Changes in voice quality after speech-language therapy intervention in older children with cerebral palsy

OBJECTIVE

We examined whether perceived voice quality is altered in a group of children with cerebral palsy (CP) following an intervention focusing on respiration and phonation, and whether possible improvements might be associated with increased intelligibility levels.

METHODS

Sixteen individuals with CP and dysarthria (9 girls, mean age 14 years, SD = 2; 9 with spastic type CP, 2 dyskinetic, 4 mixed, 1 Worster-Drought syndrome) completed intelligibility assessments on separate days twice before intervention, at termination of treatment and at 6-week follow-up using 50 words from the Children's Speech Intelligibility Measure lists, and describing cartoon strips. Experienced speech-language pathologists rated voice quality employing GRBAS scales.

RESULTS

There was no clear evidence that change in voice quality pre-post intervention was large compared with change in the pre-intervention or post-intervention periods. Asthenia demonstrated largest improvement (effect size of 0.4). Intelligibility correlated weakly with Grade, Breathiness and Asthenia, but not with Roughness or Strain. A deterioration of 1 unit on the Grade and Asthenia scales was associated with an approximately 11% decrease in intelligibility.

CONCLUSION

Perceived changes in voice quality were small compared to changes in intelligibility. Further investigations must examine other variables potentially associated with intelligibility gain to better understand the links between the respiratory-phonatory intervention and improved intelligibility.

A case study template to support experimental design in Augmentative and Alternative Communication and Assistive Technology

PURPOSE

The field of Augmentative and Alternative Communication/Assistive Technology (AAC/AT) has an extensive literature of non-experimental case descriptions. This limits the generalisation of findings. The current study aimed to develop a template to contribute to single case experimental design specifically for the field of enquiry.

METHOD

A qualitative case study methodology was adopted to construct and evaluate the content and structure of the case study template. Participants represented relevant stakeholder groups. Data were collected through template evaluations and focus groups. Data were analysed using Framework Analysis.

RESULTS

Across stakeholder groups, results produced a consensus on AAC/AT terminology, content and detail that may usefully inform single case experimental design.

CONCLUSIONS

This is a complex area of rehabilitation that can best support its service users and service commissioners by using tools that facilitate collaborative working. The findings suggest that it is possible to produce a data collection tool that is acceptable to all stakeholder perspectives.

Development of The Viking Speech Scale to classify the speech of children with cerebral palsy

Surveillance registers monitor the prevalence of cerebral palsy and the severity of resulting impairments across time and place. The motor disorders of cerebral palsy can affect children's speech production and limit their intelligibility. We describe the development of a scale to classify children's speech performance for use in cerebral palsy surveillance registers, and its reliability across raters and across time. Speech and language therapists, other healthcare professionals and parents classified the speech of 139 children with cerebral palsy (85 boys, 54 girls; mean age 6.03 years, SD 1.09) from observation and previous knowledge of the children. Another group of health professionals rated children's speech from information in their medical notes. With the exception of parents, raters reclassified children's speech at least four weeks after their initial classification. Raters were asked to rate how easy the scale was to use and how well the scale described the child's speech production using Likert scales. Inter-rater reliability was moderate to substantial (k>.58 for all comparisons). Test-retest reliability was substantial to almost perfect for all groups (k>.68). Over 74% of raters found the scale easy or very easy to use; 66% of parents and over 70% of health care professionals judged the scale to describe children's speech well or very well. We conclude that the Viking Speech Scale is a reliable tool to describe the speech performance of children with cerebral palsy, which can be applied through direct observation of children or through case note review.

Intensive dysarthria therapy for younger children with cerebral palsy

AIM

The aim of this study was to investigate if intervention targeting breath support, phonation, and speech rate increases speech intelligibility and participation in the conversational interactions of younger children with dysarthria and cerebral palsy (CP).

METHOD

Fifteen children with dysarthria and CP (nine males, six females; age range 5-11 y, mean age 8 y, SD 2 y; CP type: eight spastic, four dyskinetic, one ataxia, two Worster Drought syndrome; Gross Motor Function Classification System levels II-IV, median level II) participated in this study. Children received three sessions of individual therapy per week for 6 weeks. Intelligibility of single words and connected speech was compared across five points: 1 and 6 weeks before therapy and 1, 6, and 12 weeks after therapy. Three familiar listeners and three unfamiliar listeners scored each recording. Participation in communicative interactions was measured using the Focus on the Outcomes of Communication Under Six (FOCUS) tool. Analyses of variance and paired t-tests were used to investigate change.

RESULTS

Mean speech intelligibility increased after therapy to familiar listeners (single words 10.8%, 95% confidence interval [CI] 7.2-14.4; connected speech 9.4%, 95% CI 4.8-14.1) and unfamiliar listeners (single words 9.3%, 95% CI 6.8-11.8; connected speech 10.5%, 95% CI 7.3-13.8). FOCUS scores increased following therapy for parents (mean increase 30.3, 95% CI 10.2-50.4) and for teachers (28.25, 95% CI 14.4-42.1), but changes did not correlate with intelligibility. A wide variation was seen in individual responses to therapy.

INTERPRETATION

Brief intensive therapy is associated with gains in intelligibility and communicative interactions for some younger children with dysarthria.

Interventions for drooling in children with cerebral palsy

BACKGROUND

Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP.

OBJECTIVES

(1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning.

SEARCH METHODS

We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by MW, MS and LP and differences resolved through discussion.

MAIN RESULTS

Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies.

AUTHORS' CONCLUSIONS

It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.

Management of drooling in children: a survey of UK paediatricians' clinical practice

BACKGROUND

Drooling is common in children with disordered oral-motor control. There is little evidence about the comparative effectiveness of different interventions used to reduce the impact of drooling. Anecdotal reports suggest clinicians' management of drooling varies widely. The aims of this survey were to establish which drooling interventions are currently used, how their effectiveness is monitored and how frequently adverse effects are reported.

METHODS

151 UK paediatricians completed a questionnaire about their management of drooling.

RESULTS

Paediatricians saw one new child with problematic drooling and three follow-up children per month. The most common prescribing pattern was hyoscine first line (84.7%) followed by glycopyrronium bromide second line. The reported rate of adverse effects of medications was lower than expected (median 10% for hyoscine). Very few paediatricians used standardized methods of measuring the medication's effectiveness or adverse effects.

CONCLUSION

Paediatricians regularly see small numbers of children with problematic drooling. Their clinical management of drooling varies; this is most likely because of a lack of evidence about the most effective approach. Comparative trials of interventions and the development of evidence-based clinical guidelines would improve the management of children's drooling.

Interventions for drooling in children with cerebral palsy

BACKGROUND

Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP.

OBJECTIVES

(1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning.

SEARCH METHODS

We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by MW, MS and LP and differences resolved through discussion.

MAIN RESULTS

Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies.

AUTHORS' CONCLUSIONS

It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, power and coordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and low-pitched voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether direct intervention aimed at improving the speech of children with dysarthria is more effective than no intervention at all. To assess whether individual types of intervention are more effective than others in improving the speech intelligibility of children with dysarthria.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to April 2009, handsearched relevant journals published between 1980 and April 2009, and searched proceedings of relevant conferences between 1996-2009.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

L Pennington conducted searches of all databases and conference reports. L Pennington, N Miller and S Robson handsearched journals. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

We found no firm evidence of the effectiveness of speech and language therapy to improve the speech of children with early acquired dysarthria. No change in practice is warranted at the present time. Rigorous research is needed to investigate if the positive changes in children's speech observed in small descriptive studies are shown in randomised controlled trials. Research should examine change in children's speech production and intelligibility. It should also investigate the secondary education, health and social care outcomes of intervention, including children's interaction with family, friends and teachers, their participation in social and educational activities, and their quality of life. Cost and acceptability of interventions must also be investigated.

Effects of it takes two to talk--the hanen program for parents of preschool children with cerebral palsy: findings from an exploratory study

PURPOSE

To investigate whether It Takes Two to Talk-The Hanen Program for Parents of Preschool Children With Cerebral Palsy is associated with change in interaction between children who have motor disorders and their parents.

METHOD

Eleven children aged 19-36 months who had nonprogressive motor disorders that affected their communication, and their mothers, were observed 4 months and 1 month before mothers attended It Takes Two to Talk training, and 1 month and 4 months after its completion.

RESULTS

Interaction patterns were stable prior to training. After training, mothers initiated less and produced more responses and fewer requests. Children produced more initiations, as well as more requests and provisions of information, after training. Mothers' linguistic input did not change in amount or complexity. Changes were maintained 4 months later. Mothers' views of parenting did not change.

CONCLUSIONS

It Takes Two to Talk may be associated with positive communication change for this group. Further investigation of its clinical effectiveness is warranted.

Describing participants in AAC research and their communicative environments: Guidelines for research and practice

PURPOSE

People who use augmentative and alternative communication (AAC) vary widely in their skills and communication needs. Interventions have been developed to meet different needs, but have met with varied success. Attempts to discover why interventions succeed or fail are hindered by the lack of detailed description of the research participants and the environments in which they communicate. This paper reviews the information commonly given about AAC research participants and presents guidelines for the description of people who use AAC, their conversation partners and their communicative environments.

METHOD

Electronic databases were searched for AAC intervention research reports published between 1990 and 2004. Data on research participants and their communication environments were extracted from reviewed papers. Information given in published papers and variables known to affect communication were presented to an expert group. A modified Nominal Group technique was used to decide what information should be reported in AAC intervention research.

RESULTS

Guidelines for participant description that link with the World Health Organization International Classification of Functioning, Disability and Health were developed from the results of the nominal group.

CONCLUSIONS

Detailed information is needed to demonstrate efficacy of AAC interventions. Guidelines for participant description are presented and discussion of their utility is now needed.

What can management theories offer evidence-based practice? A comparative analysis of measurement tools for organisational context

BACKGROUND

Given the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualize and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare.

METHODS

A structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations.

RESULTS

Thirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains.

CONCLUSION

If the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management sciences. Comparison of measurement tools across domains suggests that there is scope within EBP for supplementing the current emphasis on human and technical resources to support information uptake and use by individuals. Consideration of measurement tools from the fields of KM and OL shows more content related to social mechanisms to facilitate knowledge recognition, translation, and transfer between individuals and groups.

Analysis of compositional data in communication disorders research

The study of communication and its disorders often involves coding several behaviors and examining the proportions with which individual behaviors are produced within data sets. Problems are encountered when studying multiple behaviors between data sets, because of the interdependence of the proportions: as one coded behavior increases, at least one other must decrease. The interdependence of data means that traditional statistical techniques can be used to analyse differences in the proportion of only one behavior over time or between clinical groups. We describe a statistical technique, previously used in geological and biomedical research, which can be used to analyse all behaviors in compositional data sets, and give examples of its use with interaction data. The technique allows, for the first time, full comparison of entire patterns of multiple communication behaviors, both over time and between clinical groups. The technique will aid both basic and applied communication research.

LEARNING OUTCOMES

Readers will understand the advantages and limitations of frequency counts and proportions for the analysis of multiple behaviors. Readers will be able to analyze change in proportions of multiple behaviors within a data set between groups and across time.

It Takes Two to Talk--The Hanen Program and families of children with motor disorders: a UK perspective

BACKGROUND

Speech and language therapy for young children who have motor disorders targets both the children themselves and their parents. Therapy for parents often involves training about communication and how to foster children's development. It Takes Two to Talk--The Hanen Program for Parents has become popular in the UK, but has not been specifically evaluated for this client group. This study, which was part of a larger investigation of the acceptability and potential effects of the programme on the communication patterns of mothers and their young children with motor disorders, investigated therapists' experiences of providing the training in the National Health Service (NHS) and their views on its effectiveness.

METHODS

Four focus groups, which involved 16 speech and language therapists who provide It Takes Two to Talk in NHS Trusts in England, were analysed using qualitative methods.

RESULTS

The themes indicated that therapists perceived the training programme to be effective in helping parents to develop a facilitative communication style. Therapists reported secondary outcomes of positive changes in parents' confidence and in relationships between parents and their children and between parents and therapists. Barriers to the provision and success of the programme were thought to relate to resources, parents' apprehensions about the programme's content and delivery and support from key stakeholders. Barriers were seen to be minimized in services where other members of the healthcare teams actively supported the training programme and where the intervention was integrated as part of a care pathway.

CONCLUSIONS

The information from this study may assist service providers in the marketing, planning and delivery of new intervention methods, to ensure that they are seen as valuable and acceptable by parents.

Influence of listening conditions and listener characteristics on intelligibility of dysarthric speech

Little is known about the effects of listener characteristics or listening conditions on intelligibility scores. This study compared intelligibility scores of dysarthric speech achieved under a standard listening condition with those obtained in non-standard conditions and investigated the effect of listener age, gender and familiarity with speaker accent on intelligibility scores. No differences were observed in the mean intelligibility scores across standard and non-standard listening conditions. However, mean range of scores in the standard condition was lower than in the non-standard condition (t = 3.07, df 90, p<.003; 95% CI 2.04-9.76). No main effects of listener age, gender or familiarity of accent were observed. When composite effects were examined increased age in male listeners was associated with reduced intelligibility scores. Results from the current study suggest that when conducting intelligibility research listening conditions should be standardised and that adult listeners of either gender and any age may be used to test intelligibility outcomes providing hearing acuity is taken into consideration.

Assessing adherence to the evidence base in the management of poststroke dysphagia

OBJECTIVE

To evaluate the reliability and responsiveness to change of an audit tool to assess adherence to evidence of effectiveness in the speech and language therapy (SLT) management of poststroke dysphagia.

DESIGN

The tool was used to review SLT practice as part of a randomized study of different education strategies. Medical records were audited before and after delivery of the trial intervention.

SETTING

Seventeen SLT departments in the north-west of England participated in the study.

SUBJECTS

The assessment tool was used to assess the medical records of 753 patients before and 717 patients after delivery of the trial intervention across the 17 departments. A target of 10 records per department per month was sought, using systematic sampling with a random start.

ANALYSIS

Inter- and intra-rater reliability were explored, together with the tool's internal consistency and responsiveness to change.

RESULTS

The assessment tool had high face validity, although internal consistency was low (ra = 0.37). Composite scores on the tool were however responsive to differences between SLT departments. Both inter- and intra-rater reliability ranged from 'substantial' to 'near perfect' across all items.

CONCLUSIONS

The audit tool has high face validity and measurement reliability. The use of a composite adherence score should, however, proceed with caution as internal consistency is low.

Promoting research use in speech and language therapy: a cluster randomized controlled trial to compare the clinical effectiveness and costs of two training strategies

OBJECTIVE

To evaluate the clinical and cost effectiveness of two training strategies to promote the use of research evidence in speech and language therapy (SLT) management of poststroke dysphagia.

DESIGN

Pragmatic, cluster randomized trial.

SETTING

Seventeen SLT departments in north-west England.

PARTICIPANTS

Two SLTs from each department received training and cascaded information across their department. Process of care was measured from the notes of 708 patients with acute poststroke dysphagia across eight departments allocated to training strategy A, and 762 patients across nine departments in strategy B.

INTERVENTIONS

Strategy A: training on the critical appraisal of published research papers and practice guidelines. Strategy B: strategy A plus training on management of change in clinical practice.

MAIN OUTCOME MEASURES

Pre- and post-training adherence to practice guidelines in poststroke dysphagia management, based on a review of case notes. Incremental cost of increased adherence to clinical guidelines.

RESULTS

Departments' practice differed in adherence to guidelines. Departments changed following training (F=2.22, df 16, 1436, p=0.004). The effect of training strategy on clinical practice was not significant. Strategy B departments engaged in more activities relating to research use following training than strategy A. Total costs of training averaged ł2001, 2892 Euros, $3886 (SD ł502, 726 Euros, $975) for strategy A and ł3366, 4866 Euros, $6537 (SD ł2121, 3066 Euros, $4119) for strategy B.

CONCLUSIONS

Training in research implementation in addition to critical appraisal and guideline introduction is associated with increased dissemination activities and awareness of research information, but not with changes in clinical practice within six months of training. The department in which SLTs work influences their use of research. The process of poststroke dysphagia management can be measured using a tool developed from practice guidelines.

Interaction training for conversational partners of children with cerebral palsy: a systematic review

BACKGROUND

Research has shown that children with cerebral palsy have difficulties acquiring communication skills and that conversation with familiar partners follows restricted patterns, which are characterized by high levels of partner control and children's responsivity. Speech and language therapy often includes training for conversational partners to help to them recognize children's communicative signals and to create opportunities for children to take a more equal and independent role in conversation. However, the effectiveness of this indirect therapy has not been demonstrated reliably.

AIMS

To review systematically all experimental research on communication training for conversational partners of children with cerebral palsy and to evaluate the effectiveness of this type of intervention.

METHODS & PROCEDURES

As part of a wider review, health, psychology and education electronic databases were searched up to December 2002 for reports of experimental studies on the training of conversational partners to facilitate the communication of children with cerebral palsy, which contained an element of control. References from identified studies were followed-up and relevant journals and conference reports were hand-searched. Identified studies were assessed for inclusion by the first author. Two reviewers independently abstracted data on the quality and content of each study.

OUTCOMES & RESULTS

Four studies were identified from five research reports that met the criteria for inclusion in the review, comprising three group studies and one single case experiment. Common targets for training were observed across the studies. These included positioning of the conversational partner and child for interaction, creating communication opportunities and responding to children's communicative signals. Changes were observed in the conversation patterns used by conversational partners, which should facilitate the communication of children with cerebral palsy. However, the studies contain methodological flaws and as a result they cannot demonstrate that the changes were definitely a result of the intervention.

CONCLUSIONS

Research on the effectiveness of interaction training for conversational partners of children with cerebral palsy is in its early stages. Training has incorporated common targets, which are widely acknowledged by clinicians to affect the communication of children with motor disorders. Trends in behaviour change have been suggested by research to date, but further studies that address the methodological inadequacies of the original research are needed to evaluate the effectiveness of this type of intervention. Suggestions of ways to improve the design and reporting of future studies, that will allow the mapping of interventions to clients, are discussed in this review.

Speech and language therapy to improve the communication skills of children with cerebral palsy

BACKGROUND

The production of speech, language and gesture for communication is often affected by cerebral palsy. Communication difficulties associated with cerebral palsy can be multifactorial, arising from motor, intellectual and / or sensory impairments, and children with this diagnosis can experience mild to severe difficulties in expressing themselves. They are often referred to speech and language therapy (SLT) services, to maximise their communication skills and help them to take an independent a role as possible in interaction. This can include introducing augmentative and alternative communication (AAC) systems, such as symbol charts or speech synthesizers, as well treating children's natural forms of communication. Various strategies have been used to treat the communication disorders associated with cerebral palsy but evidence of their effectiveness is limited.

OBJECTIVES

To determine the effectiveness of SLT that focuses on the child or their familiar communication partners, as measured by change in interaction patterns. To determine if individual types of SLT intervention are more effective than others in changing interaction patterns.

SEARCH STRATEGY

Searches were conducted of MEDLINE, CINAHL, EMBASE, PSYCH INFO, LLBA, ERIC, WEB of SCIENCE, NRR, BEI, SIGLE up to December 2002. References from identified studies were examined and relevant journals and conference reports were hand-searched.

SELECTION CRITERIA

Any experimental study containing an element of control was included in this review. This includes non-randomised group studies and single case experimental designs in which two interventions were compared or two communication processes were examined.

DATA COLLECTION AND ANALYSIS

L Pennington searched for and selected studies for inclusion. J Goldbart and J Marshall independently assessed separate random samples each comprising 25% of all identified studies. Two reviewers independently abstracted data from each selected study. Disagreements were settled by discussion between the three reviewers.

MAIN RESULTS

Eleven studies were included in the review. Seven studies evaluated treatment given directly to children, four investigated the effects of training for communication partners. Subjects in the studies varied widely in age, type and severity of cerebral palsy, cognitive and linguistic skills. Studies focusing directly on children suggest that this model of therapy delivery has been associated with increases in treated communication skills by individual children. However, methodological flaws prevent firm conclusions being made about the effectiveness of therapy. In addition, maintenance of these skills was not investigated thoroughly. The studies targeting communication partners describe small exploratory group projects which contain insufficient detail to allow replication, have very low power and cannot provide evidence of effectiveness of this type of treatment.

REVIEWERS' CONCLUSIONS

Firm evidence of the positive effects of SLT for children with cerebral palsy has not been demonstrated by this review. However, positive trends in communication change were shown. No change in practice is recommended from this review. Further research is needed to describe this client group, and its possible clinical subgroups, and the methods of treatment currently used in SLT. Research is also needed to investigate the effectiveness of new and established interventions and their acceptability to families. Rigour in research practice needs to be extended to enable firm associations between therapy and communication change to be made.