The nature of language problem in Bangladeshi children with cerebral palsy: an observation using neurolinguistic approach

Cerebral palsy (CP) is the leading cause of childhood disability affecting function and development. The objective of the study was to look into the language problems in Bangladeshi children with CP on the basis of neurolinguistic approach and was conducted during the period of April 2014 to December 2014 at the Department of Linguistics, University of Dhaka among children aged between 3 to 18 years. In the study, a total of 10 children with CP were enrolled purposively from two tertiary care hospitals in Dhaka (Children Development Centre of Sir Salimullah Medical College and Mitford Hospital and National Institute of Mental Health). The mean±SD age was 8.9±4.8 years. Male was predominant (60.0%). History of prolonged labour was 100%, and home attended by untrained birth attendants in 70.0%. The 90.0% of the children understood simple meaningful sentences using two words. The children were unable to understand complex sentences. The 80.0% children did not want to play or make friendship with other children; 40.0% did not understand others’ speech, 50.0% did not express their own speech, and 10.0% did not understand & express their own speech. All the children had deep thong articulation changed to mono thong in case of semi vowel articulation. In case of history of delayed crying at birth, phoneme omission occurred when the children tried to articulate any word. To the best of knowledge, this was the first study done on the neurolinguistic approach in Bengali children, but the limitation of the study were that it was with small sample size, city based and short duration. Therefore, generalization of the results would be difficult. Further studies using larger sample would be better to visualize the extent of the issue in order to insert the children with CP in their social context and to give them quality of life.

or sensory processing deficits associated with CP. 2 In contrast, several studies have demonstrated average verbal abilities of higher-functioning in children with CP and even children with early left-sided brain damage may exhibit sparing of language skills. 1,[2][3][4][5] The prevalence of CP is approximately 2.5 per 1000 live births in countries with neonatal intensive care facilities. [6][7][8] Prevalence is higher in children born with very low birth weight. However, a decline in prevalence in this group from 60.6 (99.0%, CI 37. 8-91.4) per 1000 live births in 1980 to 39.5 (28.6-53.0) per 1000 in 1996 has been observed in Europe. 9 Communication difficulties can be associated with any type of CP and may relate to limitations in the production of movements for speech, gesture and facial expression; receptive or expressive language, hearing, vision or a combination of limitations in these functions. Speech impairments are estimated to affect approximately 36.0% of children with CP and communication difficulties are observed in around 42.0%. 10 Prevalence of speech, language and communication impairment increases with severity of motor and intellectual impairment. [10][11][12][13] Children may experience communication difficulties from early infancy and, as CP is a persistent condition, communication impairments are chronic and children may require long term intervention. Previous study revealed that 75.0% of participants had clinical speech and/ or language impairments. 14 Communication challenges of any kind can lead to educational and social isolation and can have a detrimental impact on nearly all aspects of development. 15,16 Thus, identifying and treating specific speech and language problems at the earliest possible age is of the utmost importance. To date, research on speech and language development in children with CP has been limited, in part due to the extreme heterogeneity of this population. The range of possible speech, language, and communication problems is considerable. The language problem in CP children is still under attended though we have huge population with a significant portion of growing children. Therefore, in the present study, it was aimed to look into the anguage problems in Bengali children with CP on the basis of neurolinguistic approach.  Table 1 shows the distribution of demographic variables of the CP patients. It was observed that almost three fourth (70.0%) patients were found 5-7 years and rest 3 30.0% as >7 years. Within 4-5 years basic language development occurs in a normal child. If any children had problem in basic language development after 7-11 years the child became 'mute' or articulation disorder present in language development. It was observed that male was found 6 (60.0%) and female was 4 (40.0%). The respondents' relation to patients was mother 7 (70.0%), father 1 (10.0%) and others were 2 (20.0%). History of prolonged labour was found in 10 (100.0%), no history of preterm delivery in for 8 (80.0%) and home attained by untrained birth attendants in 7 (70.0%). History of delayed crying at birth was found in 7 (70.0%). The mean±SD age of the children was 8.9±4.8 years.

Discussion
The objective of the study was to look into the language problems in Bangladeshi children with CP on the basis of neurolinguistic approach and was conducted during the period of April 2014 to December 2014 at the Department of Linguistics, University of Dhaka. In this study, the mean±SD age of the children with CP was 8.9±4.8 years. O the r stud ie s re p or te d a grou p o f c h ild ren w ith m e an ± S D ag e at a sse ssm e n t 5 .4± 0 .5 ye a rs, ranged 3-6.5 years, and also a group w ith m ean age of 3.8 years ranged from 1 to 7.6 years (9 children w ere seen at <1.9 years). 1 2-1 4 It was a male predominant study. In two studies, the authors reported children with CP were male 61.9% and 49.0% respectively.12,13 Regarding the birth history of CP children, it was observed in this study that history of prolonged labour was found in all cases, no history of preterm delivery was 80.0% and home attained by untrained birth attendants was 70.0%. History of delayed crying at birth was found in 70.0%. Most (90.0%) of the parent of CP children mentioned that their children omitted any letter (phoneme) when they tried to articulate any word.
It is noteworthy and a concern that only a few children in this study were established talkers who appeared to be developing speech and language skills that were roughly commensurate with age expectations. Conversely, 85% of the children in this study showed clear evidence of a clinical speech and/ or language delay at 2 years of age. The previous work of the investigators on a similar group of children indicates that by 4.5 years of age, 75.0% of children had evidence of a clinical speech and/ or language impairment. 18 Taken together with their previous work, it appears that approximately 10.0% of the children with CP may outgrow speech/ language problems later in the preschool years. However, it is unclear whether these children catch-up on their own or any intervention leads to advancement in skill development that brings children in line with developmental expectations. 19 Speech & language therapy typically begins shortly after a child is diagnosed with CP.
The role of the speech therapy is to help children speak clearly, communicate effectively & control the muscles involved in speaking. The first step of the speech therapist is to conduct a thorough assessment of a child's physical & cognitive functionary. This assessment will determine the nature of a child's speech and communication abilities, identify causative factors and determine the best approach to therapy. Speech intelligibility is a main problem for the people who have CP. The motor disorder which characterizes CP can affect the function of the muscles involved in the production of speech. Under the speech articulator disabilities, there are CP, hyperkinetic dysarthria, Parkinson's disease and multiple sclerosis.
In general, most children CP patients have less articulator precision. Simple 'steadystate' phonemes like vowels are the easiest to produce since they do not require dynamic movement of the articulator structures. In contrast, phonetic transitions such as consonants are the most difficult to produce since they require fine motor control. Fine motor control is used to precisely move the articulators. Usually, mildly impaired and also impaired speakers differ in degree of disability rather than the quality. It is most prominently characterized by disruption in the speech prosody. 20 When a child has an articulation disorder, he or she has difficulty in making certain sounds. These sounds may be left off, added, changed or distorted making it hard for people to understand the child. Of course, leaving out or changing certain sounds is common when young children are learning to talk. A good example of this is saying 'wabbit' for 'rabbit'.
The incorrect articulation is not necessarily a cause for concern unless it continues in the age where children are expected to produce such sound correctly. It is not that the muscles of tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. Speech disorders which refers to impairment in the articulation of speech sounds, fluency and voice as well as language disorders consequently to impair-ments in the use of the spoken (or signed or written) system and may involve the form of language (grammar & phonology), the content of language (semantics) & the function of language (pragmatics). These may also be described more generally as communication disorders which are typically classified by their impact on a child's receptive skills (with the ability to understand what is said or to decode, integrate, and organize what is heard) and expressive skills (with the ability to articulate sounds, to use appropriate rate & rhythm during speech, to exhibit appropriate vocal tone and resonance and to use sounds, words and sentences in meaningful contexts).
L an g u ag e ha s a n im p o rta nc e w ith m e a nin g s, ra th e r th a n s o u n d s . A la n g u a g e d is o rd e r re fe rs to an im p a ire d a b ility to u nd e rsta n d an d / o r u se w o rd s in c on te xt. A ch ild m a y h a ve a n e x p re s siv e la n g u a g e d is o rd e r (d iffic u lty in e x p re s s in g id e a s o r n e e d s ), a re c e p tiv e la ng u ag e d iso rde r (d ifficulty in un d ersta nd in g w h a t o th ers are sa yin g) o r a m ixe d la n gu a g e d iso rd e r (w h ic h inv olve s bo th ).

Conclusion
In case of history of delayed crying at birth in the CP children, phoneme omission commonly occurred when the children tried to articulate any word understand others speech. When CP children tried to articulate vowel, it was observed that alveolar was substituted by velaric, on glide deep thong end deletion. To the best of knowledge, this was the first study done on the neurolinguistic approach in Bangladeshi children, but the limitation of the study were that it was with small sample size, city based and short duration. Therefore, generalization of the results would be difficult. Further studies using larger sample would be better to visualize the extent of the issue in order to insert the children with CP in their social context and to give them quality of life.