DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY

ORIGINAL ARTICLE

Speech, expressive language, and verbal cognition of preschool

children with cerebral palsy in Iceland
SOLVEIG SIGURDARDOTTIR 1 , 2 | TORSTEIN VIK 2 , 3
1 State Diagnostic and Counselling Centre, Kopavogur, Iceland. 2 Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and
Technology, Trondheim, Norway. 3 Department of Paediatrics, St Olavs University Hospital, Trondheim, Norway.
Correspondence to Dr Solveig Sigurdardottir at the State Diagnostic and Counselling Centre, Digranesvegur 5, 200 Kopavogur, Iceland. E-mail: solveig@greining.is
This article is commented on by Geytenbeek on pages 1011 of this issue.

PUBLICATION DATA

AIM The aim of this study was to describe speech, expressive language, and verbal cognition of

Accepted for publication 19th July 2010.

Published online 11 October 2010.

METHOD A population study included 152 Icelandic children with congenital CP (74 males, 78

ABBREVIATIONS

AAC

Augmentative and alternative

communication
DQ
Developmental quotient
WPPSI-R Wechsler Preschool and Primary
Scale of IntelligenceRevised

children with cerebral palsy (CP).

females; mean age 5y 5mo, range 4y6y 6mo). Children who spoke in sentences, phrases, or
one-word utterances were categorized as verbal. Speech was classified as normal, mild dysarthria,
or severe dysarthria. Cognition was reported as IQ (Wechsler Preschool and Primary Scale of
Intelligence Revised) or developmental quotient (DQ).
RESULTS Most children (81%) had spastic CP and bilateral symptoms (76%); 74 (49%) were at
Gross Motor Function Classification System (GMFCS) level I, 27% at levels II and III, and 24% at
levels IV and V (p<0.001). One hundred and twenty-eight children (84%) communicated verbally
whereas 24 were nonverbal. Nonverbal status and severe dysarthria were associated with greater
motor impairment (GMFCS; p<0.001). Twenty-five children (16%) had severe dysarthria. Most
(88%) of the nonverbal children had multiple disabilities compared with 18% of the verbal group
(p<0.001). Median (interquartile range) verbal IQ was 93 (73104) and performance IQ 77 (6194;
p<0.001). Sixty-eight children (45%) had normal verbal cognition and almost a quarter of the
children with severe dysarthria had a full-scale IQ DQ of 70.
INTERPRETATION Most children with CP express sentences and almost half of them have normal
verbal IQ. Nonverbal status frequently indicates multiple impairments whereas severe dysarthria
may be associated with normal cognition.

Children with cerebral palsy (CP) frequently demonstrate difficulties in communication as a result of impaired language
skills, which are often influenced by motor speech disorders.1
The aetiology most likely is multifactorial, arising directly
from the motor impairment and linked to the cognitive and or
sensory processing deficits associated with CP.2 In contrast,
several studies have demonstrated average verbal abilities of
higher-functioning children with CP,1,3,4 and even children
with early left-sided brain damage may exhibit sparing of language skills.5
Approximately 20% of children with CP are unable to produce intelligible speech2,68 whereas up to 50% of them have
less severe speech and communication difficulties.2,9,10 Direct
comparison of results can be difficult as language comprises
multiple aspects and disparate measures are used for assessment. Most studies report on speech and or language abilities7,9,11 of children with CP whereas others refer to
communication problems in a broad context.10
Capacity for language use depends on the level of motor,
cognitive, and sensory abilities.1 About 60 to 70% of children
with CP are able to complete standardized intelligence tests
74 DOI: 10.1111/j.1469-8749.2010.03790.x

whereas assessment of nonverbal and severely affected children

is challenging.4 However, various developmental scales or
alternative methods to allow children to respond to questions
can be used to facilitate verbal understanding and reasoning
abilities.4,12
Most population-based reports6,7,9 have focused on speech
of children with CP without detailed information on expressive language status or cognitive functioning of the population.
Therefore in this population study we attempted to address
speech, expressive language, and verbal cognition of a cohort
of children with CP to provide a more complete picture of
their communicative status.

METHOD
Study design
The data used in this study were routinely collected at a
national developmental centre, the State Diagnostic and Counselling Centre of Iceland. All children in Iceland with congenital CP are evaluated at this centre at 4 to 6 years of age by a
multidisciplinary team including a paediatrician, neuropsychologist, speech and language therapist, and physical therapist.
The Authors. Journal compilation Mac Keith Press 2010

Various measures and clinical descriptions are used to classify

motor, cognitive, and communicative functioning. Information
on other impairments such as hearing and visual deficits, epilepsy, and feeding difficulties are sought and reported.

Study population
The study represented all children, 152 in total, with congenital CP born in Iceland between 1989 and 2004. There were 74
males (49%) and 78 females (51%; mean age at assessment 5y
5mo, SD 6mo, range 46y 6mo).
Study variables
Exposure variables
CP was defined as group of disorders resulting in permanent
impairment of voluntary movement or posture attributed to
non-progressive disturbances occurring in the developing fetal
or infant brain.13 Clinical presentations of CP were described
as spastic (hemiplegia, diplegia, or quadriplegia), dyskinetic,
ataxic, or non-classifiable. The Gross Motor Function Classification System (GMFCS)14 was used to classify gross motor
abilities at the time of examination for children born from
1995 to 2004. For children born from 1989 to 1994, the
GMFCS levels were estimated from the recorded motor abilities. The GMFCS has five levels: at 4 to 6 years of age children at level I can walk without difficulties, children at levels
II and III can walk with mild to moderate support, whereas
children at levels IV and V are unable to walk. To get comparable groups, the number of levels was reduced from five to
three: children at level I were in one group whereas children at
levels II and III were merged into another group, and children
at levels IV and V into a third group.4
Outcome variables
Expressive language. Children were classified as either verbal
or nonverbal communicators based on their expressive language functioning, which was rated by the same speech and
language therapist throughout the study period, psychologist,
or paediatrician. Verbal communicators talked in sentences
(or phrases of at least three words) or produced one-word
utterances whereas nonverbal communicators had no expressive language. Augmentative and alternative communication
(AAC) methods were documented; language expressed by
AAC methods was classified as words or phrases augmenting
verbal communication or as nonverbal communication. If clinical evaluation indicated autism spectrum disorder, the Autism
Diagnostic InterviewRevised15 and the Autism Diagnostic
Observation Schedule16 were used for diagnostic assessment.
Speech. Speech was classified by the speech and language
therapist or paediatrician as either normal (speech appropriate
for age), mild dysarthria (intelligible speech but with some
deviations), or severe dysarthria (less intelligible or unintelligible speech), based on direct observation of the childs
speech.11 Children with normal speech or mild dysarthria
were merged into one group whereas those with severe dysarthria were kept in a separate group.
Cognition. Cognitive function was objectively assessed by
clinical psychologists. The Wechsler Preschool and Primary

What this paper adds

This population-based study indicates that 72% of children aged 4 to 6 years
with CP speak in sentences whereas 16% are nonverbal.
A quarter of children with severe dysarthria had normal or borderline cognition. Almost half of children with CP have normal verbal IQ.
Strengths appeared on the vocabulary and similarities subtests of the Wechsler Preschool and Primary Scale of Intelligence Revised.

Scale of Intelligence Revised (WPPSI-R)17 was administered

when possible and verbal IQ (VIQ), performance IQ (PIQ),
and full-scale IQ (FSIQ) obtained. Composite IQ scores are
presented as well as scores on the verbal subtests, which reflect
various aspects of language functioning such as verbal fluency,
abstract and numerical reasoning, word and factual knowledge, social judgement, and attention. Sixty-five children were
assessed with WPPSI-R (US norms)17 whereas the validated
Icelandic edition (WPPSI-Ris)18 was used to assess 51 children. A total of 106 children had FSIQ, 113 had VIQ, and
109 had PIQ.
Several developmental scales were used to assess children
unable to respond to WPPSI. These scales facilitate verbal
understanding and reasoning abilities of severely affected children.4 Twenty-nine children were assessed with the Bayley
Scales of Infant Development (2nd edition),19 four visually
impaired children were assessed with the Reynell Zinkin
Developmental Scales,20 whereas the Columbia Mental Maturity Scale21 was applied to nine children. The Leiter International Performance Scale Revised22 was applied to four
children. Scores on these measures were used to calculate a
developmental quotient (DQ).4
Cognitive functioning was categorized as FSIQ DQ at least
70 indicating normal or borderline cognitive abilities,
FSIQ DQ 50 to 69 indicating mild intellectual impairment,
and FSIQ DQ less than 50 consistent with severe intellectual
impairment.

Covariables
Hearing impairment was defined as being in need of a hearing
aid or the presence of deafness (hearing threshold at or above
65dB in better ear). Visual impairment was defined as having
visual acuity of not more than 0.3 in the best eye with correction or presence of functional blindness. Children were
defined with active epilepsy if they had a diagnosis of epilepsy
and were taking anti-epileptic medication upon assessment.
Feeding difficulties were defined as in need of gastric-tube
feeding. Gestational age at birth was categorized into very preterm birth (<32wks gestation), preterm birth (3236wks
gestation), and term birth (>36wks gestation).
Ethics
The study was reported to the Data Protection Authority and
approved by the National Bioethics Committee in Iceland
(VSNb2008020038 03.1). Omission of informed consent was
approved by the Bioethics Committee.
Statistical methods
All data were analysed using SPSS software, version 12.0
(SPSS Inc., Chicago, IL, USA). IQ scores were not normally
Speech, Language, and Cognition in CP Solveig Sigurdardottir and Torstein Vik 75

distributed and are presented as median scores with interquartile range. The KruskalWallis H test for several independent
samples was used to compare scores on verbal subtests of children with different CP types and at different GMFCS levels.
The MannWhitney U test of two independent samples was
used to compare scores of children with right and left hemiplegia. The Friedman test for several related samples was used
to compare scores on different verbal subtests, whereas the
two-related Wilcoxon signed-rank test was used to compare
median VIQ and PIQ. The v2 test or Fishers exact test were
used to analyse differences in proportions between groups,
and 95% confidence intervals (CI) were calculated according
to the method recommended by Newcombe and Altman.23
Stratification by sex and versions of WPPSI-R were used to
control for possible confounders. A two-tailed p value below
0.05 was considered statistically significant.

RESULTS
Results on expressive language and speech status were available for all children in the study group; all of them either had
FSIQ or a DQ indicating developmental level.
Expressive language
Of the 152 children, 128 (84%; CI 7889) communicated
verbally whereas 24 (16%; CI 1122) were nonverbal communicators (Table I). Mean age and proportion of males and
females did not differ between the two groups. Among the 24
nonverbal children, 16 (67%) had quadriplegia and six (25%)
had dyskinetic CP, whereas of the children who communicated verbally only 19 (15%) had quadriplegia and 13 (10%)
dyskinetic CP. Consistent with this, gross motor function
(GMFCS levels) differed between the two communication
groups (Table I). Furthermore, the nonverbal children were
more likely to have associated impairments including epilepsy

(67%), visual impairment (38%), and severe feeding difficulties

(33%). Only four children had hearing impairment and three
of them communicated verbally (Table I). The two communication groups differed in terms of gestational age categories:
20 (83%; CI 6493) of the nonverbal children were born at
term compared with 56 (44%; CI 3552) of the verbal group
(p=0.002; data not shown).
Among the 128 children who communicated verbally, 109
(85%; CI 7890) expressed themselves in sentences whereas
19 (15%; CI 1022) produced one-word utterances (Table II).
Only 21 (20%) of the children able to use sentences had intellectual impairment compared with 16 (84%) of the children
producing one-word utterances (p<0.001; Table II). Most
(88%) of the nonverbal children had severe intellectual impairment (FSIQ DQ<50; Table II).

Speech
Table II also shows that of the 25 children with severe dysarthria, six (24%) had FSIQ DQ70 compared with 85 children
(83%) with normal speech or mild dysarthria. Children with
severe dysarthria were more likely to be unable to walk
(GMFCS levels IV and V) and to have the dyskinetic and
quadriplegic subtypes than those with normal speech or mild
dysarthria (32% vs 8% [p=0.002] and 64% vs 16% [p<0.001]
respectively; data not shown). Of the 103 children with normal
speech or mild dysarthria, 101 (98%) spoke in sentences compared with eight children (32%) with severe dysarthria
(p<0.001). Indeed, half of these eight children with severe dysarthria who produced sentences had normal or borderline
cognition whereas the other half had mild intellectual
impairment (data not shown). All seven children (5%) with
autism spectrum disorder were able to use sentences, and six
(86%) of them had normal speech or mild dysarthria (data not
shown).

Table I: Expressive language function and clinical characteristics of 152 children with cerebral palsy
Total group
n (%)
152 (100)
Clinical presentation
Spastic
123 (81)
Hemiplegia
37 (24)
Diplegia
51 (34)
Quadriplegia
35 (23)
Dyskinetic
19 (13)
Ataxia
6 (4)
Unclassified
4 (3)
Severity of motor impairment (GMFCS level)
I
74 (49)
II and III
42 (27)
IV and V
36 (24)
b
Associated impairments
Autism spectrum disorder
7 (5)
Epilepsy
39 (26)
Visual impairment
19 (12.5)
Hearing impairment
4 (3)
Feeding difficulties
10 (7)
a

Verbal communicator
n (%)

95% CI

128 (100)

Nonverbal communicator
n (%)

95% CI

pa

4782

<0.001

24 (100)

107 (84)
37 (29)
51 (40)
19 (15)
13 (10)
6 (5)
2 (2)

7689
2237
3249
1022
617
210
06

16 (67)
0
0
16 (67)
6 (25)
0
2 (8)

74 (58)
38 (30)
16 (13)

4966
2238
819

0
4 (17)
20 (83)

736
6493

7 (5)
23 (18)
10 (8)
3 (2)
2 (2)

311
1226
414
17
06

0
16 (67)
9 (38)
1 (4)
8 (33)

4782
2157
120
1853

4782
1245
226
<0.001

0.241
<0.001
<0.001
0.609
<0.001

p values for differences between proportions of verbal communicators and nonverbal communicators. bFor data on intellectual impairment, see
Table II. GMFCS, Gross Motor Function Classification System.

76 Developmental Medicine & Child Neurology 2011, 53: 7480

Table II: Proportions with 95% confidence intervals (CI) of children with different expressive language and motor speech function according to full-scale IQ
(FSIQ; n=106) or developmental quotient (DQ; n=46)
Expressive language function

Normal speech
or mild
dysarthria
(n=103)

Nonverbal
communicator
(n=24)d

Verbal communicator
Sentences
phrases
(n=109)

Motor speech function

Severe
dysarthria
(n=25)e

One-word
utterances
(n=19)

FSIQ DQ score

n (%)

95% CI

n (%)

95% CI

pa

n (%)

95% CI

pb

n (%)

95% CI

n (%)

95% CI

pc

70
5069
<50

88 (81)
18 (17)
3 (3)

7287
1125
18

3 (16)
8 (42)
8 (42)

638
2364
2364

<0.001

1 (4)
2 (8)
21 (88)

120
226
6996

<0.001

85 (83)
15 (15)
3 (3)

7489
923
18

6 (24)
11 (44)
8 (32)

1143
2763
1752

<0.001

p value between categories of verbal communicators. bp value between groups of verbal and nonverbal communicators. cp value between
categories of motor speech function. dIncluding five children who expressed single words by augmentative and alternative communication
methods. eTwenty-four children had no motor speech function (classified as nonverbal).

AAC methods
Twenty-one children used AAC methods, mainly gestures and
manual signs (often indistinct), picture communication symbols, and Bliss symbols. None used technology with speech
output. Indications for introducing AAC methods did not
change over time although the use of picture communication
symbols increased. AAC methods were mainly used to supplement verbal expression (one-word utterances) whereas five
nonverbal children were able to express single words by AAC
methods (Table II). No children used AAC methods to
express phrases. Ten children (48%) using AAC methods had
severe intellectual impairment, eight had mild intellectual impairment, whereas three had normal or borderline
cognition.
Verbal cognition
Children able to complete WPPSI-R had a median (interquartile range) FSIQ of 83 (66100), a VIQ of 93 (73104),
and a PIQ of 77 (6194; p<0.001). Ninety children (80%;
CI 7186) had a VIQ of at least 70 whereas 68 (60%; CI
5169) had a VIQ in the normal range (85). Table III
shows that median VIQ was highest among children with
diplegia and hemiplegia, lowest among those with the dyskinetic and ataxic subtypes (p=0.018), whereas it did not differ
between the gross motor severity groups (p=0.088). Median
scores on all the verbal subtests differed between the various
clinical groups (CP subtypes) whereas median scores for
children at different GMFCS levels varied only on comprehension and arithmetic (Table III). When comparing scores
between the individual subtests, we observed differences
both within the whole group and for most clinical and gross
motor function groups (Table III). For the whole group,
highest median scores were obtained on the subtests vocabulary and similarities but lowest on arithmetic and comprehension.
Twenty-two children had right hemiplegia and 15 had left
hemiplegia. Two children with right hemiplegia could not

respond to the verbal tests (one had DQ=87 whereas the other
had epilepsy and DQ=50). Median VIQ (interquartile range)
and scores on the verbal subtests did not differ between children with right (92 [83106]) and left (90 [82104]) hemiplegia
(p=0.726).

Associated impairments
Figure 1 shows that 88% (CI 6996) of the nonverbal children
had two or more associated impairments compared with 18%
(CI 1226) of the verbal group. Conversely, 4% (CI 120) of
the nonverbal children had no associated impairment compared with 59% (CI 5167) of the verbal group (p<0.001).
Stratification by sex did not affect results presented in
Tables I to III and Figure 1, and comparison of composite IQ
scores and scores on the verbal subtests stratified by versions
of the test showed essentially the same results (data not
shown).
DISCUSSION
In this population study, we found that most (72%) 5-year-old
children with CP spoke in sentences or phrases of at least
three words whereas 16% were nonverbal. Both expressive
language function and speech status were highly associated
with gross motor function (GMFCS), CP subtypes, and intellectual functioning. In fact, most (88%) of the nonverbal children had multiple disabilities compared with only 18% of the
verbal group (p<0.001). Somewhat surprisingly, almost half of
the children had verbal cognition in the normal range
(VIQ85).
Strengths and limitations
We are not aware of similar studies where clinical evaluation
of expressive language and speech was supplemented by assessment of verbal cognition or developmental level of a complete
population of children with CP. The children were assessed at
a narrow age range at one developmental centre by few
clinicians, which allows for stability in categorizations.
Speech, Language, and Cognition in CP Solveig Sigurdardottir and Torstein Vik 77

Table III: Verbal IQ (Wechsler Preschool and Primary Scale of Intelligence Revised [WPPSI-R]) and scaled scores on verbal subtests, median (interquartile
ranges), of 113 children with CP
Scaled scores on verbal subtests of WPPSI-R
n

VIQ

Total group with VIQ

113
93 (73104)
Clinical presentationa
Spastic
Hemiplegia
35
94 (82104)
Diplegia
49
97 (75109)
Quadriplegia
10
88 (7595)
Dyskinetic
11
63 (59104)
Ataxic
6
73 (5886)
0.018
pb
Severity of motor impairment (GMFCS level)
I
71
95 (76107)
II and III
35
84 (70101)
IV and V
7
82 (5593)
0.088
pb

Similarities

pc

Information

Comprehension

Arithmetic

Vocabulary

8 (610)

8 (510)

8 (410)

10 (712)

9 (611)

<0.001

8 (79)
9 (712)
8 (610)
4 (39)
5 (28)
0.009

9 (711)
9 (611)
6 (69)
3 (110)
5 (38)
0.044

8 (611)
8 (411)
8 (48)
4 (19)
6 (18)
0.030

10 (812)
11 (813)
10 (610)
6 (410)
7 (69)
0.008

9 (810)
10 (812)
8 (710)
6 (412)
6 (48)
0.024

0.001
<0.001
0.122
0.002
0.058

9 (610)
8 (511)
7 (29)
0.515

9 (611)
7 (410)
6 (28)
0.031

8 (511)
6 (29)
7 (28)
0.017

10 (812)
10 (611)
7 (49)
0.132

9 (711)
8 (511)
7 (310)
0.272

<0.001
<0.001
0.138

Two children with unclassified CP were excluded. bp value between VIQ scores and scores on verbal subtests for children with different CP types
and at different GMFCS levels (Wilcoxon signed-rank test and KruskalWallis H test respectively). cp value between scores on different verbal
subtests (Friedman test). VIQ, verbal IQ; GMFCS, Gross Motor Function Classification System.

100
90
80
70
60
50
40
30
20
10
0

No associated
impairment
One associated
impairment
Two or more associated
impairments

Verbal
Non-verbal
communicators communicators

Figure 1: Percentage of children with no, one, or two or more associated

impairmentsa among 128 verbal and 24 nonverbal children. p<0.001
between groups of verbal and non-verbal communicators. aAssociated
impairments were intellectual impairment and those listed in Table 1.

Misclassification of communication and speech status is

possible but unlikely to affect our main results as none of the
nonverbal children responded to the verbal subtests (WPPSIR) compared with 87% of the verbal children. Furthermore,
by using only two speech categories for statistical analyses, we
minimized possible misclassification.
The data were collected during a 16-year period and the
WPPSI scales were revised and validated locally during that
time. However, comparison of composite IQ scores and
scores on the verbal subtests stratified by versions of the test
showed essentially the same results. It is unlikely that the findings occurred by chance, as indicated by the low p values,
especially the main clinical distinctions between the verbal
and nonverbal groups and between the two speech categories.
However, numbers in some subgroup analyses are small;
therefore lack of statistical significance must be interpreted
with caution. Confounding by sex is unlikely to explain our
78 Developmental Medicine & Child Neurology 2011, 53: 7480

results as stratification by sex revealed essentially the same

results as for the whole group.
A possible limitation of this study is its focus on preschool
children, as communicative abilities may progress after 5 years
of age. Furthermore, language measures provide information
on other aspects of language functioning than verbal cognitive
assessment although verbal cognition appears to correlate well
with formal language testing in children with periventricular
leukomalacia.24

Expressive language and speech

Our results imply that most preschool children with CP
express themselves in sentences. Another noteworthy finding
is that nonverbal status of children with CP frequently indicates multiple impairments. Most importantly, severe dysarthria should not be mistaken for severe cognitive impairment
as our results indicate normal or borderline cognition among
a quarter of that group.
Of the total group, 16% were nonverbal (or unable to
produce intelligible speech), a finding consistent with recent
population-based reports,6,7,9 which have also identified a
strong association with the quadriplegic and dyskinetic subtypes.7,9 Only 17% of our nonverbal group was born
preterm. Previous studies have in fact identified relative
sparing of both receptive vocabulary and speech skills
among children with CP owing to preterm birth and periventricular injuries,7,24 whereas children with CP of normal
birthweight are more likely to have severe motor impairment and multiple additional impairments.25 Indications for
introducing AAC methods did not change over time
although the use of picture communication symbols
increased. AAC methods were most often used to augment
verbal expression (one-word utterances) as it is challenging
to adapt AAC methods to the needs of nonverbal children
with multiple disabilities.

Verbal cognition
Interestingly, almost half of the total group had verbal intelligence scores in the normal range (median VIQ 93) whereas
median PIQ was 77. Previous reports have demonstrated normal or near-normal verbal cognition among subpopulations
with CP accompanied by deficits in visuomotor skills.1,3,11
Thus our results indicate that sparing of verbal cognition is
not confined to small subgroups but may extend to almost half
of the population.
The vocabulary and similarities verbal subtests appeared as
relative strengths, whereas weaknesses appeared on the comprehension and arithmetic subtests. High scores on the vocabulary subtest are encouraging as the test, a marker of word
knowledge and verbal fluency, can be influenced by the childs
home environment and educational experience.26 The arithmetic subtest is multifaceted, i.e. it requires numerical reasoning and working memory but also reflects visuospatial skills,26
which might explain the low scores obtained by our population. In accordance with our findings of preserved language
functioning in children with right hemiplegia, many previous
studies on children with early left-hemispheric lesions have
shown sparing of language functions5,27 and strengths on the
vocabulary and similarities subtests.27 We observed autism
spectrum disorder in seven children (5%), which is in line with
previous population-based studies.28,29
Pathophysiology
Cerebral palsy is thought to be caused by lesions or structural
defects of the brain in more than 80% of cases.30 Extent and
topography of brain lesions determine the clinical subtype of
CP and are related to the presence and severity of associated
impairments.30 Thus our finding of high prevalence of nonverbal status and associated impairments among children with

severe motor impairment and the dyskinetic and quadriplegic

subtypes is probably related to brain injury extending beyond
the corticospinal tracts to white matter, cortex, and basal ganglia (especially the dyskinetic subtype). Fortunately, plasticity
of the developing brain enables reorganization of language
skills in most children to the right hemisphere after focal
injury to the left hemisphere.5,30

Clinical implications
Assessment of language abilities of children with CP has clear
implications as social functioning and participation depend on
successful modes of communication.31 Furthermore, competency in oral language is associated with literacy. Therefore,
affected children need effective methods to promote speech as
they enter school.32
CONCLUSION
The results of our population study imply substantial variation
in communicative abilities of 5-year-old children with CP.
Most children expressed sentences and almost half of them
had normal verbal cognition. Nonverbal status and severe dysarthria were associated with intellectual status, gross motor
function (GMFCS), and the quadriplegic and dyskinetic subtypes. Evaluation of language abilities and cognition of
children with CP is important because both social development and academic progress depend on effective modes of
communication.
ACKNOWLEDGEMENTS
This study was supported by the Liaison Committee for the Central
Norway Regional Health Authority and the Norwegian University of
Science and Technology. We thank the staff of the State Diagnostic
and Counselling Centre for their contribution to this work.

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