ASSOCIATIVE CONDITIONS AND CO-MITIGATING FACTORS

SENSORY

Sensory integration disorder (SID) is a neurological disorder found commonly in children with cerebral palsy. An individual with SID experiences an inability to correctly process information received through one or more of the five senses – sight, hearing, touch, smell, and taste – and therefore has difficulty forming a proper response to external stimuli.

Sensory integration is needed to perform normal life activities. Processing sensory information allows the brain to detect pain, achieve balance, assist with joint motion, detect temperature changes, and provide directional awareness.

Individuals with SID may have varying degrees of sensory capability. For example, one person may have total vision loss and simply cannot see. Another, with partial vision loss, may have the ability to distinguish light from dark and vaguely indentify general shapes, but not have the ability for depth perception or to detect objects. A third individual may have blurry vision.

Vision Loss or Impairment

Two categories of vision impairment or loss exist:

  • Loss of visual acuity – means the child cannot see the object.
  • Loss of visual field – means the child can see the object, but has a limited field of vision which requires them to move their eyes or turn their head to do so.

Approximately 65%-70% of those with cerebral palsy have strabismus, also referred to as “cross eye,” a vision impairment caused by misaligned eyes. This creates poor vision as the brain ignores signals from one eye to compensate for the other. If left untreated, strabismus can lead to double vision and the inability to judge distance.

Hemianopia is another form of vision loss, which results in both eyes having half the field of normal vision.

Visual Integration

A visual integration disorder exists when an individual relies on sight to perform other tasks and is unsuccessful. An example would be a visual processing deficit whereby the child has a difficult time describing objects viewed. The child sees the object, but the brain isn’t processing what the eyes see. Individuals with stereognosia, on the other hand, have difficulty perceiving and identifying objects through touch.

Auditory Integration

Auditory integration challenges are similar to visual challenges in that the child can hear, but his or her brain is unable to process the information in a meaningful way. In this instance, the child will appear to be listening, but the information does not seem to “click” with the child.

Hearing Loss or Impairment

It is estimated that 8%-18% of those with cerebral palsy have a form of hearing loss or impairment, which may or may not coincide with vision impairment. The two hearing impairment classifications are sensorineural and conductive.

  • Sensorineural impairment – is damage to the auditory nerve which prevents the brain from receiving the correct signals.
  • Conductive impairment – is when the middle or outer ear prevents sound from reaching the healthy auditory nerve which in turn prevents hearing.

Difficulties with Speech and Language

The National Institute of Neurological Disorders and Stroke (NINDS) reports that more than one-third the individuals with cerebral palsy have difficulty forming words and speaking clearly. There are many reasons why communication may be difficult for a child with cerebral palsy. For example, the loss of hearing or poor respiratory control can impede speech.

Oromotor dysfunction is caused when the muscles of the face are impaired making it diffcult to chew, swallow or breath; speech requires an intricate series of muscle coordination to properly breath while attempting to talk. A study performed by the Behavioural Sciences Unit at the Institute of Child Health in London concluded that 90% of those with cerebral palsy in the study had clinically significant oral motor dysfunction, 57% had sucking difficulties, while 38% experienced swallowing problems.

Dysarthia, difficulty pronouncing words, is commonly found in those with cerebral palsy due in part over poor control of muscles that control the jaw, lips and tongue. Speech may sound mumbled, nasal, strained, or whispered. When some individuals are not able to speak, speech augmentation devices and assistive technology can be of assistance.

Whereas dysarthia involves difficulty in making sounds and forming words, asphasia is the loss of ability to understand or express speech. This may impair reading and writing skills.

Apraxia produces inconsistent use of words and sounds. Those with Apraxia often repeat words, distort them, delete or add words when speaking sometimes without knowing. Writing is usually easier and better than speech for these individuals.

In all scenarios the communication disorder should not be confused with a loss of intelligence, but rather an inability to process speech and language.

Sensory Impairment Can Lead to Learning Disabilities

A sensory impairment can lead to learning disabilities, as the child has more difficulty processing information received – or blocked – by the senses.

To diagnose, treat and manage sensory integration issues, the child may need to see a speech and language pathologist, an audiologist, an ophthalmologist, an optometrist, a physical therapist, or an occupational therapist.

Not all children with cerebral palsy have sensory integration challenges, but if they do, they may have one or more of the following:

  • Abnormal perceptions
  • Abnormal sensations
  • Astereognosis
  • Conductive impairment
  • Hearing abnormality
  • Hearing impairment
  • Hearing loss
  • Hemianopia
  • Maturational delay (language delay)
  • Perception impairment
  • Sensorineural impairment
  • Sensory integration dysfunction
  • Sensory impairment
  • Speech impairment
  • Stereognosis
  • Strabismus
  • Vision abnormality
  • Vision acuity abnormality
  • Vision field abnormality
  • Vision impairment
  • Vision loss
  • Visual acuity

Every Child’s Condition Is Unique

The list of possible primary, secondary, and associative conditions, as well as co-mitigating factors, can be grouped into categories, but not all conditions will be experienced by an individual with cerebral palsy. Some may encounter conditions not listed, as well.

Cerebral palsy can take a mild, moderate, or severe form depending on a host of factors. The type, location, and extent of impairment are considered, as well as any associative conditions and co-mitigating factors, when creating a treatment plan. Over the course of the person’s life, he or she may encounter any number of associative or co-mitigating factors.

Cerebral palsy is non-progressive, meaning the brain injury or malformation will not progress in severity. However, secondary conditions resulting from the brain damage may develop and change over time. For example, brain injury can cause facial muscle impairment which doesn’t change over time. Chewing, swallowing and aspiration can occur when facial muscles are impaired. Aspiration can lead to pneumonia, and pneumonia is a health condition that can become worse or better over time.

Impairments can change with – or without – proper management. As a person ages, the muscular-skeletal structure may age prematurely depending on postural conditions, care, treatment and therapy. Other health conditions or life circumstances may also affect the individual’s condition over time. These can include access to health care, health insurance benefits, exposure to toxins, new health conditions, socialization, exercise, and traumatic accidents or events.

MyChild™ lists the possibilities in hope of providing families with a better understanding of the types of conditions – and categories of conditions – an individual with cerebral palsy may encounter over their lifespan. An overview of the different types of professionals likely to treat these conditions is also contained here. It should be noted that MyChild™ does not dispense medical advice. Any conditions your child may experience should be discussed with his or her medical team for proper diagnosis and treatment. In the case of emergencies, contact 911 immediately.

ASSOCIATIVE CONDITIONS AND CO-MITIGATING FACTORS Proper Terminology

Because the terminology used is so specific, yet remarkably similar, terms such as primary, secondary, associative and co-mitigating conditions are used interchangeably, yet incorrectly. It is helpful to know the difference between the terms when attempting to understand cerebral palsy.

Primary condition - These are a direct result of the brain lesion or brain malformation. Primary conditions affect motor coordination, motor control, muscle tone, posture and balance. Gross motor, fine motor, and oromotor functioning are also considered primary conditions of cerebral palsy.

Secondary condition - Primary conditions, in turn, may lead to secondary conditions such as inability to chew, inability to swallow, breathing difficulties, bladder and bowel control issues, and communication difficulties. If the brain lesion or malformation that caused cerebral palsy did not exist, these secondary conditions would not be present.

Associative conditions - Research has shown that individuals with cerebral palsy often have associative conditions not caused by the same brain injury or malformation which caused cerebral palsy, but proven to be common with individuals who have cerebral palsy. If the brain injury or malformation that caused the cerebral palsy did not occur, these conditions may still be present in the individual. Associative conditions include intellectual impairment, epileptic seizures, hearing impairment, and vision impairment.

Co-mitigating factors - An individual may also have health conditions separate from cerebral palsy. Unlike associative conditions, researchers have not concluded that these conditions have a high correlation to cerebral palsy. Co-mitigating factors exist regardless of cerebral palsy. Examples of co-mitigating conditions of cerebral palsy include autism, attention deficit hyperactivity disorder (ADHD), and asthma.

Associative Conditions and Co-Mitigating Factors

There are eight major categories of associative conditions and co-mitigating factors. To learn more about them, click one of the following: