of all phonemes in a language, in the initial, medial and final position in words. The student has to name what he sees in the picture, or repeat that word which is previously pronounced by examiner. In this study we used picture material for an assessment of articulation. Assessment of pronunciation of composite words included the use of picture material as an incentive for pronunciation of words with consonant combinations and combination with phonemes such as č, ž, š - c, z, s, which may pose difficulties for the child. It can also be used in habilitation for differentiation of phonemes, stimulation of


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vocabulary, augmentatives and diminutives, as well as language forms (Krajnovic et al., 2004). Children with cerebral palsy may have difficulties in adequate articulation of speech sounds. Insufficient power for air flow and difficulties in breathing, respiratory infections and changes in the oral cavity are the most common causes of such difficulties. Teeth can be misshapen, irregularly spaced, large or small, or may be missing. Frequently, there are present anomalies in the structure of the lips, tongue (incrassated or uncoordinated tongue), jaw (protrusion and prognathia), and a short frenulum. Limited jaw mobility, low mobility of the lips and tongue (due to paresis), spastic vocal cords and soft palate, lateral bite, and hypersalivation are also frequently present. All this can greatly affect the correct pronunciation of certain speech sounds, as well as the general quality of voice and speech. Table 4 shows articulation of six students from the subgroup during pronunciation of single words as well as the pronunciation of compound words. Table 4. No.

Grade

Intellectual disabi-lity

Articulation

Distortion Omission

Substitution

Pronunciation of compound words

1. IV / intelligible

interdental stigmatism

/

/

without difficulty

2.

IV

moderate

intelligible

nasal pronunciation of the majority of phonemes

/

/

do not recognize the concepts in picture and does not name them

3. VI / intelligible

/ / / without difficulty

4. VII mild intelligible


5.

VIII

mild

unintelligible

of all phonems

recognize and differ, but does not pronounce

6. VIII mild intelligible



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Distortion of speech sounds implies that phoneme is there and it is pronounced, but its quality is changed, i.e. there are articulatory-acoustic deviations from the standard norms. Some of the typical distortions of speech sounds were: interdental, lateral and nasal stigmatism. From the table above, it can be seen that the articulation of the five children in this subsample is good and comprehensible for listener, with mild distortionsin the pronunciation of speech sounds. The presence of interdental sigmatism in students with average intellectual abilities (1.) is a consequence of the lack of teeth in upper jaw. The omission and substitution are not present in any of the students. However, one student with mild intellectual disability (5.), has an expressive form of speech muscles spasms, so that the pronunciation of all speech sounds is very difficult for her, pronunciation is distorted and speech is incomprehensible for the listener. Otherwise, it is important to note that this student recognizes all the terms in the picture and can name them in written form. This indicates that the cause of poor results in this part of the research is not due to lack of intellectual disability and failure of concepts recognition. The remaining four students, two of them with average intelligence (1,3.) and two with mild intellectual disability (4,6.) do not have difficulties with pronouncing words with complex consonant clusters, they recognize the concept from picture and name it. On the other hand, students with moderate intellectual disability (2.) does not recognize the concepts from picture and do not name them, although his speech was comprehensible and there was no major distortions in articulation during spontaneous conversation. It can be assumed that, in this student with cerebral palsy, the level of intellectual functioning and attention deficits, which exist as associated problems, are main causes of these difficulties.

Differentiation and naming of speech sounds During assessment of naming and differentiation of speech sounds (phonemic discrimination), was used picture material which consists of pairs of images with concepts that present words which differ in one or two phonemes. The child should name the concepts and recognize which sounds differ. In addition, if the child knows the letter, he can read words that are written below the picture and point out the different letters in words. The table 5 shows the results of phonemes discrimination and naming from the subgroup of students who predominantly use verbal communication. Concepts, which were used, present words which differ in one phoneme / letter (e.g. koka/kuka) and in two phonemes / letters (e.g.ruka / muva). We assessed the child's ability to discriminate and name the phoneme (P), letter (L) and terms (T). If the child was


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successfulthe box was filled with plus (+), and if he/she was unsuccessful, even in several attempts, the box was filled with minus (-). Table 5. No.

Grade

ID

Discrimination

Naming

one phoneme/letter

two phonems/letters

one phoneme /letter

two phonemes/letters

P L T P L T P L T P L T

1. IV / _ + + + + + + + + + + +

2. IV moderate

_ _ _ _ _ _ _ _ _ _ _ _

3. VI / _ + + + + + + + + + + +

4. VII mild _ + + + + + + + + + + +

5. VIII mild + + + + + + + + _ + + _

6. VIII mild _ + + _ + + + + + + + +

A student with cerebral palsy and moderate intellectual disability (2.) was the only one unsuccessful on all tasks of discrimination and naming of phonemes and letters. It can be assumed that the degree of intellectual disability is one of the key reasons for this failure, because in this subsample he had a lowest degree of intellectual abilities. Besides, he is the only student from this group who does not read and does not even recognize single letters. The other five students, from I to VIII grade, were mostly successful in this task. The phonemic discrimination was the most common difficulty during distinguishing one or two phonemes which were pronounced by the examiner. Differentiation and naming of letters and terms as well as pronunciation (naming) of phonemes were not a problem for these students. Only female student with mild intellectual disability (5.), due to spasm of speech muscles, had difficulties in the naming of concepts which she differs and recognizes, and she pronounced a single phonemes and named individual letters successfully, but with great effort.

Analysis and synthesis of words With pictures and written materials it can be assessed the ability of child to perform analysis and synthesis of words. In this study, child was asked to name the terms within three pictures. These terms consisted of phonemes at the beginning, middle and end of the word.


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This assessment may be conducted separately for all 30 phonemes in Serbian language. Then, child was asked to determine the position of this phoneme in words, to determine of which phonemes the word is consisted (word analysis), to link the spelled or mixed phonemes (synthesis) or to observe and write the missing letter. The word analysis refers to the separation of phoneme, as part of a word, and the determination of its place in it, and it is subjected to the principle “from the general to the particular”. The word synthesis means the assembling of separated set of phonemes into the word as well as recognition of word meaning, and it is subjected to the principle “from the particular to the general”. Successfully performed analysis and synthesis of words is one of the important prerequisites for a successful mastering of reading and writing in school. The table 6 shows data suggesting the effectiveness of analysis and synthesis of words in students who predominantly use verbal communication. If the child was successful the box was filled with plus (+), and if he/she was unsuccessful, even in several attempts, the box was filled with minus (-). Table 6. No.

Grade

ID

Naming the terms from picture

Word analysis

Position phonemes in the word

Perception of the omitted letters

Word synthesis

1. IV / + + + + + 2. IV moderat

e - - - - -

3. VI / + + + + + 4. VII mild + + + + + 5. VIII mild + + + + + 6. VIII mild + + + + +

From the results we can see that the only student with cerebral palsy and moderate intellectual disability (2.) was not successful in any task. The other five students were successful on all five tasks. These students have cerebral palsy and average intellectual ability or mild intellectual disability. It was possible to assessed naming of terms from picturesas well as other abilities in oral and written form, so that even student with severe spasms (5.) showed good results. As already pointed out, success in these tasks is an important prerequisite for a successful mastering of reading and writing in school. Five student have not had difficulties with reading, and thus, within the limits of their intellectual abilities, they successfully mastering curriculum. It is important to note that only student with moderate intellectual disability (2.), does not read and write. He can hold a pencil,


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but does not recognize the letters, and he does not draw. The other five students have developed the ability to write, but because of motility limitations, four of them used only printed, while one student used printed and cursive letters.

Completing the sentence We assessed the child's ability to complete a sentence with one word (to begin or end the sentence) on the basis of the displayed pictures. Students were given six pictures depicting animals (e.g. cat sleeps ... ducks that swim ... bird which stands at tree branch ...). The student was able to complete the sentence in written and oral form. Of the six students, only students with moderate intellectual disability did not recognize any of terms from picture and could not complete the sentence. The other five students recognized concepts and action from picture, and successfully completed the sentencein oral and /or written form.

Telling the story based on series of pictures The students were given three pictures with few elements which, in a sequence, represent a story. The student was expected to tell a story where we focused attention on evaluation of the recognition and naming of terms from the picture, the complexity and grammatical construction of sentences, and the number of sentences used to tell the story. The sentences could have been simple, compound and complex, and grammatical constructions could have been correct or incorrect (table 7). Table 7. No.

Grade

ID

Recognition and naming of terms

Complexity of sentences

Grammatical construction of sentences

The number of sentences

1. IV / + complex correct 4 2. IV moderate - / / 0 3. VI / + complex correct 4 4. VII mild + simple correct 2 5. VIII mild + simple correct 2 6. VIII mild + compound correct 3

A student, who has cerebral palsy and moderate intellectual disability (2.), was unsuccessful on all tasks. The other five students successfully recognized and named terms from images, and phrases that they used were grammatically correct. From the table it can be noticed the differences in language abilities of students are probably caused by intellectual abilities. Differences, between students with average


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intelligence on the one hand and a mild intellectual disability on the other hand, were observed in number of used sentences and their complexity. Both students with average intellectual abilities used exclusively complex sentences and both used four sentences in order to tell the story. On the other hand, one student with a mild intellectual disability used three compound sentences, and the remaining two students, with the same degree of intellectual disability, used only two simple sentences consisting of two elements (e.g.“bird flies”).

CONCLUSION

Speech and language development is a complex process which requires, among other things, proper development and functioning of the perceptual and motor skills, CNS and the speech organs. From the results we can conclude that, in children with cerebral palsy, speech and language development is frequently not consistent with the expected relative to calendar age. The reason for this may be primarily motor disorders already mentioned, paresis and paralysis that are main features of the cerebral palsy, as the primary disorder of the students from the sample. It was noted that the children from the sample who have an average intelligence without associated disorders exhibited only mild speech deficits (voice distortion), and language development was normal. On the other hand, ten students, from I to VIII grade, have associated disorders which are common feature of cerebral palsy. Speech and language deficits, shown in the results, are due to different degrees of intellectual disability (highly expressed in children with moderate and severe ID), associated deficits of attention, memory and concentration, and seizures. Half of the children in the sample, the students in I, III, and V grade aged from 7 to 16.5 years, predominantly use non-verbal communication, due to very limited or underdeveloped verbal communication and deficits in comprehension. This result indicates the seriousness and gravity of the CP as a disorder and its associated deficits. Speech and language deficits in children with CP and intellectual disability, who predominantly use verbal communication, are manifested as difficulties in recognition of concepts, analysis and synthesis of words and in construction of complex sentences. Of the total sample (12 students), seven students have not developed reading and writing skills, probably because of level of ID, degree of motor disorders and deficits of attention and memory. On the other hand, the five students, two of them with average intellectual abilities and three with mild intellectual disability, read and write, but because of motor limitations, only four of them use printed, while one student use printed and cursive letters. As it is presented, one can see that children with cerebral palsy, as well as other people with severe disabilities and disorders, sometimes can not achieve communication by means of natural, conventional speech and writing. In that case,


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augmentative and alternative communication can be used, as a kind of supplement or replacement for natural speech or writing (Jovanovic-Simic, 2007). Speech and language abilities of students in the sample, which range from alogia, difficult and meager speech to a typical development, indicate a high heterogeneity in population with cerebral palsy. Also, that points out potential difficulties that they may encounter in the educational process, because the speech, language, listening, comprehension, reading and writing are equally important skills which are interrelated during mastering of the school curriculum. Differences in speech and language and other abilities, suggest excessive need for individual plans and programs, as well as a variety of activities, didactic materials, means, methods and techniques of teaching. In addition, the role of speech and language therapist in rehabilitation of children with cerebral palsy is invaluable because of necessity of prelingual stimulation and long-term, continuous work on language development, verbal communication and communication in general. Speech and language therapy aims to maximize children’s ability to communicate through speech, gesture, and/or supplementary means, such as communication aids, and to enable them to become independent communicators.

ACKNOWLEDGEMENT

This paper resulted from the project of the Ministry of Science and Technological Development of Serbia entitled “Evaluation of treatment in acquired speech and language disorders” no. 179068.

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