Implementation of Early Detection and Intervention for Cerebral Palsy in High-Risk Infant Follow-Up Programs: U.S. and Global Considerations

A Pilot Investigation on the Relationship Between Infant Vocal Characteristics at 12 Months and Speech Motor Impairment at 4-5 Years

PURPOSE

The objective of this pilot study was to investigate the relationship between infant vocal characteristics and later speech motor impairment in children at risk for cerebral palsy (CP) to inform the early prediction of speech motor impairment.

METHOD

Vocal complexity, volubility, and consonant inventories of 13 infants at risk of CP were examined at approximately 12 months. We examined their association with later levels of speech motor impairment as measured by the Viking Speech Scale (VSS).

RESULTS

Children in our sample with greater speech motor impairment at age 4 years produced lower rates of developmentally complex vocalizations in infancy but showed no significant differences in vocal stage attainment, volubility, or consonant diversity.

CONCLUSIONS

Our results are in line with trends found in prior literature examining vocal characteristics of infants at risk for speech motor involvement. These results can inform data-driven hypotheses in future studies aimed at the early prediction of speech motor impairment through the study of infant vocal production.

Long-term impact of early identification of cerebral palsy

PURPOSE OF REVIEW

Early identification of cerebral palsy (CP), as in all neurologic conditions, has a profound impact on the ability to initiate interventions, support the education and empowerment of parents, ameliorate the effect of the conditions, and importantly identifies cohorts for neuroprotection or repair to address the primary injury. CP is a life span condition. Rapid initiation of services, support and anticipatory guidance is essential to maximize functional outcomes, prevent or manage complications and improve quality of life.

RECENT FINDINGS

CP diagnosis should not be delayed. Early imaging as well as motor and neurologic evaluation can aid in early detection of CP before age 5 months. Early therapeutic intervention can influence function and assist in prevention of complications that can impact abilities. There is important ongoing research with efforts to prevent CP or alter the phenotype of the condition.

SUMMARY

Literature review provides evidence to change in standard of care in diagnosing CP. There are published guidelines on how to pursue the diagnosis during early infancy. Early identification results in early intervention with the purpose of enhancing functional skill development, prevention of complications, and establishing parental support. Early identification provides an optimistic view and opportunity to intervene immediately in hopes to have an impact in the functional outcome and improving quality of life.

Evidence-Based Infant Assessment for Cerebral Palsy: Diagnosis Timelines and Intervention Access in a Newborn Follow-up Setting

Evidence-based assessment pathways inform early detection of cerebral palsy and access to intervention. This study investigated the relationships between early evidence-based assessments, diagnosis timeline, and rehabilitation intervention access in a population of children with cerebral palsy who were seen between 2010 and 2022 at the University of Wisconsin Waisman Center Newborn Follow Up Clinic. Cerebral palsy-specific assessments were increasingly integrated after the publication of early detection guidelines by Novak et al. in 2017. Age at cerebral palsy first mention (high risk for cerebral palsy) decreased over time, although age at diagnosis remained similar. Infants who received multiple evidence-based assessments were diagnosed at a younger age. Ninety-nine percent of children were referred to rehabilitation therapies before diagnosis. Infant age at referral to outpatient therapies decreased over time. This study provides novel clinical data on diagnosis timelines and identifies remaining gaps related to implementation feasibility toward improved early diagnosis and intervention access.

Identifying Opportunities for Early Detection of Cerebral Palsy

This study aimed to evaluate assessment and referral practices for the early detection and diagnosis of children at risk for or with cerebral palsy (CP) by health care and education providers in Maryland and Delaware. A secondary aim was to identify barriers for using early detection tools and identify opportunities for change to support early diagnosis and improve care. Seventy-two participants answered ≥ 50% of the survey questions. Most were occupational or physical therapists (86%) working in early intervention (61%). Eighty-eight percent indicated awareness that CP can be diagnosed by 12 months. Though 86% stated they typically suspect a diagnosis of CP between 0 and 12 months, only 19% reported that their patients received a CP diagnosis < 12 months. The Developmental Assessment of Young Children (73%) and the Peabody Developmental Motor Scales-2 (59%) were used most. Many respondents indicated never using magnetic resonance imaging (70%), the General Movements Assessment (87%), or the Hammersmith Infant Neurological Exam (69%). Participants identified clinical signs and symptoms prompting a referral for the diagnostic assessment of CP, most commonly stiffness in legs (95%), excessive head lag (93%), and persistent fisting (92%). Policy and organizational change, clinician education, and training are needed to support the implementation of CP early detection guidelines.

A Call for Early Detection of Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.

Vocal Characteristics of Infants at Risk for Speech Motor Involvement: A Scoping Review

PURPOSE

The purpose of this scoping review was to (a) summarize methodological characteristics of studies examining vocal characteristics of infants at high risk for neurological speech motor involvement and (b) report the state of the high-quality evidence on vocal characteristic trends of infants diagnosed or at high risk for cerebral palsy (CP).

METHOD

The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) extension for scoping reviews was followed for reporting our review. Studies measured prelinguistic vocal characteristics of infants under 24 months with birth risk or genetic conditions known to commonly present with speech motor involvement. Fifty-five studies met criteria for Part 1. Eleven studies met criteria for synthesis in Part 2.

RESULTS

A smaller percentage of studies examined infants with or at risk for CP compared to studies examining genetic conditions such as Down syndrome. The median year of publication was 1999, with a median sample size of nine participants. Most studies were conducted in laboratory settings and used human coding of vocalizations produced during caregiver-child interactions. Substantial methodological differences were noted across all studies. A small number of high-quality studies of infants with or at risk for CP revealed high rates of marginal babbling, low rates of canonical babbling, and limited consonant diversity under 24 months. Mixed findings were noted across studies of general birth risk factors.

CONCLUSIONS

There is limited evidence available to support the early detection of speech motor involvement. Large methodological differences currently impact the ability to synthesize findings across studies. There is a critical need to conduct longitudinal research with larger sample sizes and advanced, modern technologies to detect vocal precursors of speech impairment to support the accurate diagnosis and prognosis of speech development in infants with CP and other clinical populations.