Speech and language therapy to improve the communication

skills of children with cerebral palsy (Review)

Pennington L, Goldbart J, Marshall J

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 9
http://www.thecochranelibrary.com

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) i
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Speech and language therapy to improve the communication

skills of children with cerebral palsy

Lindsay Pennington1 , Juliet Goldbart2 , Julie Marshall3

1
Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. 2 Department of Psychology and Speech Pathology,
Manchester Metropolitan University, Manchester, UK. 3 Professional Registration Dept, Manchester Metropolitan University, Manch-
ester, UK

Contact address: Lindsay Pennington, Institute of Health and Society, Newcastle University, Sir James Spence Institute - Royal Victoria
Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK. lindsay.pennington@ncl.ac.uk.

Editorial group: Cochrane Movement Disorders Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 9, 2011.
Review content assessed as up-to-date: 30 January 2011.

Citation: Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with
cerebral palsy. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003466. DOI: 10.1002/14651858.CD003466.pub2.

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
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 sensory impairments. 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 as independent a role as possible in interaction activities.
Therapy can include introducing augmentative and alternative communication (AAC) systems, such as symbol charts or communication
aids with synthetic speech, as well as 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 methods
Searches were conducted of MEDLINE, CINAHL, EMBASE, PsycINFO, LLBA, ERIC, WEB of SCIENCE, Scopus, NRR, BEI,
SIGLE (to January 2011). A previous version of this review included studies up to the end of 2002. References from identified studies
were examined and relevant journals and conference reports were handsearched.
Selection criteria
Any experimental study containing an element of a 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
All authors searched for and selected studies for inclusion. L Pennington (LP) assessed all papers for inclusion, J Goldbart (JG) and
J Marshall (JM) independently assessed separate random samples, each comprising 25% of all identified studies. Two review authors
independently abstracted data from each selected study. Disagreements were settled by discussion between the three review authors.
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 1
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results

Sixteen studies were included in the review. Nine studies evaluated treatment given directly to children, seven investigated the effects
of training for communication partners. Participants 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 speech and communication skills by individual children. However, methodological flaws and small sample sizes prevent firm
conclusions being made about the effectiveness of the therapy. In addition, maintenance of these skills was not investigated thoroughly.
The studies targeting communication partners used small exploratory group designs which often contained insufficient detail to allow
replication, although more recent studies have improved in this area. Overall, the studies of indirect intervention have very low power
and cannot provide evidence of effectiveness of this type of treatment.

Authors’ 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 updated 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 the communication change to be made. There
are now sufficient data to develop randomised controlled studies of dysarthria interventions and group parent training programmes.
Such research is urgently needed to ensure clinically effective provision for this group of children, who are at severe risk of social and
educational exclusion.

PLAIN LANGUAGE SUMMARY

Speech and language therapy for children with cerebral palsy might improve their communication skills, but more research is
needed.

Cerebral palsy (CP) is a movement disorder caused by damage to the brain before, during or soon after birth. The ability for people with
CP to communicate effectively is often impaired by problems with speech and also gestures usually used in communication. Speech and
language therapy aims to help people with CP maximise their communication skills. This can include ways of enhancing natural forms
of communication, introducing aids such as symbol charts or devices with synthetic speech, and training communication partners. The
review found some weak evidence that speech and language therapy might help children with CP, but more research is needed.

BACKGROUND
Cerebral palsy describes a “group of persistent disorders of the de-
velopment of movement and posture, causing activity limitation,
that are attributed to non-progressive disturbances that occurred
in the developing fetal or infant brain” (Bax 2005). Subgroups of
cerebral palsy have been classified according to the clinical signs of
spastic, ataxic and dyskinetic syndromes, plus mixed forms (SCPE
2000).
The prevalence of cerebral palsy is approximately 2.5 per 1000 live
births in countries with neonatal intensive care facilities (Colver
2000; Yeargin-Allsopp 2008; Himmelmann 2010). Prevalence is
higher in children born with very low birth weight. However, a
decline in prevalence in this group from 60.6 (99%CI 37.8-91.4)
per 1000 live births in 1980 to 39.5 (28.6-53.0) per 1000 in 1996
has recently been observed in Europe (Platt 2007). Communica-
tion difficulties can be associated with any type of cerebral palsy
and may relate to limitations in the production of movements for
speech, gesture and facial expression; receptive or expressive lan-
guage; hearing; vision; or a combination of limitations in these
functions. Speech impairments are estimated to affect approxi-
mately 36% of children with cerebral palsy and communication
difficulties are observed in around 42% (Parkes 2010). Prevalence
of speech, language and communication impairment increases
with severity of motor and intellectual impairment (Kennes 2002;
Bax 2006; Parkes 2010; Sigurdardottir 2010). Children may expe-
rience communication difficulties from early infancy and, as cere-
bral palsy is a persistent condition, communication impairments

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 2
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
are chronic and children may require long term intervention. In
a review of speech and language therapy caseloads in the UK,
Enderby 1986 estimated that cerebral palsy was the sixth most
common medical cause of speech disorder, and the proportion of
referrals of children with this diagnosis remains static (Petheram
2001).
Speech and language therapists (also known as speech thera-
pists, speech-language pathologists) assess, diagnose and treat the
communication disorders associated with cerebral palsy. The aim
of treatment is to maximise children’s ability to communicate,
through speech, gesture and supplementary means such as com-
munication aids, to enable them to become independent commu-
nicators. As the problems experienced by children with a diagnosis
of cerebral palsy are wide in range there is no single, universally
appropriate form of treatment. Intervention can focus directly on
spoken output, expressive or receptive language development, or
helping children to develop conversation skills such as asking ques-
tions and repairing conversation when misunderstandings occur
(for example Letto 1994). Work to develop children’s language or
communication skills could involve children using any method of
communication. Intervention can also involve children’s familiar
conversation partners, such as their families, friends and teaching
staff (Culp 1988; Pennington 1996). Such indirect therapy aims to
teach people who are in close contact with children with cerebral
palsy, to facilitate their communication development by creating
opportunities for them to use new skills in conversation. Effective
indirect intervention would lead to changes in conversation style
for both the familiar conversation partners and the children.
Speech and language therapy may be delivered in a range of set-
tings, including clients’ homes, community clinics, hospitals and
schools (RCSLT 1999). It is usual for speech and language ther-
apists to liaise with families and teaching staff regarding therapy
to ensure that intervention goals are incorporated into daily life,
where possible (Calculator 1991). Therapy may be delivered on
an individual basis or in groups. Interventions may also vary in
duration and intensity.
Speech and language therapy for this group of children is often
long term, requiring significant health service resources. The ef-
fectiveness of speech and language therapy has been called into
question (Enderby 1997). For this client group it is necessary to
know if changes that occur in children’s communication are a re-
sult of SLT intervention or other factors, such as maturation. If it is
demonstrated that speech and language therapy is effective, infor-
mation about the effectiveness of different kinds or components
of therapy is needed for children from different clinical subgroups
to ensure appropriate use of resources.
In 2001 we set out to conduct an exploratory systematic review
of studies of speech and language therapy for children who have
communication disorders associated with cerebral palsy. This ini-
tial, broad review investigated the forms of SLT currently used to
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
remediate different types and severities of communication disor-
ders associated with cerebral palsy, and their relative effectiveness,
with a view to providing directions for future research. As little
evidence was found in the original review, this current updated re-
view remains exploratory in nature investigating all areas of speech
and language therapy intervention.
OBJECTIVES
1 To assess whether direct intervention aimed at improving the
communication skills of children with cerebral palsy is more ef-
fective than no intervention at all.
2 To assess whether intervention aimed at changing the conver-
sational style of the familiar communication partners of children
with cerebral palsy is more effective than no intervention at all
in: (i) changing partners’ conversational style, and (ii) developing
communication skills of children with cerebral palsy.
3 To assess whether individual types of intervention are more ef-
fective than others in improving the communication skills of chil-
dren with cerebral palsy.
4 To assess whether one particular type of intervention is more
effective than others in changing the conversation style of the
familiar communication partners of children with cerebral palsy.
METHODS
Criteria for considering studies for this review
Types of studies
To provide an overview of the evidence for speech and language
therapy interventions provided to a diverse client group we in-
cluded any controlled study of interventions aimed at improving
communication skills, reported in any language, in this review.
Translations were sought, when necessary. Controlled studies in-
cluded group and single case experimental designs. Group studies
were included if participants were allocated to different interven-
tions or acted as their own control, receiving the novel intervention
following usual treatment. Single case experimental designs were
included if communication behaviours were allocated to treatment
or control and both behaviours were measured at baseline, inter-
vention and follow-up phases, thereby allowing causal inference.
Observational studies which used an AB design replicated across
participants were excluded from this review.
3
Types of participants
Any child or individual under 20 years of age with any communi-
cation disorder associated with cerebral palsy, including dysarthria,
dyspraxia, ataxia and mixed syndromes; or their communication
partners. No exclusions were made on the basis of additional im-
pairments (intellectual or sensory impairments, the presence of
epilepsy) or prior receipt of speech and language therapy. This age
range was selected as people who have identified special needs are
entitled to statutory education provision up to 19 years of age in
England, which could specify speech and language therapy.
Types of interventions
Any therapy aimed at improving communication skills whether
provided individually or in groups; in the child’s home, school or
health service settings. Exceptions were therapies provided as part
of a holistic approach (for example, in conductive education).
1. Therapies given directly to the child with the aim of developing
the child’s communication skills.
These are distinguished from the following.
2. Therapies given to familiar communication partners (families,
teachers, teaching assistants, peers) with the aim of changing the
communication partners’ conversation style to help them facilitate
children’s communication development.
Types of outcome measures
1. Measures of communication:
a) World Health Organisation International Classifcation of Func-
tioning, Disabiltiy and Health (ICF) body function level out-
comes: children’s expressive and receptive language skills, speech
production;
b) ICF activity level outcomes: conversation and pragmatic skills,
intelligibility, communicative competence;
c) ICF environmental level outcomes: partners’ communication
and interaction strategies.
Measures used may be, for example: rating scales, language tests,
coding schemes developed for individual research studies that in-
clude validity and reliability data.
2. Family stress and coping (e.g. Questionnaire on Resources and
Stress, Carer Strain Index).
3. Children’s quality of life.
4. Children’s particpation.
5. Satisfaction of patient and family with treatment.
6. Noncompliance with treatment.
Search methods for identification of studies
1. The review is based on the following search strategy:
a. cerebral palsy AND child
b. speech OR speech disorder OR speech intelligibility OR speech
therapy OR speech and language therapy
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
c. language OR language disorders OR language development dis-
orders OR sign language OR child language OR language therapy
d. communication OR communication aids for disabled OR com-
munication disorders OR communication methods, total OR
manual communication OR nonverbal communication
e. #b OR #c OR #d
f. a AND e
The following electronic databases were searched (up until January
2011): MEDLINE (from 1966); CINAHL (from 1982); EM-
BASE (from 1980); PsycINFO (from 1967); Web of Science (from
1981); Scopus (from 2002); Language and Linguistic Behaviour
Abstracts (from 1973); British Education Index (from 1986); Na-
tional Research Register (completed and ongoing research); ERIC
(from 1966); SIGLE (from 1980).
2. The following journals were handsearched (from their incep-
tion or from 1980 onwards): International Journal of Language
and Communication Disorders; Augmentative and Alternative
Communication; Child Language Teaching and Therapy; Devel-
opmental Medicine and Child Neurology; Child: Care, Health
and Development and the Ambulatory Child; Journal of Child
Psychology and Psychiatry and Allied Disciplines; Topics in Lan-
guage Disorders; European Journal of Special Needs Education;
Journal of Communication Disorders; Journal of Psycholinguis-
tic Research; Journal of Special Education; International Journal
of Rehabilitation Research; Folia Phoniatrica et Logopaedica; Ap-
plied Psycholinguistics; Journal of Speech, Language and Hearing
Research; Asia Pacific Journal of Speech, Language and Hearing;
International Journal of Speech-Language Pathology; American
Journal of Speech-Language Pathology; International Journal of
Disability, Development and Education, Speech, Language and
Hearing in Schools. The current titles are given for journals expe-
riencing name changes since 1980.
3. Published conference proceedings of the following organisations
were checked: European Academy of Childhood Disability (1996
to 2010), International Society for Alternative and Augmentative
Communication (1996 to 2010), American Speech and Hearing
Association (1999 to 2002), Royal College of Speech and Lan-
guage Therapists (1998 to 2009).
4. Reference lists of all studies selected for possible inclusion were
checked for other possibly eligible studies.
5. Authors of included trials were contacted for unpublished stud-
ies. Calls for assistance were made via national professional asso-
ciations.
Data collection and analysis
One review author (LP) assessed the studies identified by the search
strategies for inclusion according to specified criteria. The other
two authors independently assessed separate random samples each
comprising 25% of all identified studies plus any studies whose
inclusion status was ambiguous. Agreement on inclusion was cal-
culated using the Kappa statistic. The opinion of the third review
4
author was sought if there was any disagreement regarding the
inclusion of a trial.
Two review authors reviewed each identified study, abstracted
data using forms developed for the review and graded the study’s
methodological quality. Where necessary, authors were contacted
at their last known address to provide missing data for included
trials.
As per the Cochrane Handbook, attention was paid to whether
studies demonstrated protection from the following types of bias:
• selection bias, i.e. true random sequencing, true
concealment up to the time of allocation, comparison of known
confounding variables between groups, comparison of
developmentally similar processes in single case experimental
designs;
• performance bias, i.e. differences in types of treatment (co-
interventions) between the two groups;
• exclusion bias, i.e. withdrawal after entry to the trial;
• detection bias, i.e. ’unmasked’ assessment of outcome.
Decisions regarding potential biases were recorded in the risk of
bias table for each study.
The methodological quality of single case experimental designs
was also rated on the description of the participant and interven-
tion, whether baseline performance was adequately established,
the duration of treatment and follow up and the frequency of mea-
surement across the phases of the experiment.
Individual criteria were rated as ’met’, ’partially met’, ’unmet’ or
’unclear’. Disagreements were resolved with a third review author.
Agreement on methodology assessment was calculated using the
Kappa statistic (K).
Information from studies meeting criteria for inclusion was en-
tered into RevMan. Most studies that were included used single
case experimental designs. Four group trials were identified but
only one included randomisation and the participants were het-
erogeneous. Data were therefore not combined for the review and
data were not analysed using RevMan.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Searches yielded 911 abstracts. Of these, 771 clearly did not fit
the inclusion criteria for the review. Full texts of 140 papers were
considered for potential inclusion. Authors agreed on 78 of the
81 papers randomly selected for reliability check, K = 0.873. Dis-
agreements were resolved with a third review author for the other
papers. Seventeen papers (reporting 16 studies) were included for
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
full review. The main reasons for exclusion were that included par-
ticipants did not have cerebral palsy or those with cerebral palsy
could not be disaggregated from other participants, or the study
did not include any experimental control. Most reports were writ-
ten in English. Papers in other languages were read by translators
who discussed the content with review authors; none were found
to fit the inclusion criteria for the review.
Therapy focusing on children
Nine of the included studies evaluated therapy that focused di-
rectly on children, who varied widely in age, type and severity of
cerebral palsy and additional impairments. These studies aimed to
facilitate the development of pre-intentional communication skills
(behaviours such as mutual gaze, anticipation of behaviours in fa-
miliar routines that can be interpreted as communication by oth-
ers, but which are not performed with the intention of conveying a
message), pragmatic or communicative functions used in conversa-
tion, such as asking questions, providing information or repairing
misunderstandings, speech production, expressive language struc-
tures or receptive vocabulary. The studies focusing on dysarthria
are also discussed in a separate review (Pennington 2009).
Pre-intentional communication
Richman 1977 used operant teaching strategies to train a nine
year old girl with severe cognitive impairment, who lived in an in-
stitution, to produce three pre-intentional communication skills:
maintaining eye contact and head control and increasing vocal im-
itations (ICF body functions). Forty hours of therapy were given
over 20 weeks. Ten minute intervals were sampled for the presence
of the three behaviours.
Communicative functions
Five studies focused on the production of nonverbal messages,
teaching children to use individual communicative functions (ICF
activity level outcomes). Hunt 1986, Pinder 1995 and Sigafoos
1995 taught children to use requests for objects or actions. Hunt
1986 included one seven year old girl with cerebral palsy who had
severe cognitive impairment and multiple disabilities in a multiple
probe multiple baseline across participants design. Other partici-
pants did not have cerebral palsy. The subject was taught to request
four objects or events by eye pointing to line drawings symbol-
ising the object or action. Operant teaching methods were used,
including interrupted chain training. Treatment was given twice
daily, with 55 sessions in total. Requests were probed across the
treatment sessions. Pinder 1995 taught four infants with cerebral
palsy to produce either requests for objects or requests for more of
an activity using micro teaching techniques (creating a commu-
nication environment, modelling the target skill, expectant delay,
prompting and reinforcement). The children were aged 11 to 13
months, had severe cerebral palsy with no independent sitting and
5
less than 50 on the Mental Development Index. Therapy was given
twice a week for up to 12 weeks. Taught and untaught requests
were probed in the teaching situation and across a second familiar
communication situation. Sigafoos 1995 reported the training of
a six year old boy with severe cerebral palsy and moderate cognitive
impairment to request three items using micro-teaching strategies,
requests were probed throughout treatment. Three sessions were
given per week, with 19 sessions in total.
Davis 1998 taught two children to produce responses to statements
made by others in conversation. One of the participants was a 15
year old boy with severe cerebral palsy who usually communicated
by yes/no responses only but who had access to a voice output
communication device with pre-stored phrases and spelling for
novel words. Communication partners provided structured op-
portunities for the boy to respond to statements in conversation
with further information that maintained the interaction. These
elicitations were added to the conversation of three partners in
succession. Responses to statements were recorded across the treat-
ment sessions with the three partners. Therapy was given two to
three times per week, 36 sessions in total.
Hurlbut 1982 trained three teenage boys with severe cerebral palsy
and cognitive impairments to label objects using Blissymbols or
iconic line drawings using micro-teaching strategies. The duration
and frequency of therapy sessions was not stated. The proportion
of Blissymbols and iconic symbols used to label taught and un-
taught items was calculated before and throughout training.
Speech production
One study focused on speech production (Pennington 2009b),
training children to control the loudness of their speech and main-
tain their respiratory effort for speech. Sixteen children aged 12 to
18 years, 15 of whom had cerebral palsy and one who had Worster
Drought Syndrome, were taught to control their speech rate and
loudness. Individual sessions, lasting 35 to 40 minutes took place
three times per week over 6 weeks. Speech intelligibility in single
words and connected speech to familiar and unfamiliar listeners
was measured at six weeks before, one week before, one week after
and six weeks after intervention (ICF activity level outcomes).
Receptive vocabulary
Dada 2009 taught three children with cerebral palsy aged 8 to 12
years to understand 24 spoken words (ICF body function level
outcome), using an aided language stimulation programme which
involved pairing a spoken word with a graphic symbol. Eight vo-
cabulary items were taught in one activity carried out five times
in one week (each activity lasting 15 to 25 minutes). In the sec-
ond week a different activity with eight new vocabulary items was
used and the activity and vocabulary items were changed again
in the third week, so that 24 vocabulary items were taught in to-
tal. Teaching comprised repeated pairing of spoken word and vi-
sual symbols representing the target vocabulary. The proportion
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
of items correctly selected when named was measured three times
a week prior to and across the three week intervention period.
Expressive language
Campbell 1982 used operant training techniques to teach a 10
year old boy with severe cerebral palsy and moderate language
delay to produce “is/are” in three linguistic structures (ICF body
function level outcome). Two 15 minute therapy sessions were
given each day, with 155 sessions in total. Frequency of correct “is/
are” production in each of the three target structures was measured
during each training session.
Therapy focusing on parents or other conversation partners
Eight papers investigated the success of training communication
partners to facilitate the communication development of children
with cerebral palsy, measuring ICF environmental level outcomes
(Basil 1992; Hanzlik 1989; McCollum 1984; McConachie 1997;
Olswang 2006; Pennington 1996a; Pennington 2009a; Tait 2004).
Pennington 1996a reported the same information, but in different
format, as McConachie 1997 and will be excluded from further
discussion.
Participants
Children
Children whose parents and educators received training in the
seven studies appear heterogeneous. However, insufficient infor-
mation was given to provide a clear picture of their overall level of
functioning. They ranged from eight months of age to 17 years,
had cerebral palsy classed as mild to severe and cognitive skills
ranging from within normal limits to severely impaired. Hanzlik
1989 included 20 infants aged 8 to 32 months, who had cerebral
palsy of different types and severity ranging from mild to severe.
Mental age was at least one standard deviation below the mean,
range two to 18 months. None of the infants were able to am-
bulate either independently or with aids. Some, although it was
difficult to tell how many, fell into the category containing speech
impairment. However, some of those children may not have been
expected to communicate intentionally given their chronological
and mental age. Levels of communication development were not
specified. McCollum 1984 included one child with severe cerebral
palsy, of unknown type, aged 18 months. He was reported to vo-
calise but to exhibit few social behaviours. No other information
was given regarding his developmental level. Basil 1992 studied
four Spanish children aged seven to eight years who had cerebral
palsy of unstated type. They had no independent mobility and up-
per limb function was severely affected. One child scored 4.5 years
on a test of mental development, the others did not reach baseline.
6
These children communicated by vocalisation, eye gaze, facial ex-
pression and produced one symbol messages on their communi-
cation boards, which contained 52 to 188 symbols. McConachie
1997 included nine children aged seven to 17 years who had cere-
bral palsy of differing types. No information was given on the
severity of their motor impairments, cognitive or sensory skills. All
had symbol communication systems (six used Blissymbolics, three
Rebus Symbols), with access to 175 to 1000 plus symbols. Two
children also had voice output communication aids. No informa-
tion was given about how the children used their communication
systems or their communicative level. Olswang 2006 studied two
children with cerebral palsy aged 14 and 20 months, who were
unable to sit independently, had severe cognitive impairments and
vision and hearing that were within normal limits. Both children
were preverbal communicators, who looked at objects, but did
not look back to the parents to request items. Pennington 2009a
included 11 children, 10 of whom had cerebral palsy of differing
types. The children were aged 19 to 36 months at the start of
the study. Gross motor function was rated using the gross Motor
Function Classifaction Scale (Palisano 1997); most children had
difficulty using their hands but could bring two hands together
to act on a toy. All had severe dysarthria and were unintelligible
to their parents out of context. Most children had severe receptive
language delay (Preschool Language Scales mean percentile rank =
6, SD = 9) and severe intellectual impairment. Tait 2004 studied
six children aged 16 to 47 months who had spastic type cerebral
palsy which affected all four limbs. Two children had cortical vi-
sual impairments, one child had a mild visual impairment, one
child had a hearing impairment and two children had epilepsy.
Four of the children had receptive language scores that were within
six months of their chronological age, one child had receptive lan-
guage skills within nine months of their chronological age and one
child had a profound language delay and scored at a two month
developmental level.
Adult conversation partners
With the exception of McConachie 1997, who trained teachers
and education assistants, parents were the subjects of the research.
Overall, very little information is provided on the people who were
trained, their communication style before intervention, previous
training and relationship with the participant children. None of
the studies included information on parental stress and coping,
which has been found to affect communication (Dunst 1988).
Basil 1992 trained three mothers and one father. They were com-
pared with teachers who received no training. No information was
given on prior training or other characteristics of either group other
than the pre-intervention interaction measures which showed dif-
ferent communication styles between the two groups. The moth-
ers who participated in Hanzlik 1989 had completed varying lev-
els of education, from partial high school to college graduation.
Half of the families in each group had other children. The employ-
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ment of parents ranged from major professionals to semi-skilled
workers. However, it was not clear if any of the mothers were em-
ployed outside the home or how social status was classified. The
mother in McCollum 1984 was a single parent with a lower-mid-
dle income, no other information was given. McConachie 1997
included nine teachers and 10 assistants in the experimental group
who received training and eight teachers and six assistants who
received no intervention. No other information was given on the
adult participants, who volunteered to take part and who were
assigned by their managers to the two groups. Authors stated that
the participants and controls were matched on gender and extent
of interaction with the participant children, however no support-
ing evidence was presented in the paper. Olswang 2006 trained
two mothers. One mother had older children, was Caucasian and
had been born and brought up in the USA. The other was a sec-
ond generation Ukranian immigrant living in the USA with her
mother (who spoke only Ukranian) and had no other children.
Both mothers had graduated from high school. No other details
were provided. Pennington 2009a trained 11 mothers. Two were
single parents; five had completed high school education; three
had received received some further education and three had com-
pleted university degrees. Five mothers worked outside the home,
four on a part-time basis. Families lived in urban and rural areas
and levels of deprivation varied across the sample. All mothers were
White British or White Australian. Tait 2004 trained mothers of
children in their study, but no information on the mothers was
provided.
Intervention
The training given all related to facilitating communication de-
velopment. McCollum 1984, Hanzlik 1989, Olswang 2006 and
Tait 2004 concentrated on pre-verbal communication. McCollum
1984 provided direct teaching of target skills specific to the parent
and child receiving therapy. In total 10 weekly home visits were
made, in which target behaviours were watched on video-tape and
practiced and treated and untreated communication behaviours
measured. Hanzlik 1989 gave a generic model of training to each
mother, focusing either on interaction and the use of adaptive seat-
ing for the experimental group, or neurodevelopmental therapy
for the control group. Training in this study was given at home in
one session that lasted one hour. Olswang 2006 and Pennington
2009a used a specified training protocol in which parents were all
taught to create communication opportunities, to wait for their
child to communicate, to recognise their child’s communication
and to shape this communication into more sophisticated signals.
Olswang 2006 devised training specifically for their study. Indi-
vidual training took place twice per week for three weeks. Each ses-
sion lasted approximately 45 minutes. The parents in Pennington
2009a received It Takes Two to Talk®, the Hanen parent program,
which was delivered to groups of parents in seven or eight sessions
of two and half hours over 12 to 13 weeks. In both the interven-
7
tion by Olswang and It Takes Two to Talk parents also received
home visits for individual coaching. Tait 2004 developed an indi-
vidualised training programme for each parent-child pair, on how
to respond contingently to their child’s pre-linguistic communi-
cation and how to prompt the use of more sophisticated commu-
nication signals. A written summary of the teaching strategies was
also provided for parents. Parents then implemented the teaching
strategies in 6 to 12 individual sessions of 30 minutes, which com-
prised three types of interactions: mealtime, play with a toy and
social interaction (for example peek-a-boo, pretend play). Parents
received feedback on their use of target strategies after each practice
session. Basil 1992 and McConachie 1997 both undertook group
teaching to facilitate interaction with individual AAC users. Basil
1992 trained a group of parents in one session then followed this
training up with three home visits to each family to individualise
intervention and help parents practice techniques. McConachie
1997 trained teachers and assistants in their own school in five 90
minute workshop sessions which concentrated on one child. Both
Basil 1992 and McConachie 1997 used short talks, brainstorming
and videotapes in their group teaching.
Outcome measures
Each study used outcome measures developed specifically for the
research project, which related to the specific aims of the therapy.
Only one (Hunt 1986) had information on validation. Inter-rater
reliability of use of the coding schemes was given in each paper.
Risk of bias in included studies
See Table 1and Table 2 for ratings of the methodological quality
of included studies.
It is rarely possible or advisable to blind patients and clinicians to
the type and aims of intervention in trials of speech and language
therapy, but this does leave them open to performance and attrition
bias.
Group studies
(Basil 1992; Hanzlik 1989; McConachie 1997; Pennington
2009a; Pennington 2009b)
1. Randomisation and concealment of allocation
Basil 1992, McConachie 1997, Pennington 2009a and
Pennington 2009b did not randomly assign participants to treat-
ment or control groups. Basil 1992 gave training to parents and
compared their communication with that of teachers who re-
ceived no training. Teachers and assistants who participated in the
McConachie 1997 study were assigned to treatment and control
group by their school managers on the basis of school timetable, as
staff were released to participate in training workshops. Allocation
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was not concealed as the person(s) who allocated participants also
decided on their eligibility. Both of the studies, therefore, had sig-
nificant weakness in their allocation strategies and selection bias
was likely. In both Pennington 2009a and Pennington 2009b an
interrupted time series design was used in which participants acted
as their own controls. In both studies participants were recruited
through the researchers’ speech and language therapy colleagues,
who were given a list of inclusion and exclusion criteria. Referring
therapists selected participants from their caseloads and thus se-
lection bias is likely. Hanzlik 1989 recruited parents through col-
leagues. Parents who were willing to take part in the study were
allocated to group as they were recruited by the investigator by her
taking a piece of folded paper out of a bag; 20 papers were created,
10 consigned parents to control and 10 to experimental group.
2. Similarity of participants at baseline
Information on recruitment to the studies was not provided for
Basil 1992 and McConachie 1997, nor were inclusion and exclu-
sion criteria cited. For Basil 1992 participants and controls dif-
fered in their relationship to the children; parents received training,
teachers were controls and received no training. The two groups
clearly differed in their pre-intervention patterns of interaction.
No information was provided on other possible confounding vari-
ables such as previous training in communicating with children
who use augmentative and alternative communication (AAC), be-
liefs about interaction, age, education, socio-economic status, and
extent of knowledge and experience of AAC. This study was rated
as inadequate on participant similarity. Participants and controls
in McConachie 1997 were matched on gender, occupation and
extent of contact with the target children by managers. Pre-inter-
vention communication ratings and information on possible con-
founders such as those listed above were not given. Therefore, it
was not possible to detect how similar the two groups were be-
fore training. Hanzlik 1989 provided sufficient information on
participants to assess the similarity of the groups and to replicate
the research with similar samples. She cited inclusion criteria that
related to children’s locomotor, cognitive and sensory skills and
excluded mothers who had received previous training in either
of the intervention strategies used in the study. The gender, type
and severity of cerebral palsy, extent of locomotor skills, chrono-
logical and mental age was given for the children in each group
in terms of frequencies, means and SDs, with groups seeming to
be equally matched. Mothers were similar across groups in edu-
cation and half of those in each group had other children. The
range of socio-economic status (SES) of the households of the two
groups was slightly wider for the control group, and the num-
bers of participant families in each SES group is not given. Pre-
intervention scores (means and SDs) for interaction behaviours
were given for the mothers and infants in both groups and appear
similar. Pennington 2009a provided sufficient detail on partici-
pants to allow replication. Selection criteria were chosen to reflect
8
the population of children with cerebral palsy referred to speech
and language therapy clinics. Criteria related to presence, type
and extent of motor disorder; vision; hearing; communication and
lack of previous parental communication training. The gender,
type and severity of cerebral palsy, extent of locomotor skills, up-
per limb function, speech production, chronological age, recep-
tive language, nonverbal understanding and expressive vocabulary
is given for all children. The number of mothers in the group
with university degrees was higher than in the general population.
Pennington 2009bprovided exclusion and inclusion criteria. In-
formation was provided on group scores for type and distribution
of motor disorder, severity of dysarthria, age and gender and ability
to follow simple instructions. No further information was given
on children’s cognitive and language functioning.
3. Participant numbers
Most of the studies provided information on how the number
of participants was chosen. Pennington 2009b stated that sample
size was determined by feasibility, with restrictions imposed by
the data collection schedule, therapy duration and by the school
day and term times. Number of participants ranged from eight
(Basil 1992) to 20 (Hanzlik 1989). With such small numbers of
participants it is unlikely that the sample can reflect the population
of people who regularly converse with children who have cerebral
palsy. The studies also have very low chances of detecting a true
effect of training.
4. Blinding
Appropriately for therapies involving training and participant co-
operation, none of the studies included the blinding of the par-
ticipants or of the clinicians providing therapy. However, with the
exception of Pennington 2009a and Pennington 2009b the out-
comes of the interventions were inappropriately assessed by the
clinicians providing the therapy, which increased the risk of detec-
tion bias. In Pennington 2009a the first coder collected the data
and was aware of time at which data were collected when analysing
behaviour. A second (naive) rater coded a random 20% of set of
data from each participant, thereby reducing but not eliminat-
ing detection bias. In Pennington 2009b listeners heard speech
recordings blind to the data collection point. In the studies in
which the therapists who undertook intervention also measured
outcomes bias was reduced, but not eliminated, by the inclusion
of a reliability check of coding with a blind assessor. Basil 1992
checked a nonrandom sample of 12.5% sessions from before, dur-
ing and after therapy, with agreement 90%, 92%, 98%. Hanzlik
1989 reported K = 0.75 to 1.0 agreement from data from each of
the children, across 14 categories but did not state the amount of
data on which this was calculated. In McConachie 1997 half of
the data were coded by the second author, half by a blind assessor,
with agreement calculated as 76% (71% to 79%) on 15% of the
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total data. As only small proportions of data were included in the
reliability checks, each of the studies was still open to detection
bias.
5. Description of the intervention
From the information given in the studies it would not be possible
to replicate the intervention provided by Basil 1992 or Pennington
2009b. It was also unclear how similar the intervention was be-
tween participants within the groups. McConachie 1997 provided
fuller description of the intervention and the training programme
used has been published (Pennington 1993), allowing replica-
tion. Hanzlik 1989 provided additional information on the treat-
ment protocols, which would allow partial replication. Pennington
2009a followed a well known, published therapy protocol for
which therapists also receive training and certification.
6. Analysis
Data were analysed in the category to which participants were
originally allocated. No cross-over was reported or could be de-
tected in any of the three group comparison studies. Basil 1992
and Hanzlik 1989 analysed data from the very small numbers of
participants as groups, using parametric tests, which were unsuit-
able for such a small sample size. McConachie 1997, Pennington
2009a and Pennington 2009b used appropriate statistical tests.
Hanzlik 1989 measured 14 variables from the samples of inter-
action, and Basil 1992 measured 10, increasing the likelihood of
obtaining a statistically significant result by chance. However, this
was not taken into account in the authors’ conclusions. Losses
to follow up occurred only in McConachie 1997, where a high
attrition rate was observed, especially for the control group. The
attrition was unexplained and left the study open to attrition bias.
Single case studies
1. Participant description
For replication of single case studies and moving from hypoth-
esis generation to hypothesis testing participants need to be de-
scribed in detail. All of the studies included in the review gave
the participant child’s chronological age and most gave a rating
of their severity of cerebral palsy (mild, moderate, severe). Some
gave children’s type of cerebral palsy and rated the severity of any
additional cognitive impairments. Few gave information on sen-
sory impairments (Olswang 2006; Pinder 1995; Tait 2004) and
epilepsy or details of children’s receptive language development.
Most cited children’s present modes of communication and gave
a very brief overview of their use of their communication skills in
interaction. Only Dada 2009 was judged to include sufficient de-
tail to select, with certainty, other participants with a similar type
9
of cerebral palsy, level of locomotor skills, cognitive and commu-
nication development. Davis 1998, Hunt 1986, Hurlbut 1982,
Olswang 2006, Pinder 1995 and Tait 2004 were judged to give a
partial account of children’s level of functioning. The descriptions
given by Campbell 1982, McCollum 1984, Richman 1977 and
Sigafoos 1995 were judged to be inadequate for replicating the
study.
2. Equality of skills assigned to treatment and control
Intervention is deemed to have an effect if outcome measures
change at the point of, or after, intervention for each child in suc-
cession but no change is observed prior to intervention. Allocation
of skills to control and treatment and similarity of skills in treat-
ment and control were judged to be not applicable for this study.
When different skills are assigned to treatment and control, in or-
der to avoid selection bias and the effect of maturation, skills need
to be of similar developmental level and prognostic indication and
assigned at random to treatment or control with later treatment
in multiple baseline designs. Richman 1977 compared communi-
cation skills with a motor skill. Tait 2004 compared looking at an
object with looking at a graphic symbol, for which the visual-cog-
nitive processing is quite different. Pinder 1995 and Sigafoos 1995
selected target skills that were very similar, and which may have
been expected to generalise for the included participants. There-
fore, an increase in control skill as well as treated skill would be
expected. The other studies investigated skills of similar prognos-
tic indication and were rated adequate in skill selection. However,
none of the studies stated if skills were assigned to treatment (or
a place in a sequence of treatments for multiple baseline across
processes designs) or control randomly, which could introduce se-
lection bias. All studies were rated as unclear on this criterion.
3. Description of the intervention
For single case studies to be replicated, interventions, which are
often innovative in these designs, need to be described in de-
tail. Dada 2009, Davis 1998, Olswang 2006, Richman 1977 and
Sigafoos 1995 were judged to describe the intervention in suffi-
cient detail for it to be replicated. Dada 2009, Davis 1998, Hunt
1986; Olswang 2006 and Tait 2004 reported checks of treat-
ment integrity, which show fidelity of treatment across partici-
pants and that treatment was undertaken according to the pro-
tocol. Campbell 1982, Hunt 1986, Hurlbut 1982, McCollum
1984, Pinder 1995 and Tait 2004were judged to give only part of
the information needed to replicate intervention. Information was
usually provided on the frequency and duration of treatment but
was lacking on the exact methods of eliciting skills from individ-
ual children. For example, incomplete information was provided
on which communication situations were used to elicit particular
skills, the point in an activity at which communication opportu-
nities were provided and the methods used to teach a communi-
cation strategy to a mother.
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4. Blinding
None of the studies included blinding participants or clinicians to
the aims or type of therapy. In all studies except Olswang 2006
data on outcome measures were collected by the investigators,
but included checks on the reliability of coding by a second ob-
server, which could reduce detection bias. Olswang 2006 used
students who were trained to criterion on communication cod-
ing, but it was not clear if coding was undertaken blind to time
of data recording. All studies except McCollum 1984 used data
collected from the participants during the study. Amount of data
checked ranged from 17% to 50%; only that used by Pinder 1995
was selected randomly. Most studies calculated agreement using
percentage (agreement-disagreements/total number of behaviours
coded), which does not adjust for chance agreement. Agreement
ranged from 75% to 100%. Pinder 1995 calculated agreement
using Kappa (K), achieving more than K = 0.60 for each partici-
pant. Taking into account the amount of data checked, the selec-
tion method used and the agreement achieved, Dada 2009, Davis
1998, Olswang 2006 and Pinder 1995 were judged to partially
meet the blinding criterion. Campbell 1982, Hunt 1986, Hurlbut
1982, McCollum 1984, Richman 1977, Sigafoos 1995 and Tait
2004 were judged inadequate and to be at considerable risk of
detection bias.
5. Duration of phases and measurement
To show that intervention leads to change in single case experi-
ments, frequent measurements should be taken in baseline, inter-
vention and follow up or maintenance phases, and phases should
be of similar duration. Without the use of randomisation tests
(Edgington 1995), baseline should be adequately established with
a plateau across at least three measurements or with a downward
trend. If treatment is successful a clear upward trend should be
observed during the intervention phase. In studies aiming for the
acquisition of new skills the behaviour should continue at similar
levels to the intervention phase in follow up or maintenance with
no intervention.
Campbell 1982, Dada 2009, Davis 1998, Hurlbut 1982, Pinder
1995 and Richman 1977 showed baselines that were adequate,
with demonstration of stable behaviours. Hunt 1986, McCollum
1984 and Sigafoos 1995 did not demonstrate stable behaviour at
baseline and were rated inadequate. Some participants in Olswang
2006 and Tait 2004 did not show a stable baseline and these stud-
ies are rated as partial. The interventions in Campbell 1982, Dada
2009, Hunt 1986 and Hurlbut 1982 showed a clear upward trend
in target behaviour. Similar changes were partially demonstrated
by Davis 1998, Pinder 1995 and Tait 2004 with higher scores
than baseline but variability. In Olswang 2006 and Sigafoos 1995
scores were higher in intervention but were variable within treat-
ment, which should have been continued to investigate possible
trends. No clear trends were demonstrated by McCollum 1984 or
Richman 1977 with lots of variation in the scores. The follow-up
10
phases of all studies were rated as partial or inadequate due to their
absence, short duration or change in target behaviours.
Measurements of all target skills were taken continuously across
phases by Campbell 1982, Dada 2009, Olswang 2006, Pinder
1995, Richman 1977 and Tait 2004. Data across sessions were ag-
gregated by Davis 1998, taken infrequently for control behaviours
by Hunt 1986 and presented as means by Hurlbut 1982; partially
meeting the criterion relating to measurement. McCollum 1984
and Sigafoos 1995 included one measurement only for follow up
and Sigafoos 1995 measured control processes at baseline and fol-
low up only.
6. Confounding variables
None of the studies discussed confounding variables and all were
rated unclear on this criterion. It is possible that for Sigafoos 1995
and Pinder 1995 the control skill was too similar to the treated
skill and would be expected to generalise without treatment for
the participants.
7. Analysis
Statistical tests have been developed for single case experimental
designs (Edgington 1995). However they have not been widely
used and none of the studies included in the review employed sta-
tistical analysis. Analysis involved visual inspection of the graphed
data and subjective interpretation.
8. Replication
Dada 2009, Hurlbut 1982, Olswang 2006, Pinder 1995 and
Tait 2004 included replication across participants, who appeared
similar in prognostic indication. Other studies included in the
review did not systematically replicate their interventions to other
children with cerebral palsy. Some included children with other
medical diagnoses.
Effects of interventions
Studies of interventions focused on children
The studies focusing on children aimed to facilitate different as-
pects of communication development. Each aspect targeted is dis-
cussed separately.
Pre-intentional communication
Richman 1977aimed to increase a child’s amount of eye contact,
time she kept her head in an upright position and her imitative
vocalisations. These behaviours were compared with control of
drooling, which received no intervention. Wide variation was seen
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in each of the behaviours across baseline. Increases in each be-
haviour were observed during their individual intervention phases.
Behaviours reduced during reversal and then increased again once
the treatment was recommenced. However, during the second
treatment phase behaviours did not reach the levels of the initial
treatment phase. Follow up at one month after intervention had
ceased showed similar levels to the second treatment phase for head
control and imitative vocalisation. Increased scores were observed
for the three behaviours at 12 month follow up.
Communicative functions
Hunt 1986, Pinder 1995 and Sigafoos 1995 all trained children
to produce requests. Hunt 1986 taught one girl to make requests
for objects or actions in a multiple baseline design. Baseline was
stable, showing infrequent use of any of the requests. The first
request showed a steady increase and reached criterion (three suc-
cessive correctly produced requests) in 16 sessions, the second in
the sequence was produced without direct teaching. The third re-
quest in the sequence also increased steadily in the intervention
phase reaching criterion in 13 sessions. The final request also gen-
eralised without direct teaching. Pinder 1995 taught four children
to request either an object or ’more’ by looking at the adult and
the object, the untaught request acted as a control. Requests were
taught in play with toys and also assessed in snack time as a gener-
alisation situation. Baselines were stable for three of the children,
with requests made to less than 20% of probes. For one child,
who had earlier been taught to make the same requests by actively
reaching towards an object, increases in the target behaviour ap-
pear to have been made towards the end of baseline. For each of
the four children increases in the production of both the taught
and untaught requests were observed during intervention across
both the treatment and generalisation situations. For two children
increases were noted with the onset of intervention. For the other
two increases in the behaviours were observed after three to four
sessions of therapy. Levels of requests were maintained for four
weeks after therapy had been withdrawn. Sigafoos 1995 aimed to
teach a boy to use three requests for objects in a multiple baseline
design. During baseline percentage correct production of the three
requests (not separated) ranged from 0% to 35%. For the first re-
quest production increased to 35% to 60% with verbal prompting
and increased to 80% to 100% when expectant delay was used and
verbal prompts were faded. However, although requests increased
from the first to the second phase of intervention they showed a
downward trend in the latter part of the second phase. The other
target requests were tested after intervention for the first and were
correct for 65% and 30% of 17 trials, showing some generalisa-
tion. The trial was then stopped due to the school year ending.
Davis 1998 trained a boy to produce responses to statements in
conversation partners in a multiple baseline design across three
communication partners, by pairing obligatory requests (ques-
tions) with a nonobligatory request (statement). Prior to interven-
11
tion responses to statements were rare, being produced following
0% to 20% of statements made by each of the three partners in con-
versation (means = 1.8%, 2.5% and 4.0%). During intervention
responses immediately increased, following an average of 41.7%
and 52% of statements by the first two partners. Increases were
only observed with the individual partners once the treatment had
started. However, there was considerable variation in frequency of
responses during intervention, ranging from 0% to 60% and 20%
to 80% with each partner. Intervention was not carried out with
the third partner due to the child’s family moving away from the
area in which the research was conducted. Responses to statements
with this partner remained at baseline level throughout the study.
Hurlbut 1982 trained three children to use Bliss and iconic sym-
bols to name objects. For each child trials to criterion were faster
for iconic symbols than Bliss. Each child also produced iconic
symbols more frequently than Blissymbols in maintenance and
generalisation probes, and named more untrained objects using
iconic symbols than Bliss.
Expressive language
Campbell 1982 taught one child to use “is/are” in three linguis-
tic structures in a multiple baseline design. In baseline is/are were
produced correctly in 0% to 10% of wh questions, 0% to 10%
of yes/no reversal questions and 0% to 35% of statements. For
the first two structures baselines were stable, whereas statements
seemed to show an upward trend in correct production. During
intervention the percentage of correct productions rose steeply for
all three targeted structures. Levels were also maintained at a much
higher rate than baseline for these structures, but showed consid-
erable variation during the maintenance phase. Generalisation to
use in spontaneous speech showed increases from baseline for yes/
no questions, but much lower levels than observed with interven-
tion. Wide variation was noted for the generalisation of is/are in
statements, with no clear pattern observed during baseline, treat-
ment or maintenance phases.
Receptive vocabulary
Dada 2009 taught four children to select 24 graphic symbols when
named. During baseline two children selected two out of the 24
items named. During intervention the percentage of correct iden-
tification rose steeply for all target items. During follow up chil-
dren continued to select items from the first two sets of vocabulary
items. However, follow up was not long enough to show retention
of the third set of taught words.
Speech production
Pennington 2009b delivered dysarthria therapy focusing on res-
piratory and phonatory control, and control of speech rate and
phrase length. No change in percentage of words in single word
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utterances and connected speech that were understandable to fa-
miliar and unfamiliar adults was observed at six weeks and one
week prior to treatment. Following treatment the estimated in
increase in intelligibility to familiar listeners was 14.7% (95%
CI 9.8 to 19.5) for single words and 12.1% (95% CI 4.3% to
20.0%) for connected speech. For unfamiliar listeners the imme-
diate post-therapy estimated increase was 15.0% (95% CI 11.73%
to 18.17%) for single words and 15.9% (95% CI 11.8% to 20.0%)
for words in connected speech. No differences were observed be-
tween post-intervention scores and follow-up scores taken at one
and six weeks after intervention completion for either single words
or connected speech when heard by either familiar or unfamiliar
listeners.
Therapy focusing on communication partners
Parents
Basil 1992, Hanzlik 1989, McCollum 1984, Olswang 2006,
Pennington 2009a, Tait 2004 all trained parents, with the inten-
tion of changing their interaction style and thus facilitate chil-
dren’s communication. Basil 1992 found no difference between
the percentage of turns taken in conversation, or the proportion of
responses to children’s utterances by trained parents or untrained
teachers before and after intervention. Parents asked fewer open
questions than teachers prior to therapy, but increased these af-
ter intervention whilst teachers’ use of open questions remained
stable ( F (3, 1) = 8.35, P = 0.063). After one hour of instruc-
tion parents in Hanzlik 1989 changed behaviour that related to
’doing’, but not that which involved verbal interaction. Mothers
who received instruction on changing physical and verbal inter-
action used less physical guidance (F(1, 18) = 6.34, P = 0.02),
more face to face contacts (F(1, 18) = 28.49, P = 0.00005) and
less physical contact (F(1, 18) = 10.11, P = 0.005) than moth-
ers in the control group who received neurodevelopmental ther-
apy. No differences were observed in mothers’ verbal directiveness,
praise, questions or verbal interaction before and after instruction
for either group. McCollum 1984 trained a mother to bring her
face close to her child’s. The behaviour increased from baseline
and was maintained after intervention had finished. The mother’s
imitation of her child’s vocalisation increased during intervention
but showed a lot of variation, and a possible downward trend to-
wards the end of treatment. The skills appeared to generalise to an
untreated play situation, but were not maintained once treatment
had stopped. Contrary to expectation one mother in the study by
Olswang 2006 used higher rates of target behaviours at the start of
each phase of the study and rates reduced during each of the three
phases: baseline, intervention and withdrawal of treatment. Her
child showed variable rates of engagement in interaction in each of
the three phases, but a gradual increase from baseline to treatment
withdrawal. The other mother showed a fairly stable baseline, in-
creases in rates of target behaviours during the treatment phase
12
and a reduction in rates of target behaviours when treatment was
withdrawn. Her child’s engagement was correspondingly stable
during baseline, increased during intervention and reduced during
the withdrawal phase. In Pennington 2009a no differences were
observed in mothers’ communication at four and one month prior
to intervention. Mothers started fewer conversational exchanges
in the month after therapy (t(10) = -2.730, P = .011, d = -.823)
and responded more to children’s communication (t(10) = 3.891,
P = .002, d = 1.173) than in the month prior to training. In the
month after intervention mothers also used fewer directives (t(10)
= -2.630, P = .013, d = -.793). The changes observed in mothers’
communication were maintained without further therapy at fol-
low up, four months after intervention completion. The complex-
ity of mothers’ language directed to their children did not change
during the study, nor did their responses to the Parental Sense of
Competence questionnaire.
Teachers and educational assistants
Teachers and educational assistants who received training in
McConachie 1997 used more strategies to facilitate children’s com-
munication four months after training (X2 (4) = 15.84 P ≤ 0.01).
Post hoc analysis suggested that these differences were already ob-
servable for teachers at one month post-training, but not for as-
sistants (X2 (4) 11.82, P < 0.01). Teachers and assistants who did
not receive training showed no changes in their communication
patterns.
Secondary outcomes for children
Basil 1992, Hanzlik 1989 and McCollum 1984 also looked at
changes in children’s communication that were associated with
training given to parents. In Basil 1992 prior to parent training
children failed to respond to parents’ interaction more often than
to teachers’, but increased their responses to parents after inter-
vention (F (3, 1) = 17.94, P = 0.024). Similarly, children commu-
nicated less often using their symbol communication boards with
their parents than with their teachers, but their use with parents
increased after training (F (3, 1) = 16.93, P = 0.026). Hanzlik
1989 observed an increase in voluntary responsiveness (F (1, 18) =
11.53, P < 0.003) and less physically directed compliance (F (1 to
18) = 4.44, P < 0.05) but no differences in the amount of indepen-
dent play for the infants whose mothers had received interaction
training. The child in the study by McCollum 1984 showed an
increase in vocalisation concurrent with his mother’s training and
increase in the frequency with which she brought her face close
to her child’s. The child of the mother in the study by Olswang
2006 who used higher rates of target behaviours at the start of
each phase of the study but whose rates reduced during each phase
showed variable rates of engagement in interaction in each of the
three phases, but a gradual increase from baseline to treatment
withdrawal. The child of the mother who had a fairly stable base-
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
line, with increases in rates of target behaviours during the treat-
ment phase and a reduction in rates of target behaviours when
treatment was withdrawn, showed engagement which was corre-
spondingly stable during baseline, increased during intervention
and reduced during the withdrawal phase. The communication
patterns of children in Pennington 2009a showed no differences
between recordings taken at four and one month prior to parent
training. Children initiated more conversations (t(10) = 3.150, P
= .005, d = .950) and used more of their turns in conversation
to control the interaction and their mother’s behaviour (t(10) =
2.987, P = .007, d =.901) in the month after their parents had
received training than in the month prior to training. Changes ob-
served following therapy were maintained at four month follow-
up, during which time no further intervention was given to par-
ents or children. Tait 2004 observed children’s use of more sophis-
ticated communication signals to make requests, make choices,
protest and to show response to their name before, during and
after their parents were given training in communication teaching
techniques. Four children increased their use of more sophisticated
communication signals in three communication activities during
treatment and maintained the use of these more sophisticated sig-
nals during follow up. Two children produced more sophisticated
signals for one out of three messages targeted. One of these two
children may have maintained the new behaviour but one reverted
to prelinguistic behaviours during follow up.
DISCUSSION
Principal findings
• This exploratory review found 17 papers (reporting 16
studies) that investigated the effects of different methods of
speech and language therapy (SLT) for children with cerebral
palsy, who differed in age, type and severity of motor disorder,
presence and severity of intellectual impairment, or their
communication partners. Nine of these studies evaluated therapy
that focused on children. Seven studies concentrated on adult
conversational partners (one study contained data subsumed into
another trial and the larger study only is discussed). Therapy for
children targeted pre-intentional communication skills, the use
of individual communicative functions, expressive language,
receptive vocabulary and speech production. Training for
conversational partners included parents and education workers,
teaching them to facilitate the communication of individual
target children, usually augmentative communication system
users.
• Although the results observed suggest possible trends in
communication change, the methodological quality of the
studies included in the review is generally poor and this review
provides insufficient evidence to support the general effectiveness
13
of SLT for either children with cerebral palsy or their
communication partners.
• Since the original review in 2003 group studies have been
published and show the potential impacts of therapy on
children’s speech production and training for parents on parent-
child interaction patterns. These studies provide the data
necessary to develop rigorous controlled investigations of the
effectiveness of therapy.
• The participants of the studies included in the review are
heterogeneous and are often poorly described. Consensus on the
description of participants and the choice of outcome measures
in research reports is needed to establish potential clinical
subgroups. Children and conversational partners within
subgroups may resemble those with other primary disorders, for
example children with severe cognitive impairment.
• Consensus is needed on the aims and methods of standard
therapies targeting different areas of communication used with
clinical subgroups. Once consensus is gained, investigations of
the effectiveness of standard therapies can be developed.
Consensus among communities of practice could be gained
through focus groups followed by a survey of SLTs working in
the clinical field.
• New therapy techniques should be applied in single case
experimental designs, which should be rigorously designed and
reported. These need to be replicated with similar participants,
from a defined clinical subgroup, and evaluated in exploratory
group trials. Should they show positive findings, the intervention
should be tested in pragmatic trials.
• Participants in trials of SLT interventions should be
followed up to evaluate the long term impact of therapy on
communication activity, participation and quality of life.
• Valid, reliable generic outcome measures are needed to
assess communication activity outcomes and allow cross trial
comparisons.
• The acceptability of interventions for families has not been
evaluated and needs further study.
Therapy focusing on children
Nine studies were found that investigated the effects of therapy
given directly to children. All but one (Pennington 2009b) used
single case experimental designs to show the impact of treatment
for individual children. Children included in the studies ranged
in age from infancy to late teens, had moderate to severe motor
impairments, mild to severe speech, language and communication
disorders and intellectual impairment ranging from mild to severe.
Although each of the studies has methodological flaws, the provi-
sion of therapy does seem to be associated with increases in the pro-
duction of pre-intentional communication behaviours (Richman
1977), requests for objects or actions (Hunt 1986; Pinder 1995),
responses to others’ communication (Davis 1998) use of expressive
language structures (Campbell 1982) and understanding of spo-
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ken words (Dada 2009) for the children studied. For three teenage
children with severe cognitive impairment it appeared that iconic
communication symbols were easier to acquire than Bliss symbols
(Hurlbut 1982). For the studies using single case methodology
we can only conclude that the intervention employed in the stud-
ies may have been effective in helping the individual children in-
volved to develop communication skills. Given the methodology
employed we cannot extend the findings to other children with
cerebral palsy. Replication of the studies with other participants
and exploratory group studies are needed to generalise findings
to possible clinical subgroups, and move from hypothesis genera-
tion to hypothesis testing. The group study by Pennington 2009b,
along with others described in the systematic review by Penning-
ton, Miller and Robson (Pennington 2009), suggests that speech
and language therapy targeting control of respiration and phona-
tion for speech may be associated with gains in intelligibility to
both familiar and unfamiliar listeners. Pennington 2009b provides
the data necessary to develop rigorous controlled trials of the ef-
fectiveness of this type of intervention.
Training for conversation partners
The studies that focused on communication partners provided
training in facilitating the communication skills of individual chil-
dren for parents, teachers and education assistants. Four stud-
ies were group trials, three studies used single case experimen-
tal design. Four of the studies (Basil 1992; McCollum 1984;
McConachie 1997; Olswang 2006) have serious methodological
flaws and cannot demonstrate the effects of therapy for the par-
ticipants who participated. The study by Hanzlik 1989, involved
parents of infants receiving a one hour individual training session
focusing on the use physical and verbal interaction techniques. Re-
sults suggest that following the short period of intervention moth-
ers changed their interaction style using more face to face com-
munication and less physical contact with their infants. Overall,
interaction was rated as more positive following training, but use
of verbal interaction strategies did not appear to change. Follow
up was not included in the study, therefore it is not possible to
determine if change was maintained for the participants or if chil-
dren’s communication development was facilitated. Replication of
this study with follow up is needed to investigate the effectiveness
of the training programme used. Pennington 2009a observed the
effects of the group training programme It Takes Two to Talk®
for a group of parents and their preschool children aged 19 to 36
months. Although this programme was not specifically designed
for parents of children with motor impairments positive changes
were observed in the communication patterns of mothers and their
children after training. Changes were maintained four months af-
ter intervention without any further therapy. Furthermore, in a
separate interview study (Pennington 2010) parents reported their
experiences of the programme as largely positive, although some
advised that more reference to augmentative and alternative com-
14
munication (AAC) should be included when using the programme
with families of children with severe motor disorders. Even with
this suggestion parents appeared to view the training as acceptable
and effective in helping to learn more about their child’s commu-
nication needs and fostering their child’s communication devel-
opment. The study provides the information needed to develop
a pragmatic randomised control trial of the effectiveness of the
training programme for parents and their young children with
motor disorders. Further, more rigorous investigations are needed
of the training given in the other studies, as they aimed to teach the
same communication strategies, which are widely acknowledged
by clinicians to affect the communication of children with speech
disorders and cerebral palsy.
Methodological quality of investigations
Participants
Children with cerebral palsy who receive SLT range in age from
infancy to late teens and vary widely in their functional levels of
movement, learning, communication, vision and hearing. When
reporting new interventions it is necessary to describe for whom
they may be suitable. However, the descriptions of children and
adults who participated in the studies included in this review were
generally poor. It would therefore not be possible to replicate most
studies or to decide whether children on clinical caseloads were
similar to those in the original study and may benefit from the in-
tervention. Descriptions of subjects should include all features that
may confound studies. This includes children’s chronological age,
type and severity of cerebral palsy, gross and fine motor function-
ing, cognitive developmental level, presence, type and severity of
epilepsy, sensory skills, receptive and expressive language develop-
ment, educational placement and previous therapy. Valid systems
now exist to classify the motor skills of children with cerebral palsy
(Eliasson 2006; Palisano 2007) and these should be routinely ap-
plied in research. Communication skills should be described in de-
tail, and should include measures of speech intelligibility, methods
of communication used and communicative functions produced
in conversation. Schemes are currently being developed to classify
the communication of children with cerebral palsy (Barty 2009;
Hidecker 2009) and it is hoped that in the near future they will be
validated for use in research For training of conversation partners
details of their relationship to target children, gender, educational
level, previous training and present communication style should
be given. With such descriptions it may be possible to identify clin-
ical subgroups of children with cerebral palsy who display similar
skills and who react to interventions in similar manners. However,
as cerebral palsy is associated with a wide range of disorders it is
possible that some children will not fit into such groups and the
evaluation of interventions for them will comprise N of one trials.
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Intervention
The interventions investigated in the studies included in this re-
view were generally well described and their primary features could
be replicated. For therapy focusing directly on children, techniques
included operant and micro-teaching. Training for conversation
partners included short talks, brainstorming, video examples, prac-
tice and feedback. Full description with examples of interaction
during intervention would facilitate replication. However, some
differences would still be likely to occur due to the fluid nature
of conversation and effects of different communication environ-
ments and circumstances. Some studies (Dada 2009; Davis 1998;
Hunt 1986; Olswang 2006; Tait 2004) reported checks of treat-
ment integrity, which should be included in study design to show
constancy of treatment across participants and that treatment was
undertaken according to the protocol.
Blinding
Due to the nature of participation in therapy and training it is
not possible to blind participants and clinicians to therapy, which
leaves trials of SLT, including those in this review, open to attrition
bias. People may agree to participate, but withdraw when allocated
to the intervention they least support. Attempts were made in
each of the studies to reduce detection bias by including checks of
data coding by a second rater. To improve the rigour of studies,
outcomes should be assessed by persons other than those giving the
therapy, who are blind to the allocation of treatment and control.
Sample size
The group studies in the review were exploratory in nature. Some
(Pennington 2009a; Pennington 2009b) could be used by future
researchers to calculate sample sizes reliably to test the effects of
similar interventions.
Single case experimental design
It is important to show, in these hypothesis generating studies,
that intervention addresses a target behaviour and that changes in
behaviour are not due to maturation. This demands the establish-
ment of an adequate baseline, with sufficient data collection points
throughout the baseline, intervention and follow-up phases, and
the comparison of a treated skill with an untreated behaviour that
is similar in prognostic indication. Some studies failed to show
that behaviours were stable before therapy, and it is therefore possi-
ble that behaviours attributed to intervention may have developed
without it. Randomisation tests may have addressed the lack of a
stable baseline, but these were not used. Other studies included
control behaviours that were untreated, or treated later, which were
too similar to the treated behaviour and also changed, probably as
a result of the intervention. One of the studies (Richman 1977)
used a motor skill which would not have been expected to show
15
the same pattern of development as the treated communication
skills. None of the studies included adequate follow up to show the
maintenance of behaviour change, which is vital if we are seeking
to show the acquisition of communication skills.
Outcome measures
Communication
The aim of SLT is to improve communication. As such, outcome
measures should relate directly to aspects of communication be-
haviour. Depending on the particular difficulties children experi-
ence, therapy could aim to improve a child’s speech production,
understanding, expressive language, voice, range of communica-
tive functions or use of an augmentative or alternative commu-
nication system. Training for parents and other communication
partners involves changing their communication patterns to give
children opportunities to develop and use new communication
skills. The studies involved in this review targeted different aspects
of communication and used different outcome measures. Even
studies that looked at similar skills, for example those targeting re-
quests for objects and actions, used different measures to evaluate
outcome. This makes replication of studies harder than if generic
tools were used, as clinicians and researchers need to be trained
to use the measures reliably. The use of the same outcome mea-
sures across studies would also help in the collection of a bank of
information about the communication of children with cerebral
palsy and their conversation partners, in the formation of clinical
subgroups and in the assessment of the clinical significance of re-
ported interventions. In addition to describing the change in the
individual skills targeted it would be useful if authors examined
the rate of change in other areas of communication, using well
known outcome measures. This would provide rates of change for
individuals and groups that may or may not be associated with
intervention and which may be used to aid clinical practice and
to inform future research.
Quality of life and participation
Recent research has observed an negative correlation between com-
munication skill and both relationships with parents and participa-
tion of children with cerebral palsy (Dickinson 2007; Fauconnier
2009). With the exception of Pennington 2009a, which had an
accompanying qualitative study (Pennington 2010), the studies
included in this review did not examine the wider impact of ther-
apy. In addition to investigating the change in children’s commu-
nication, and that of their conversation partners, it is important to
examine if children and their families find interventions accept-
able and worthwhile, and if interventions are associated with chil-
dren’s increased quality of life and participation in social, educa-
tion and family life. Such additional information could be gained
by the use of published measures of participation, family stress and
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
functioning and through interviews with both parents and chil-
dren. Qualitative studies are now more prevalent (Clarke 2001;
Goldbart 2004; Lund 2007a; Lund 2007b; Marshall 2008) and
some have shown unexpected results. For example in Clarke 2001
young AAC users supported a model in which children are with-
drawn from classrooms to learn new communication skills, con-
trary to current clinical practice in which skills are taught in nor-
mal class activities. We cannot assume that parents and families
involved in the studies of this review view the intervention they
received positively as therapy was of short duration and with min-
imal follow up, making attrition due to unsuitability of treatment
less likely.
AUTHORS’ CONCLUSIONS
Implications for practice
Considering the range of aspects of communication targeted,
methods used and participants involved in the studies included
in this review, and the methodological weaknesses of the studies,
it is not possible to conclude at the present time that speech and
language therapy focusing on children with cerebral palsy or their
communication partners is more effective than no intervention at
all. However, no evidence has been found of any harmful effects
of SLT for children with cerebral palsy and their families, and
therapy has not been shown to be ineffective. Changes in therapy
provision are not warranted given current evidence.
Implications for research
This exploratory review highlights the paucity of rigorous research
on the effectiveness of speech and language therapy (SLT) that
aims to improve the communication skills of children with cere-
bral palsy. Further research is needed to define possible clinical
subgroups of children with cerebral palsy and their communica-
tion partners and to investigate the most effective methods of in-
tervention for these subgroups. To this end a bank of research ev-
idence is needed, including the following.
• Detailed description of research participants including their
age, type and severity of cerebral palsy, gross and fine motor
function (e.g. Gross Motor Function Classification System,
Manual Ability Classification System), cognitive level, presence
and type of epilepsy, sensory skills, receptive and expressive
language skills, method of communication, range of
communication skills and speech intelligibility. Where possible
researchers should use the same validated measures across
reports. Communication partners should also be described
thoroughly, including information on their relationship to the
child, age, gender, educational history, employment, previous
training in communication, attitudes towards augmentation and
alternative communication (AAC), present communicative style.
16
 • Development of valid and reliable generic measures of
speech function and communication activity for children with
motor impairments.
• Definition of the methods currently used to treat different
areas of communication development for (subgroups of )
children with cerebral palsy and their conversational partners,
gained through focus groups and surveys.
• Randomised controlled trials of the effectiveness of
dysarthria therapy focusing on respiratory and phonatory control
and communication training for parents.
• Rigorous series of single case experiments to test new
interventions with clients from a potential subgroup, and for
clients who do not fit inclusion criteria for identified subgroups.
• Exploratory trials of new interventions with groups of
children/conversational partners to investigate the feasibility of
using the new therapy in typical clinical situations and of
extending the therapy to a group of clients who vary more than
those involved in a single case series. If positive results are
achieved these studies would lead to pragmatic trials comparing
new and standard therapies for subgroups of children and
conversation partners.
• Follow up of participants for at least three months after
therapy to investigate the maintenance of skills development.
• The inclusion of participation and quality of life measures
to evaluate wider impacts of interventions.
• Qualitative research studies to investigate children’s and
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Basil 1992 {published data only}
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these interventions.
As this review has shown, SLT for children with cerebral palsy is
a complex intervention. Children have complex communication
disorders, associated with their varied underlying impairments,
and each disorder may require a different type of treatment. In ad-
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ACKNOWLEDGEMENTS
We thank the anonymous referees who provided helpful comments
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Buzolich 1994 {published data only}
Buzolich MJ, Lunger J. [Empowering system users in peer
training]. Augmentative and Alternative Communication
1994;11(1):37–48.
Carter 1998 {published data only}
Carter M, Maxwell K. Promoting interaction with children
using augmentative communication through a peer-directed
intervention. International Journal of Disability, Development
and Education 1998;45(1):75–96. [MEDLINE: 131]
Chan 2002 {published data only}
Chan JS, Yau MK. A study on the nature of interactions
between direct-care staff and persons with developmental
disabilities in institutional care. British Journal of
Developmental Disabilities 2002;48(1):39–51. [MEDLINE:
807]
Cohen 2000 {published data only}
Cohen KJ, Light JC. Use of electronic communication to
develop mentor-protege relationships between adolescent
and adult AAC users: pilot study. Augmentative
and Alternative Communication 2000;16(4):227–38.
[MEDLINE: 146]
Darrah 2004 {published data only}
Darrah J, Watkins B, Chen L, Bonin C. Conductive
education intervention for children with cerebral palsy: an
AACPDM evidence report. Developmental Medicine and
Child Neurology 2004;46(3):187–203.
DiCarlo 2000 {published data only}
DiCarlo CF, Banajee M. Using voice output devices to
increase initiations of young children with disabilities.
Journal of Early Intervention 2000;23(3):191–9.
[MEDLINE: 188]
Dowden 1995 {published data only}
Dowden PA, Marriner NA. Augmentative and alternative
communication: treatment principles and strategies.
Seminars in Speech and Language 2000;16(2):140–58.
[MEDLINE: 193]
Durand 1993 {published data only}
Durand VM. Functional communication training using
assistive devices: effects on challenging behavior and affect.
Augmentative and Alternative Communication 1993;9(3):
168–76. [MEDLINE: 203]
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
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Enderby 1981 {published data only}
Enderby P, Hamilton G. Clinical trials for communication
aids? A study provoked by the clinical trials of SPLINK.
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181–95. [MEDLINE: 222]
Erickson 1997 {published data only}
Erickson KA, Koppenhaver DA, Yoder DE, Nance J.
Integrated communication and literacy instruction for
a child with multiple disabilities. Focus on Autism and
Other Developmental Disabilities 1997;12(3):142–50.
[MEDLINE: 223]
Fox 2005 {published and unpublished data}
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voice treatment (LSVT) on speech intelligibility in children
with spastic cerebral palsy. Movement Disorders 2005;20
(10):s149.
Galliers 1987 {published data only}
Galliers JR. ’Intelligent’ communication aid for Bliss users:
a case study. International Journal of Rehabilitation Research
1987;10(4):425–8. [MEDLINE: 257]
Gibbon 2003 {published data only}
Gibbon FE, Wood SE. Using electropalatography (EPG)
to diagnose and treat articulation disorders associated with
mild cerebral palsy: A case study. Clinical Linguistics and
Phonetics 2003;17(4-5):365–74.
Glennen 1985 {published data only}
Glennen SL, Calculator SN. Training functional
communication board use: a pragmatic approach.
Augmentative and Alternative Communication 1985;1(3):
134–42. [MEDLINE: 811]
Goossens 1985 {published data only}
Goossens C, Kraat A. Technology as a tool for conversation
and language learning for the physically disabled. Topics in
Language Disorders 1985;6(1):56–70. [MEDLINE: 272]
Goossens 1989 {published data only}
Goossens C. Aided communication intervention before
assessment: a case study of a child with cerebral palsy.
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14–26. [MEDLINE: 271]
Hall 1997 {published data only}
Hall LJ, Macvean ML. Increases in the communicative
behaviours of students with cerebral palsy as a result of
feedback to, and the selection of goals by, paraprofessionals.
Behaviour Change 1997;14(3):174–84. [MEDLINE: 284]
Harris 1982 {published data only}
Harris D. [Communicative interaction processes involving
nonvocal physically handicapped children]. Topics in
Language Disorders 1982;2(2):21–38.
Harris 1996 {published data only}
Harris L, Doyle ES, Haaf R. Language treatment approach
for users of AAC: experimental single-subject investigation.
Augmentative and Alternative Communication 1996;12(4):
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Heim 1990 {published data only}
Heim M. Communicative skills of nonspeaking CP
children: a study on interaction. Paper presented at 4th
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and Alternative Commuication. Stockholm, Sweden,
August 12–16, 1990. [MEDLINE: 303]
Hetzroni 2000 {published data only}
Hetzroni OE, Belfiore PJ. Preschoolers with communication
impairments play Shrinking Kim: an interactive computer
storytelling intervention for teaching Blissymbols.
Augmentative and Alternative Communication 2000;16(4):
260–9. [MEDLINE: 309]
Hooper 1987 {published data only}
Hooper J, Connell TM, Flett PJ. Blissymbols and manual
signs: a multimodal approach to intervention in a case
of multiple disability. Augmentative and Alternative
Communication 1987;3(2):68–76. [MEDLINE: 319]
Horn 1996 {published data only}
Horn EM, Jones HA. Comparison of two selection
techniques used in augmentative and alternative
communication. Augmentative and Alternative
Communication 1996;12(1):23–31. [MEDLINE: 321]
Hsieh 1999a {published data only}
Hsieh M, Luo C. Morse code text typing training of
a teenager with cerebral palsy using a six-switch Morse
keyboard. Technology and Disability 1999;10(3):169–73.
[MEDLINE: 330]
Hsieh 1999b {published data only}
Hsieh MC, Luo CH. Morse code typing training of
an adolescent with cerebral palsy using microcomputer
technology: case study. Augmentative and Alternative
Communication 1999;15(4):216–21. [MEDLINE: 331]
Hulme 1989 {published data only}
Hulme JB, Bain B, Hardin M, McKinnon A. The
influence of adaptive seating devices on vocalization.
Journal of Communication Disorders 1989;22(2):137–45.
[MEDLINE: 333]
Hunt 1996 {published data only}
Hunt P, Alwell M, Farron-Davis F, Goetz L. [Creating
socially supportive environments for fully included students
who experience multiple disabilities]. Journal of the
Association for Persons with Severe Handicaps 1996;21(2):
53–71.
Hunt 2002 {published data only}
Hunt P, Soto G, Maier J, Muller E, Goetz L. [Collaborative
teaming to support students with augmentative and
alternative communication needs in general education
classrooms]. Augmentative and Alternative Communication
2002;18(1):20–35.
Hustad 2002a {published data only}
Hustad KC, Sassano K. Effects of rate reduction on severe
spastic dysarthria in cerebral palsy. Journal of Medical
Speech-Language Pathology 2002;10(4):287–92.
Hustad 2002b {published data only}
Hustad KC, Garcia JM. The influences of alphabet
supplementation, iconic gestures, and predictive messages
on intelligibility of a speaker with cerebral palsy. Journal of
Medical Speech-Language Pathology 2002;10(4):279–85.
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
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Hustad 2003a {published data only}
Hustad KC, Cahill MA. Effects of presentation mode
and repeated familiarization on intelligibility of dysarthric
speech. American Journal of Speech-Language Pathology
2003;12(2):198–208.
Hustad 2003b {published data only}
Hustad KC. Implementing speech supplementation
strategies: Effects on intelligibility and speech rate of
individuals with chronic severe dysarthria. Journal of Speech,
Language, and Hearing Research 2003;46(462-474).
Hustad 2008a {published data only}
Hustad KC, Lee J. Changes in speech production associated
with alphabet supplementation. Journal of Speech, Language,
and Hearing Research 2008;51(6):1438–1450.
Hustad 2008b {published data only}
Hustad KC. The relationship between listener
comprehension and intelligibility scores for speakers with
dysarthria. Journal of Speech, Language, and Hearing
Research 2008;51(3):562–573.
Iacono 1993 {published data only}
Iacono T, Mirenda P, Beukelman DR. Comparison of
unimodal and multimodal AAC techniques for children
with intellectual disabilities. Augmentative and Alternative
Communication 1993;9(2):83–94. [MEDLINE: 339]
Jeffries 1987 {published data only}
Jeffries K. Assessing the effects of teaching a learning
disabled child. British Journal of Special Education 1987;14
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Jouannaud 1972 {published data only}
Jouannaud B, Bregeon F, Tardieu C, Tardieu C.
Development of imitative lingual praxias in the normal
child: application to their evaluation in the disturbances
of speech in cerebral palsy Evolution des praxies linguales
d’imitation chez l’enfant normal: application a leur
evaluation dans les troubles du langage de l’infirme moteur
cerebral. Revue de Neuropsychiatrie Infantile et d’Hygiene
Mentale de l’Enfance 1972;20(8-9):673–80. [MEDLINE:
353]
Kaiser 1993 {published data only}
Kaiser A, Ostrosky MM, Alpert CA. [Training teachers to
use environmental arrangement and mileu teaching with
nonvocal preschool children]. Journal of the Association for
Persons with Severe Handicaps 1993;18(3):188–99.
Kent-Walsh 2010 {published data only}
Kent-Walsh J, Binger C, Hasham Z. Effects of parent
instruction on the symbolic communication of children
using augmentative and alternative communication during
storybook reading. American Journal of Speech-Language
Pathology 2010;19:97–107.
Kertoy 2007 {published data only}
Kertoy MK, Richardson K. Language development in
children and adolescents with cerebral palsy. Developmental
Medicine and Child Neurology 2007;49(110):12.
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Ketelaar M, Vermeer A, Helders PJ, Hart H. Parental
participation in intervention programs for children with
cerebral palsy: a review of research. Topics in Early Childhood
Special Education 1998;18(2):108–17. [MEDLINE: 362]
King 1997 {published data only}
King GA, Specht JA, Schultz I, Warr-Leeper G, Redekop
W, Risebrough N. Social skills training for withdrawn
unpopular children with physical disabilities: a preliminary
evaluation. Rehabilitation Psychology 1997;42(1):47–60.
[MEDLINE: 368]
King 1998 {published data only}
King G, Tucker MA, Alambets P, Gritzan J, McDougall J,
Ogilvie A, et al.The evaluation of functional, school-based
therapy services for children with special needs: a feasibility
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Kozleski 1991 {published data only}
Kozleski EB. [Expectant time delay for teaching requests].
Augmentative and Alternative Communication 1991;7:11–9.
Kratzer 1993 {published data only}
Kratzer DA, Spooner F, Test DW, Koorland MA. [Extending
the application of constant time delay: teaching a requesting
skill to students with severe multiple disabilities]. Education
and Treatment of Children 1993;16(3):235–53.
Lagerman 1982 {published data only}
Lagerman U, Hook O. Communication aids for patients
with dys/anarthria. Scandinavian Journal of Rehabilitation
Medicine 1982;14(4):155–8. [MEDLINE: 391]
Lancioni 2001 {published data only}
Lancioni GE, O’Reilly MF, Oliva D, Coppa MM.
A microswitch for vocalization responses to foster
environmental control in children with multiple disabilities.
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Light 1999 {published data only}
Light JC, Binger C, Agate TL, Ramsay KN. Teaching
partner-focused questions to individuals who use
augmentative and alternative communication to enhance
their communicative competence. Journal of Speech,
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[MEDLINE: 418]
Lovett 1994 {published data only}
Lovett MW, Barron RW, Forbes JE, Cuksts B, Steinbach
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Mathisen 2009 {published data only}
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Assistive Technology 2009;4(5):376–83.
McCarthy 2001 {published data only}
McCarthy J, Light J. Instructional effectiveness of
an integrated theater arts program for children using
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review)
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augmentative and alternative communication and their
nondisabled peers: preliminary study. Augmentative
and Alternative Communication 2001;17(2):88–98.
[MEDLINE: 459]
McEwen 1989 {published data only}
McEwen IR, Karlan GR. Assessment of effects of position
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McNairn 2000a {published data only}
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part one. Part 1: can we talk? Parents’ perspectives on
augmentative and alternative communication. Exceptional
Parent 2000;30(2):72–3. [MEDLINE: 469]
McNairn 2000b {published data only}
McNairn P, Shioleno C. Augmentative communication -
- part two. Can we talk? Parents’ perspectives on AAC:
making sense of technology and making it work. Exceptional
Parent 2000;30(3):80–83. [MEDLINE: 468]
McNairn 2000c {published data only}
McNairn P, Shioleno C. Augmentative communication -
part three. Can we talk? Parents’ perspectives on AAC:
selecting the right system, now and as your child grows.
Exceptional Parent 2000;30(4):74–6. [MEDLINE: 470]
Mechling 2006 {published data only}
Mechling LC, Cronin B. Computer-based video
instruction to teach the use of augmentative and alternative
communication devices for ordering at fast-food restaurants.
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Millar 2006 {published data only}
Millar DC, Light JC, Schlosser RW. The impact of
augmentative and alternative communication intervention
on the speech production of individuals with developmental
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and Hearing Research 2006;49:248–64.
Mitchell 1995 {published data only}
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Olswang 1995 {published data only}
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relevance to voice output communication aid use.
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Palmer 1997 {published data only}
Palmer FB. Evaluation of developmental therapies in cerebral
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Patel 2006 {published data only}
Patel R, Salata A. Using computer games to mediate
caregiver-child communication for children with severe
dysarthria. Journal of Medical Speech-Language Pathology
2006;14(4):279–84.
Paul 1997 {published data only}
Paul R. Facilitating transitions in language development
for children using AAC. Augmentative and Alternative
Communication 1997;13(3):141–8. [MEDLINE: 553]
Pennington 2003 {published data only}
Pennington L, Goldbart J, Marshall J. Speech and language
therapy to improve the communication skills of children
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2003, (3).
Pennington 2005 {published data only}
Pennington L, Goldbart J, Marshall J. Direct speech and
language therapy for children with cerebral palsy: findings
from a systematic review. Developmental Medicine and Child
Neurology 2005;47(1):57–63.
Pennington 2006 {published data only}
Pennington L, Smallman C, Farrier F. Intensive dysarthria
therapy for older children with cerebral palsy: findings from
six cases. Child Language Teaching and Therapy 2006;22:
255–73.
Pennington 2007 {published data only}
Pennington L, Thomson K. Providing It Takes Two to
Talk - The Hanen program to parents of children with
motor disorders: a UK perspective. Child: Care, Health and
Development 2007;33:691–702.
Pennington 2009 {published data only}
Pennington L, Miller N, Robson S. Speech therapy for
children with dysarthria acquired before three years of age
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Petersen 2010 {published data only}
Petersen DB, Gillam SL, Spencer T, Gillam RB. The
effects of literate narrative intervention on children with
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neurologically based language impairments: an early stage
study. Journal of Speech, Language, and Hearing Research
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Pirila 2007 {published data only}
Pirila S, van der Meere J, Pentikainen T, Ruusu-Niemi P,
Korpela R, Kilpinen J, Nieminen P. Language and motor
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Pueyo 2008 {published data only}
Pueyo R, Junque C, Vendrell P, Narberhaus A, Segarra
D. Ravens coloured progressive matrices as a measure of
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Puyuelo M, Rondal JA. Speech rehabilitation in 10 Spanish-
speaking children with severe cerebral palsy: A 4-year
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Ray J. Functional outcomes of orofacial myofunctional
therapy in children with cerebral palsy. International Journal
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Reichle J, Johnston SS. Teaching the conditional use
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Reinhartsen 1997 {published data only}
Reinhartsen DB, Edmondson R, Crais ER. Developing
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Romski 1988 {published data only}
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Romski 1994a {published data only}
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Romski 1994b {published data only}
Romski MA, Sevcik RA, Wilkinson KM. Peer-directed
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22
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Romski MA, Sevcik RA, Robinson BF, Mervis CB, Bertrand
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Romski 1997 {published data only}
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Rowland 2000 {published data only}
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augmented communication on the daily lives of speech-
impaired children. Part I: Daily communication and
activities. Technology and Disability 2004;16(3):157–67.
Sanger 2007 {published data only}
Sanger TD, Henderson J. Optimizing assisted
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Sevcik 1995 {published data only}
Sevcik RA, Romski MA, Watkins RV, Deffebach KP.
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uses AAC. Augmentative and Alternative Communication
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Thomas-Stonell 2009 {published data only}
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Udwin O, Yule W. [Augmentative communication systems
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∗
Indicates the major publication for the study

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 26
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Basil 1992

Methods Controlled before and after study, comparing communication strategies of trained (par-
ents) versus untrained (teachers) communication partners. Assessor seemed to be exper-
imenter. Reliability checked on non-random sample

Participants Three mothers and 1 father of 4 Spanish children. Children: 3 F, 1M, aged 7.4-8.
8 years, severe CP affecting all four limbs, severe intellectual impairment, language
age 3-5 years, communicated using vocalisation, facial expression, eye gaze and Picture
Communication Symbols (52-188 symbols available). No details provided on subjects
(parents) or controls (teachers)

Interventions One group session on using communication boards, child’s methods of selecting symbols,
reducing own speech rate, prompting AAC use, asking open questions and increasing
responses to child’s communication, followed by 3 home visits of unspecified duration
or frequency. Controls received no training

Outcomes Frequency of adult’s initiations, responses, nonresponses, open questions, closed ques-
tions; and child’s initiations, responses, nonresponses, utterances conveyed by their com-
munication board, utterances conveyed by other modes (not AAC) were measured in 3
sessions before and 3 sessions after treatment by one non blinded assessor, and in 12.5%
of sessions, with a blinded assessor. Agreement of treatment with protocol not reported

Notes Number of controls (teachers) unclear

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk No random allocation. Parents trained,
bias) teachers not trained.

Allocation concealment (selection bias) Unclear risk Not used

Blinding of outcome assessment (detection High risk Coding from transcribed interaction.
bias) Blinding of second rater only, who assessed
All outcomes only 12.5% of data. High agreement be-
tween raters (>90%)

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 27
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Campbell 1982

Methods Single case experimental design: within subject multiple baseline across 2 behaviours,
plus one control untreated behaviour

Participants One boy aged 10 years with CP affecting lower limbs, and moderate language delay

Interventions Correct production of “is/are” in three syntactic structures (“wh” questions, “yes/no”
reversal questions and statements) was reinforced using behaviour modification tech-
niques. Two 15 minute sessions were given each school day, with 155 sessions in total

Outcomes Frequency of correct “is/are” production in the three target syntactic structures was
recorded online by an unblinded observer in each training session, and by a second
assessor in 17% of sessions

Notes Second single case using same design also reported in same paper. Second child did not
have cerebral palsy and information not reported in this review

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection High risk Online, live data collection. Reliability be-
bias) tween two independent raters on 17% of
All outcomes sessions ranged from 68-90%

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Unclear risk All expected outcomes reported

Dada 2009

Methods Single case experimental design replicated across participants: within subject multiple
baseline across 3 activities

Participants Three children with fewer than 15 spoken words, aged 8-12 years

Interventions Aided language stimulation. One set of 8 vocabulary items taught in a week, same
activity repeated each day for five days. Activity 15-25 minutes in duration. Three weeks
intervention. Total of 24 vocabulary items taught

Outcomes Number of objects correctly selected when named.

Notes Intervention targeted receptive vocabulary. Intervention provided in English. English

was not children’s first language

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 28
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Dada 2009 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection High risk Coding from videotaped recordings. Not
bias) clear if the outcome assessor was blind to
All outcomes time of recording. 20% of data checked
by second rater. High agreement between
raters (>90%)

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Davis 1998

Methods Single case experimental design: multiple baseline design across 3 communication part-
ners. Intervention was not implemented with one partner, who acted as control

Participants American boy aged 15 years, with spastic quadriplegia with athetosis, who communicated
using vocalisation, gesture and one word phrases via voice output communication aid
containing 500+ stored messages. Other development not reported.
Communication partners: 2 female graduate students employed as home tutors of maths,
reading and communication, and a male personal care attendant. No further details on
the communication partners given

Interventions Communication partners trained to use nonobligatory requests in conversation to pro-

mote response. Treatment 2-3 times per week at home. 36 sessions in total

Outcomes Percentage responses to blocks of 5 elicitation sequences was recorded by unblinded

assessor. Reliability of treatment according to protocol and data coding were checked on
25% of sessions with a second, unblinded assessor

Notes Two children took part in the study. The second child did not have cerebral palsy and
data from that subject is not included in this review

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 29
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Davis 1998 (Continued)

Blinding of outcome assessment (detection Unclear risk Online, live coding of interaction. Second,
bias) independent rater coded 25% of sessions.
All outcomes Inter-rater agreement > 94%

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Hanzlik 1989

Methods Randomised controlled trial, comparing intervention with neurodevelopmental therapy

Participants Parents of 20 US children with non-ambulatory cerebral palsy who had received no
previous training on interaction or neurodevelopmental therapy. Children: aged up to 32
months, with no major sensory handicaps and mental age at least one standard deviation
below mean for age. in experimental and control groups. Unstratified random allocation,
with no attempt to match groups on possible confounding variables

Interventions Experimental group: One hour home visit from therapist with instruction on turn tak-
ing in interaction, increasing responsiveness, increasing face to face contact, reducing
directiveness, and therapeutic holding techniques. Mothers practised techniques with
the therapist and received an advice leaflet. Control group: One hour home visit from
therapist to demonstrate neurodevelopmental therapy technique, practice with feedback
from therapist and handout

Outcomes Parent-child interaction during free play was video-taped for 15 minutes during the visit
in which intervention was given and again two weeks later.
The proportion of 15 second samples in which target interaction strategies were observed
was compared before and after training. Assessments were made by the therapist and by
a blind assessor

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Methods: drawing lots

bias)

Allocation concealment (selection bias) High risk Lots to be drawn not adequately concealed

Blinding of outcome assessment (detection Low risk All interaction was coded by two re-
bias) searchers from videotape, one blind to the
All outcomes aims of the study. Inter-rater agreement was
high k<0.75

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 30
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hanzlik 1989 (Continued)

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Hunt 1986

Methods Single case experimental design. Multiple baseline across four request situations

Participants North American girl aged 7 years with severe intellectual impairment and multiple
disabilities. No further details provided on underlying impairments. Communicated by
vocalisation, 1 gesture, 2 manual signs, and by touching the listener. Could not use
pictures for communication. Limited success matching representation to real object

Interventions Interrupted chain training of 4 requests. Treatment given twice daily in familiar routines,
with 55 sessions in total

Outcomes Probes were made daily of the request currently under investigation. Content, form and
function of communicative behaviour was assessed by therapist. Reliability of assessment
was checked with by independent observer in 20% sessions

Notes Three children took part in the study. Only one had cerebral palsy. The other children’s
results will not be included in this review

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection High risk Online, live coding of interaction. Second,
bias) independent rater coded 20% of sessions.
All outcomes Inter-rater agreement > 92%

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Hurlbut 1982

Methods Single case experimental design. Alternating treatments design across 3 subjects. Com-
pared trials to acquisition and response generalisation for Blissymbols and iconic symbols

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 31
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hurlbut 1982 (Continued)

Participants Three US males, aged 14, 16, 18 years with severe spastic quadriplegia, moderate athetosis
and severe choreoathetosis and severe speech impairment. No other further information
supplied on cognitive and sensory skills. Communicated by idiosyncratic gestures, yes/
no responses and 1-3 Blissymbols (1)

Interventions Participants trained to use 5 Blissymbols and 5 iconic symbols to criterion (10 correct
responses) in response to “What’s this?”. Teaching strategies included modelling, verbal
prompting, physical and verbal prompting and reinforcement. Duration and frequency
of therapy sessions not specified

Outcomes Percentage correct naming of 10 trained and 10 untrained items using Bliss and iconic
language was measured before and after intervention. Trials to acquisition for both
systems was also calculated. Data were measured by an unblinded assessor, and by an
independent observer on approximately half of the sessions

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection Low risk Online, live coding of interaction. Sec-
bias) ond, independent rater coded 50% of base-
All outcomes line, 50% of intervention phase and 33-
50% of sessions in which spontaneous use
of behaviours was coded. Mean inter-rater
agreement 98%

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

McCollum 1984

Methods Single case experimental design. Multiple baseline across 2 communication targets in
two conditions treated (play without toys) and untreated (play with toy)

Participants US mother and her son, aged 18 months, severe cerebral palsy. No further information
given on developmental levels. Lower middle income, single parent family

Interventions Six weekly home visits of unspecified duration, training mother to move her face closer to
child and to imitate child’s vocalisation in play without toys, by modelling and providing
feedback on practice

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 32
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
McCollum 1984 (Continued)

Outcomes Percentage of 10 second intervals containing vocalisations by the child and/or target
behaviours by the mother were measured across 3 baseline, 6 treatment and 1 follow-
up sessions in play without toy (experimental condition) and play with toy (control).
Reliability of coding was established prior to the experiment

Notes Two other children also included in study. They did not have cerebral palsy and their
results are not reported in this review

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection High risk Interaction coded from videotapes. Asses-
bias) sor not blind to outcome or phase of study.
All outcomes Second rater coded 11% of data. Inter-rater
agreement >80%

Incomplete outcome data (attrition bias) Unclear risk No missing data

All outcomes

Selective reporting (reporting bias) Unclear risk All expected outcomes reported

McConachie 1997

Methods Controlled before and after study in which school staff were assigned to training or
control (no treatment) trial

Participants 35 UK education staff who worked with 9 children (5 M, 4 F) aged 7-17 years who had
cerebral palsy of mixed, dystonic or spastic type, and who used symbol systems containing
175-1000+ symbols to communicate. 2 children also used voice output communication
aids. Experimental group: 9 teachers, 10 teaching assistants. Controls: 8 teachers, 6
assistants. Staff were allocated to group by school management and were matched on
gender, occupation and extent of contact with child

Interventions Training followed “My Turn to Speak”, which comprises five 90 minute sessions over 10-
12 weeks, concentrating on child’s positioning on function, methods of accessing AAC
systems, communication and communication breakdown. Teaching strategies included
short talks, video demonstrations, written tasks, brainstorming, role play and interven-
tion planning. Controls received no training related to AAC during the study

Outcomes Five minute video clips of each adult interacting with their target child were made in
the month prior to training, one month after its completion and four months later.
Facilitation of AAC users’ communication was rated on 11 categories using a 3 point
scale by one of the trainers and by a blind assessor coding 50% of the clips each, with
reliability checked on approximately 20% of the clips
Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 33
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
McConachie 1997 (Continued)

Notes High attrition rate, not explained.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Allocation assigned by school managers
bias)

Allocation concealment (selection bias) High risk Not used

Blinding of outcome assessment (detection Unclear risk Two raters each coded 50% of data. One
bias) rater only blind to group allocation and
All outcomes data collection point. Agreement on 20%
of data >80%

Incomplete outcome data (attrition bias) High risk 50% of controls lost at Time 2, >50% of
All outcomes participants and controls lost at Time 3

Selective reporting (reporting bias) Unclear risk All expected outcomes reported

Olswang 2006

Methods Single case experimental design replicated across participants

Participants Two girls with quadriplegia 14 and 20 months of age, unable to sit independently, severe
cognitive impairments, vision and hearing within normal limits. Preverbal communica-
tors, who looked at objects, but did not look back to the parents to request items

Interventions Responsive interaction training. Parents trained to respond contingently to child’s com-
munication and to shape more sophisticated signals. Two training sessions each week for
three weeks.Sessions = 45 minutes

Outcomes Rate (number of times per minute) parents created communication opportunities, waited
for their child to communicate, recognised their chid’s communication and shaped the
child’s communication. Rate at which children looked actively at their parent or an
object;looked back and forth between parent and object; produced a gesture; failed to
respond; protested

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 34
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Olswang 2006 (Continued)

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection Low risk Outcome assessed by independent raters.
bias) Second raters independently coded one
All outcomes third of the data. Inter-rater agreement k=
0.78

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Pennington 1996a

Methods Data included in McConachie 1997 study

Participants

Interventions

Outcomes

Notes

Pennington 2009a

Methods Interrupted time series

Participants Eleven children with nonprogressive motor disorders. 10 children with cerebral palsy
aged 19-36 months; GMFCS median = 3, IQR = 2-5; severe dysasrthria, unintelligible
to familiar adults out of context

Interventions It Takes Two to Talk® the Hanen parent program.

Outcomes Proportions of turns taken in conversation by mothers and children that were initiations
or responses and proportions of turns that were directive. Complexity and rate of moth-
ers’ spoken language and number of different vocabulary items used. Parental Sense of
Competence Scale (Gimbaud and Waterson, 1979)

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 35
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pennington 2009a (Continued)

Random sequence generation (selection Unclear risk Participants acted as own controls
bias)

Allocation concealment (selection bias) Unclear risk Participants acted as own controls

Blinding of outcome assessment (detection High risk Interaction coded from videotapes. Primary rater not blind to
bias) data collection point. 20% of all recordings coded by indepen-
All outcomes dent second rater, k=0.75

Incomplete outcome data (attrition bias) Low risk One family lost to follow-up
All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Pennington 2009b

Methods Interrupted time series

Participants 15 children with cerebral palsy, 1 child with Worster Drought, aged 12-18 years (M=14,
SD = 2). 9 spastic type cerebral palsy, 2 dyskinetic, four mixed (spastic and dyskinetic)
. Dysarthria rate mild - severe by referring therapists. All children able to comprehend
simple instructions

Interventions Individual therapy focused on stabilising respiratory and phonatory effort and control,
speech rate and phrase length/syllables per breath

Outcomes Percentage of words intelligible in single words and connected speech to familiar and
unfamiliar listeners

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Participants acted as own controls
bias)

Allocation concealment (selection bias) Unclear risk Participants acted as own controls

Blinding of outcome assessment (detection Low risk Listeners blind to time of recording
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk One child’s data missing at Time 1
All outcomes

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 36
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pennington 2009b (Continued)

Selective reporting (reporting bias) Low risk All expected outcomes reported

Pinder 1995

Methods 4 single case experiments.

Participants Four US children, (2 M, 2 F), aged 11.5-13.5 months with mixed athetoid or spastic
diplegia type cerebral palsy, who had difficulty grasping and releasing objects and did not
sit independently. All with IQ < 50 Bailey Mental Development Index, vision correctable
with glasses and hearing within normal limits

Interventions Twice weekly sessions of 50-60 minutes for up to 12 weeks in which children were taught
to request objects or request more by gaze and /or reaching and grasping. Teaching
strategies included modelling, expectant delay and reinforcement

Outcomes Requests for more and requests for objects were probed once per week in play with
toys (experimental condition) and at snack time (control condition). Unblinded assessor
recorded response to elicitations and modes used to make response. Reliability checked
with a second observer using randomly selected 20-25% of data for each child

Notes Generalisation across acts expected. Design not able show effects of treatment

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection High risk Coding of interaction from videotapes. Primary rater not
bias) blind to data collection point. Second rater, independently
All outcomes coded 22% of all data, k>0.69

Incomplete outcome data (attrition bias) Low risk No missing data

All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Richman 1977

Methods Single case experimental design. Multiple baseline with reversal and reinstatement of
treatment across three behaviours

Participants US girl aged 9 years, severe spastic quadriplegia and severe cognitive impairment. No
further developmental information supplied

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 37
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Richman 1977 (Continued)

Interventions Operant teaching strategies were used to encourage the maintenance of eye contact and
head control and the production of vocal imitations in 10 minute therapy sessions given
four days per week for 40 weeks

Outcomes Percentage of time eye contact and head control were maintained during each training
session. Vocal imitation was requested 30 times in each session, percentage response
recorded. Data collected during each session by the therapist. Reliability checked with a
number of trained observers on 12.5% session

Notes Child absent for 3 sessions over treatment period.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection Unclear risk Online, live coding. Second, independent
bias) observer coded 25% of samples, inter-rater
All outcomes agreement >80% (mean = 92%)

Incomplete outcome data (attrition bias) Low risk 3/80 sessions missed
All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Sigafoos 1995

Methods Single case experimental design.

Participants Australian boy aged 6 years with severe cerebral palsy of unspecified type, who had
moderate cognitive impairment, very poor upper limb control and required assistance
for all activities of daily living. Participant was reported to understand various spoken
commands and communicated using eye gaze

Interventions Trained to request objects by eye gaze in 19 sessions over 8 weeks. Teaching strategies
included: creating communicative environment, expectant delay, verbal prompting, in-
creasing expectant delay. reinforcement of response by use of object requested

Outcomes Therapist assessed percentage of trials in which object requested. Reliability of coding
established with independent observer using approximately 50% of sessions

Notes Requests for objects generalised across the three objects. All used in same activity, probably
inter-related in communication

Risk of bias

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Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sigafoos 1995 (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection Low risk Online, live coding. Second, independent observer
bias) coded approximately 50% of samples, inter-rater
All outcomes agreement >83%

Incomplete outcome data (attrition bias) High risk Child absent from school for replication phase
All outcomes

Selective reporting (reporting bias) Low risk All expected outcomes reported

Tait 2004

Methods Single case experimental design: multiple baseline design replicated across subjects

Participants Six children with spastic quadriplegia aged 16-47 months (M= 29 months); 1 child had
hearing impairment; 2 children had cortical visual impairments; 1 child had mild visual
impairment; 2 children had epilepsy. 5 children’s receptive language was 6-9 months
behind chronological age; 1 child had profound language delay equivalent to 2 month
developmental level

Interventions Functional Communication Training. Parents taught to how to train their child to use
more sophisticated communication signals in place of prelinguistic communication. 18-
21 practice sessions for parents to use strategies taught. Each session approximately
30 minutes, comprising three activities to elicit specific communication behaviours.
Feedback and coaching given to parents after each session

Outcomes Number of communication opportunities provided by parents; number of prelinguistic

communication signals produced by child; number of times signals replaced with more
sophisticated communication behaviours

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not used - single case experimental design
bias)

Blinding of outcome assessment (detection Unclear risk Videotaped interactions coded. Second, in-
bias) dependent observer coded approximately
All outcomes one third of samples, inter-rater agreement
ranged from 79-99%, mean =93%

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 39
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tait 2004 (Continued)

Incomplete outcome data (attrition bias) Unclear risk Baseline for all children for two of three
All outcomes activities tested

Selective reporting (reporting bias) Unclear risk All expected outcomes reported

(1). Blissymbols: symbol system with written words printed beneath symbol.
(2). Allocation concealment: A = allocation could not be predicted, B = method of allocation not made clear, C = allocation could be
predicted or circumvented, D = no random allocation of subject or process

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Abrahamsen 1989 Subjects with different aetiologes included. Not possible to study children with cerebral palsy as subgroup

Alant 1996 Before and after study. No control group or control intervention

Almeida 2005 Before and after single case study. No experimental control.

Amari 1999 Subject had cererbal palsy but speech production intact. Treated for selective mutism

Batarowicz 2006 Description of intervention and case studies. No experiment.

Bedrosian 1997 Conceptual review. No subjects or experimentation.

Bedrosian 1999 Conceptual review. No subjects or experimentation.

Binger 2008 Narrative review

Bishop 1994 Conceptual review. No subjects or experimentation.

Blackstone 1994 Discussion paper. No subjects or experimentation.

Boose 1999 Observational group study. No control group or control intervention

Bruno 1989 Descriptive case study. No control processes or control intervention

Bruno 1998 Before and after study. No control group or control intervention

Buzolich 1991 Multiple baseline across subjects design. No control process

Buzolich 1994 Before and after study. No control group or control intervention

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 40
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Carter 1998 Multiple baseline across subjects design, insufficient iterations across similar subjects. Baselines not adequately
established. Intervention not replicable

Chan 2002 Description of communication. No intervention.

Cohen 2000 Observational study. No control group or control intervention

Darrah 2004 Generalised intervention approach, not specifically speech therapy

DiCarlo 2000 Subjects did not have cerebral palsy.

Dowden 1995 Conceptual review. No subjects or experimentation.

Durand 1993 Multiple baseline across subjects design. No control processes

Enderby 1981 Description of an AAC system and users’ views. No experimentation

Erickson 1997 Descriptive case study design. No experimentation.

Fox 2005 Multiple baseline across subjects design. No control processes

Galliers 1987 Descriptive case study. No experimentation. Aetiology of subject not given

Gibbon 2003 No experimental control

Glennen 1985 Single case study with insufficient sessions at baseline and follow-up to observe behaviour. “Control” process
only tested at baseline and follow-up

Goossens 1985 Two descriptive case studies. No experimentation.

Goossens 1989 Descriptive case study. No experimentation.

Hall 1997 Multiple baseline across subjects design. No control processes

Harris 1982 Description of communication. No experimentation.

Harris 1996 Subject did not have cerebral palsy.

Heim 1990 Description of communication. No experimentation.

Hetzroni 2000 Subjects did not have cerebral palsy.

Hooper 1987 Descriptive case study. No experimentation.

Horn 1996 Method of accessing AAC system rather than use for communication investigated

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 41
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Hsieh 1999a Method of accessing AAC system rather than use for communication investigated

Hsieh 1999b Descriptive case study. No experimentation.

Hulme 1989 Investigated effects different types of seating. Not a communication intervention

Hunt 1996 Not specific SLT intervention.

Hunt 2002 Not specific SLT intervention.

Hustad 2002a Includes adults with cerebral palsy

Hustad 2002b Includes adults with cerebral palsy

Hustad 2003a Includes adults with cerebral palsy

Hustad 2003b Includes adults with cerebral palsy

Hustad 2008a Includes adults with cerebral palsy

Hustad 2008b Includes adults with cerebral palsy

Iacono 1993 Subjects did not have cerebral palsy.

Jeffries 1987 Not a communication intervention.

Jouannaud 1972 Description of tongue movements in children with and without cerebral palsy. No intervention

Kaiser 1993 Subjects did not have cerebral palsy.

Kent-Walsh 2010 Mulitple probe design replicated across participants. Only one participant with cerebral palsy

Kertoy 2007 Not an intervention study

Ketelaar 1998 Critical review of intervention for children with cerebral palsy. No quantitative analysis

King 1997 Social skills training, not specifically communication intervention

King 1998 School based therapy services evaluated; speech and language therapy services cannot be disaggregated. Before
and after study. No control group or control intervention

Kozleski 1991 Single case design. Three treatment phases with one probe after each phase. Treatments not tested across all
phases, therefore no control

Kratzer 1993 Multiple baseline design across two subjects. Multiple interventions given consecutively to improve one skill.
Treatments not measured across all phases, therefore no control

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 42
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Lagerman 1982 Descriptive case study. No experimentation.

Lancioni 2001 Multiple baseline across subjects design. No control processes. Intervention to increase switch activation,
not communication intervention

Light 1999 One child with cerebal palsy included in multiple baseline across subject design. When the subject examined
individually design becomes ABABA with no control process

Lovett 1994 Subjects with different aetiologies included. Not possible to study children with cerebral palsy as subgroup

Mathisen 2009 Case study. No experimental control

McCarthy 2001 Observational study. No control group or control intervention

McEwen 1989 Investigates success of diferent methods of access. Not a communication intervention

McNairn 2000a Discussion paper. No experimentation.

McNairn 2000b Discussion paper. No experimentation.

McNairn 2000c Discussion paper. No experimentation.

Mechling 2006 Participants did not have cerebral palsy

Millar 2006 Review paper, no experimentation

Mitchell 1995 Conceptual review. No experimentation.

Okimoto 2000 Investigates playfulness. Measures of communication cannot be disaggregated

Olswang 1995 Observational, qualitative study.

Oxley 2000 Conceptual review. No experimentation.

Pahn 1972 Description of intervention. No experimentation.

Palmer 1997 Critical review of physiotherapy for children with cerebral palsy. Not speech and language therapy

Park 1979 Description of an AAC system. No experimentation.

Parker 2006 No experimental control

Patel 2006 Case report. No experimental control.

Paul 1997 Conceptual review. No experimentation.

Pennington 2003 Earlier version of part of this review

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 43
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Pennington 2005 Earlier version of part of this review

Pennington 2006 No experimental control

Pennington 2007 Qualitative study of speech and language therapists’ views of It Tales Two to Talk© parent training

Pennington 2009 Systematic review of interventions.

Petersen 2010 Mulitple probe across participants. Only one participant with cerebral palsy

Pirila 2007 Observational study. No intervention.

Pueyo 2008 Observational study. No intervention.

Puyuelo 2005 No experimental control

Ratcliff 1996 Before and after case study. No control processes or control intervention

Ray 2001 No experimental control

Reichle 1999 Subjects did not have cerebral palsy.

Reinhartsen 1997 Description of intervention. No experimentation.

Romski 1988 Not a multiple baseline design across phases or subjects design. Description of instruction across phases with
baseline, teaching and probe sessions

Romski 1994a Subjects with different aetiologies inlcuded. Not possible to study children with cerebral palsy as subgroup

Romski 1994b Subjects with different aetiologies inlcuded. Not possible to study children with cerebral palsy as subgroup

Romski 1995 Subjects with different aetiologies inlcuded. Not possible to study children with cerebral palsy as subgroup.
No control group

Romski 1997 Conceptual review of research. No experimentation.

Rowland 2000 Subjects did not have cerebral palsy.

Salmien 2004 No experimental conrtol

Sanger 2007 No speech therapy intervention

Sevcik 1995 Subjects with different aetiologies inlcuded. Not possible to study children with cerebral palsy as subgroup

Sigafoos 1999 Aetiology of subjects not given.

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 44
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Sigafoos 2004 Review paper, no experimentation

Signorino 1997 Description of rehabilitation for deaf-blind children, including those with cerebral palsy. No experimentation

Soro 1993 Three single case studies. No control processes or control intervention

Soto 2008 Mulitple probe across participants design. No control process

Soto 2009 Single case AB design, no control process

Spiegel 1993 Single case study containing description of intervention with baseline and intervention scores for trained
stimuli. Assessment of untrained stimuli before and after intervention

Sternberg 1983 Subjects with different aetiologies included. Not possible to study children with cererbal palsy as a subgroup

Swinehart-Jones 2009 Literacy study

Thomas-Stonell 2009 No experimental control. Chidlren with cerebral palsy cannot be separated from group

Treviranus 1987 Observational study. No experimentation. Intervention to access devices, not communication intervention

Truxler 2007 Intervention targeted phonological awareness, not communication

Udwin 1987a Critical review. No experimentation.

Udwin 1987b Observational study. No experimentation.

Udwin 1990 Observational study. No experimentation.

Udwin 1991 Observational study. No experimentation.

Watkins 1988 Observational study. No experimentation.

Woods 1997 Subject has mild hemiplegia arising from cerebral palsy, speech disorder incidental

Worth 2001 Observational study. No experimentation.

Wu 2004 Before and after study. No experimental control.

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 45
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
This review has no analyses.

ADDITIONAL TABLES
Table 1. Methodological quality of group studies

Study Assign- Allocation Eligibility Groups Sample Blinding Pro- Missing Loss to fol-
ment concealed criteria similar size tocol com- values low-up
pliance

Basil 1992 I I U I I U U G U

Hanzlik I I A A U I P G G
1989

Mc- I I U U U I A G P
Conachie
1997

Penning- N/A I A N/A U I P G G

ton 2009a

Penning- N/A A P N/A P A A G G

ton 2009b

KEY A = Ade- P = Partial I = Inade- U = Un- N/A=not KEY G = KEY G =

quate quate clear applicable Good P = Good P =
Poor U = Poor U =
Unclear Unclear

Table 2. Methodological quality of single case studies

Study Subject Therapy Blinding Control Assign- Baseline Interven- Follow-up Measure-
descrip- descrip- similar ment tion ment
tion tion

Campbell I P I A U A A I A
1982

Dada 2009 A A P A U A A P A

Davis P A P A U A P I P
1998

Hunt 1986 P P I A U I A P P

Hurlbut P P I A U A A I P
1982

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 46
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of single case studies (Continued)

McCollum I P I A U I I I I
1984

Olswang P A P I U P I I A
2006

Pinder P P P A U A P I A
1995

Richman I A I I U A I I A
1977

Sigafoos I A I A U I I I I
1995

Tait 2004 P P I U U P I P A

WHAT’S NEW
Last assessed as up-to-date: 30 January 2011.

Date Event Description

6 February 2011 New search has been performed Studies 2003-2011 included in updated review. Conclusions changed

27 March 2003 Amended Review updated. No new studies.

HISTORY
Protocol first published: Issue 1, 2002
Review first published: Issue 2, 2004

Date Event Description

31 January 2011 New search has been performed Substantive update

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 47
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS
All review authors devised the protocol and search strategy. L Pennington selected studies for inclusion, with reliability checks conducted
by J Goldbart and J Marshall. All review authors were involved in extracting data from included studies and writing the review. L
Pennington was the primary author.

DECLARATIONS OF INTEREST
None

SOURCES OF SUPPORT

Internal sources
• No sources of support supplied

External sources
• Royal College of Speech and Language Therapists, UK.
• National Institute for Health Research, UK.
Salary funding for Lindsay Pennington during update of review. This report is independent research arising from a Career
Development Fellowship supported by the National Institute for Health Research. The views expressed in this publication are those
of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

INDEX TERMS

Medical Subject Headings (MeSH)

∗ Language Therapy; ∗ Speech Therapy; Cerebral Palsy [complications; ∗ rehabilitation]; Communication; Communication Disorders
[etiology; ∗ rehabilitation]; Parents; Randomized Controlled Trials as Topic

MeSH check words

Adolescent; Child; Child, Preschool; Humans; Infant

Speech and language therapy to improve the communication skills of children with cerebral palsy (Review) 48
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.