treatment

Signs and Symptoms

Reaching the expected developmental benchmarks of infancy and childhood – sitting, rolling over, crawling, standing and walking – are a matter of great joy for parents, but what if a child’s developmental timetable seems delayed? There are many tell-tale signs that a child may have cerebral palsy, but those factors can be indicative of many conditions.


Signs and symptoms of cerebral palsy

Signs of cerebral palsy are different from symptoms of cerebral palsy.

Signs are clinically identifiable effects of brain injury or malformation that cause cerebral palsy. A doctor will discern signs of a health concern during the exam and testing.

Symptoms, on the other hand, are effects the child feels or expresses; symptoms are not necessarily visible.

Impairments resulting from cerebral palsy range in severity, usually in correlation with the degree of injury to the brain. Because cerebral palsy is a group of conditions, signs and symptoms vary from one individual to the next.

The primary effect of cerebral palsy is impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes, and posture. Oral motor dysfunction, such as swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate cerebral palsy.

Associative conditions, such as sensory impairment, seizures, and learning disabilities that are not a result of the same brain injury, occur frequently with cerebral palsy. When present, these associative conditions may contribute to a clinical diagnosis of cerebral palsy.

Many signs and symptoms are not readily visible at birth, except in some severe cases, and may appear within the first three to five years of life as the brain and child develop.

In these instances, the most apparant early sign of cerebral palsy is developmental delay. Delay in reaching key growth milestones, such as rolling over, sitting, crawling and walking are cause for concern. Practitioners will also look for signs such as abnormal muscle tone, unusual posture, persistent infant reflexes, and early development of hand preference.

If the delivery was traumatic, or if significant risk factors were encountered during pregnancy or birth, doctors may suspect cerebral palsy immediately. In moderate to mild cases of cerebral palsy, parents are often first to notice if the child doesn’t appear to be developing on schedule. If parents do begin to suspect cerebral palsy, they will likely want to ask their physician to evaluate their child for cerebral palsy.

Most experts agree; the earlier a cerebral palsy diagnosis can be made, the better.

However, some caution against making a diagnosis too early, and warn that other conditions need to be ruled out first. Because cerebral palsy is the result of brain injury, and because the brain continues to develop during the first years of life, early tests may not detect the condition. Later, however, the same test may, in fact, reveal the issue.

The earlier a diagnosis is made the sooner a child can be enrolled in early intervention programs and treatment protocols. Early interventions and therapies have proven to help a child maximize their future potential. Early diagnosis also helps families qualify for government benefit programs to pay for such measures.



Eight clinical signs of cerebral palsy

Since cerebral palsy is most often diagnosed in the first several years of life, when a child is too young to effectively communicate his or her symptoms, signs are the primary method of recognizing the likelihood of cerebral palsy.

Cerebral palsy is a neurological condition which primarily causes orthopedic impairment. Cerebral palsy is caused by a brain injury or brain abnormality that interferes with the brain cells responsible for controlling muscle tone, strength, and coordination. As a child grows, these changes affect skeletal and joint development, which may lead to impairment and possibly deformities.

The eight clinical signs include muscle tone, movement coordination and control, reflexes, posture, balance, gross motor function, fine motor function and oral motor function. These are detailed below.


Girl getting exam by doctor


Muscle tone

The most noticeable sign of cerebral palsy is impairment of muscle tone – the ability of muscles to work together by maintaining proper resistance. Muscles coordinate with other muscles, oftentimes in pairs. As some muscles contract, others must relax. Even something as simple as sitting requires coordination of many muscles; some flexing while others relax. The brain injury or malformation that caused cerebral palsy impairs the ability of the central nervous system to coordinate muscle movement.

Proper muscle tone allows limbs to bend and contract without difficulty, enabling an individual to sit, stand, and maintain posture without assistance. Improper muscle tone occurs when muscles do not coordinate together.

When this happens, those muscles that work in pairs – biceps and triceps, for example – may both contract or relax at the same time, impeding movement and coordination. Trunk muscles might relax too much, making it difficult to maintain a tight core; this can result in impaired posture and an inability to sit or to move from a sitting to standing position.

A child with cerebral palsy may demonstrate any combination of these signs. Different limbs may be affected by different impairments. The two most common signs of abnormal muscle tone are hypotonia and hypertonia, but tone can be defined in other ways as well:

  • Hypotonia – decreased muscle tone or tension (flaccid, relaxed, or floppy limbs)
  • Hypertonia – increased muscle tone or tension (stiff or rigid limbs)
  • Dystonia – fluctuating muscle tone or tension (too loose at times and too tight at others)
  • Mixed – the trunk of the body may be hypotonic while the arms and legs are hypertonic
  • Muscle spasms – sometimes painful, involuntary muscular contraction
  • Fixed joints – joints that are effectively fused together preventing proper motion
  • Abnormal neck or truncal tone – decreased hypotonic or increased hypertonic, depending on age and cerebral palsy type
  • Clonus – muscular spasms with regular contractions
    • Ankle/foot clonus – spasmodic abnormal movement of the foot
    • Wrist clonus – spasmodic movement of the hand


boys walking on dirt path


Movement coordination and control

The impairment of muscle tone affects a child’s limbs and body in different ways, although all children with cerebral palsy will likely feel some effect on muscle control and coordination. Different muscle control impairments can combine to cause limbs to be perpetually extended, contracted, constantly moving in rhythmic patterns or jerking spastically.

Some signs will be more apparent when the child is under stress. Some may be task related, such as reaching for an object. Sometimes signs will seem to disappear when the child is asleep and muscles are relaxed.

It is common for a child to experience different types of impaired muscle control in opposite limbs. Coordination and control can likewise be affected differently in each limb.

The impairment of coordination and control fall under the following types:

  • Spastic movements – hypertonic movements where the muscles are too tight resulting in muscle spasms, scissoring of the legs, clonus, contracture, fixed joints, and over-flexed limbs
  • Athetoid or dyskinetic movements – fluctuating muscle tone causing uncontrolled, sometimes slow, writhing movements which can worsen with stress
  • Ataxic movements - poor coordination and balance making tasks – such as writing, brushing teeth, buttoning shirts, tying shoes, and putting keys into slots – difficult
  • Mixed movements – a mixture of movement impairments, most commonly a combination of spastic and athetoid types, affecting different limbs
  • Gait disturbances – control impairments affecting the way a child walks

Gait disturbances include:

  • In-toeing – toes angle or rotate inward
  • Out-toeing - toes angle or rotate outward
  • Limping - more weight is placed on one foot than the other, causing a dipping, or wavy stride
  • Toe walking – the weight is unevenly placed on the toes
  • Propulsive gait – a child walks hunched over in a stiff posture with the head and shoulders bent forward
  • Spastic and scissor gait - the hips flex slightly making it look like the child is crouching while knees and thighs slide past one another like scissors
  • Spastic gait – one leg drags due to muscle spasticity
  • Steppage gait – toes drag because the foot drags
  • Waddling gait - duck-like walking pattern that can appear later in life


doctor checking child’s reflex


Reflex

Reflexes are involuntary movements the body makes in response to a stimulus. Certain primitive reflexes are present at or shortly after birth, but disappear at predictable stages of development as the child grows. Specific reflexes that do not fade away – or those that don’t develop as the child grows – can be a sign of cerebral palsy.

Certain abnormal reflexes may also indicate cerebral palsy. Hyperreflexia are excessive reflex responses that cause twitching and spasticity. Underdeveloped or lacking postural and protective reflexes are warning signs for abnormal development, including cerebral palsy.

Abnormal primitive reflexes may not function properly in children with cerebral palsy, or they may not disappear at specific points in development as they do with children with no impairment. Common primitive reflexes that may improperly function or persist include, but are not limited to:

Common primitive reflexes that may improperly function or persist include, but are not limited to:

  • Asymmetrical tonic reflex – when the head turns, the legs on the same side will extend, and the opposite limbs contract like in a fencing pose. Asymmetrical tonic reflex should disappear around six months of age.
  • Symmetrical tonic neck reflex – the infant assumes a crawling position when the head is extended. Symmetrical tonic neck reflex should disappear between eight and 11 months.
  • Spinal gallant reflexes – when the infant lies on its stomach, the hips will turn towards the side of the body that is touched. Spinal gallant reflexes should disappear between three and nine months.
  • Tonic labyrinthine reflex – when the head is tilted back, the back arches, the legs straighten, and the arms bend. Tonic labyrinthine reflex should disappear by three-and-a-half years of age.
  • Palmer grasp reflex – when stimulating the palm the hand flexes in a grasping motion. Palmer grasp reflex should disappear around four to six months.
  • Placing reflex – when an infant is held upright and the back of a foot touches the surface, the legs will flex. Placing reflex should disappear by five months.
  • Moro (startle) reflex – when the infant is tilted so his or her legs are above their head, the arms will extend. Moro reflex should disappear by six months.

Early hand preference can also indicate possible impairments. A child normally develops hand preference in his or her second year. As this is a wide timeframe and rough average, development of hand preference, especially if it is early preference, is cause for concern. Various sources state that early hand preference falls between six-18 months.


Chiropractor working on boys spine


Posture

Cerebral palsy affects posture and balance. Signs may appear as an infant begins to sit up and learn to move about. Typically, posture is expected to be symmetrical. For example, a baby in a sitting position would normally have both legs in front. When bent, they become mirror images of one another.

Asymmetrical posture means the right and left limbs will not mirror one another. The hip-joints are one area where this is often prominent in instances of cerebral palsy. One leg will bend inward at the hip, and the other will bend outward.

Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops. Impairment may be a possibility if the responses do not develop, or if they are asymmetric.

Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops. Impairment may be a possibility if the responses do not develop, or if they are asymmetric.

Common postural responses are:

  • Traction
  • Landau reflex – when the infant is supported in a lying position, pushing the head down will cause the legs to drop, and lifting the head will cause them to rise. This response appears around four or five months of age.
  • Parachute response – when the infant is positioned with his or her head towards the ground, the infant should instinctively reach as if bracing for impact. This response appears around eight to 10 months of age.
  • Head righting – when an infant is swayed back and forth, his or her head will remain straight. This response appears around four months of age.
  • Trunk righting – when a sitting infant is quickly pushed to the side, the infant will resist the force and use opposite hand and arm to brace against impact. This response appears around eight months of age.


Boy sitting on map in therapy


Balance

The impairment of gross motor function can affect a child’s ability to balance. Signs become recognizable as a child learns to sit, rise from a sitting position, and begins crawling or walking. Infants need to use their hands often as they learn these skills. They develop the strength, coordination, and balance to accomplish the task when mastering it without the use of their hands.

A child’s inability to sit without support can be a sign of cerebral palsy. The Gross Motor Function Classification System, or GMFCS, a five-level system commonly used to classify function levels, uses balance while sitting as part of its severity level system.

Signs to look for when a child sits include:

  • Requiring both hands for support
  • Having difficulty balancing when not using hands for support
  • Unable to sit without using hands for support

Other signs to look for include, but are not limited to:

  • Swaying when standing
  • Unsteady when walking
  • Difficulty making quick movements
  • Needing hands for activities that require balance
  • Walking with abnormal gait

Balance is often the same whether a child’s eyes are open or closed. Balance impairment is most often associated with ataxic, and to a lesser degree, spastic cerebral palsy.


Boy during therapy session using large therapy ball


Gross motor function

As a child develops, signs of impaired or delayed gross motor function may be noticeable. The ability to make large, coordinating movements using multiple limbs and muscle groups is considered gross motor function.

Gross motor function may be impaired by abnormal muscle tone, especially hypertonia or hypotonia.

For example, hypertonic limbs can be too tight, or inflexible, to allow proper flexion and movement; whereas hypotonic limbs may be too loose to properly support a child’s movements.

As a baby’s brain and body develop, they are expected to reach developmental milestones. Reaching the milestone later than expected, or reaching it but with low quality of movement (such as favoring one side while crawling), are possible signs of cerebral palsy.

  • Impaired gross motor functions – limited capability of accomplishing common physical skills such as walking, running, jumping, and maintaining balance.
  • Delayed gross motor functions – physical skills developed later than expected; often used in conjunction with developmental milestones for predictable stages of development.

Significant milestones of gross motor function include:

  • Rolling
  • Sitting up
  • Crawling
  • Standing
  • Walking
  • Balancing

These should be monitored to note when the baby reaches the milestone, and the quality of movement.


Girl rolling clay


Fine motor function

Executing precise movements defines the category of fine motor function. Fine motor control encompasses many activities that are learned, and involve a combination of both mental (planning and reasoning) and physical (coordination and sensation) skills to master.

Impaired or delayed fine motor skills are an indicator of possible cerebral palsy. Intention tremors, where a task becomes more difficult as it gets closer to completion, is one such sign.

Examples of fine motor function development are:

  • Grasping small objects
  • Holding objects between thumb and forefinger
  • Setting objects down gently
  • Using crayons
  • Turning pages in a book


Doctor checking boy’s facial muscles


Oral motor function

Difficulty in using the lips, tongue, and jaw indicate impaired oral motor function; this is a sign that may be present in up to 90% of preschool-aged children diagnosed with cerebral palsy. Signs of oral motor function impairment include, but are not limited to difficulty with:

  • Speaking
  • Speaking
  • Swallowing
  • Feeding/chewing
  • Drooling

Speech requires proper intellectual and physical development. Cerebral palsy impairs the physical aspects of speaking by improperly controlling the muscles required to speak. Oral motor impairment can affect:

  • Breathing – the lungs, and specifically the muscles controlling inhalation and exhalation necessary for proper speech patterns. The diaphragm and abdominal muscles are important for proper air flow and posture.
  • Articulating – muscles controlling the face, throat, mouth, tongue, jaw, and palate all must work together to form the proper shape necessary for pronunciation of words and syllables.
  • Voicing – vocal cords are controlled by muscles that essentially stretch the vocal folds between two regions of cartilage.
Apraxia, an inability of the brain to effectively transmit proper signals to the muscles used in speaking, is one type of speech impairment common to cerebral palsy. It is divided into two types:

  • Verbal apraxia – affects the articulation muscles, especially regarding the specific sequence of movements needed to carry out proper pronunciation. It is common in children with hypotonia.
  • Oral apraxia – affects the ability to make nonspeaking movements of the mouth, but is not related solely to speaking. Example of oral apraxia would be the inability to lick the lips, or inflate the cheeks.

Dysarthria is another speech impairment common to cerebral palsy. Like apraxia it is a neurological impairment, as opposed to a muscular condition. It is often found in cerebral palsy that result in hypertonia and hypotonia. Dysarthria is broken into the following subgroups:

  • Ataxic dysarthria – slow, erratic, inarticulate speech caused by poor breathing and muscular coordination
  • Flaccid dysarthria – nasal, whiny, breathy speech caused by the inability of the vocal chords to open and close properly. There may be difficulty with consonants.
  • Spastic dysarthria – slow, strenuous, monotone speech and difficulty with consonants
  • Mixed dysarthria – all three may be present.

Drooling is another sign of cerebral palsy that results from muscles in the face and mouth not being able to properly control coordination. Some specific factors which can contribute to drooling are impairments in:

  • Swallowing
  • Closing the mouth
  • Positioning the teeth
  • Inability to move saliva to back of mouth
  • Tongue thrusting

Feeding difficulties can be present with cerebral palsy. They typically manifest as decreased ability to chew and swallow, and may also involve choking, coughing, gagging, and vomiting.


RESOURCES

Signs of Cerebral Palsy

For other sources with general information on the signs and symptoms of cerebral palsy, MyChild recommends the following:

Centers for Disease Control and Prevention:

American Academy of Pediatrics Cerebral Palsy

March of Dimes:

National Dissemination Center for Children with Developmental Disabilities



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    The journey: Awaiting diagnosis of cerebral palsy – you are not alone

    A parent may be concerned about developmental delays or a doctor may observe a sign outside of growth norms. There is no definitive test for cerebral palsy, causing doctors to diagnose over time. For parents that suspect a child may have cerebral palsy, the long wait between that initial suspicion and an official diagnosis can be an emotional one. But, what is often a time of anxiety evolves into an empowering experience that leads to acceptance and unconditional love.
    The Cerebral Palsy Journey: Awaiting Diagnosis »

  • baby with big eyes gazing playfully

    Cerebral palsy risk factors

    Cerebral palsy risk factors are events, substances or circumstances that increase the risk of developing cerebral palsy. A risk factor does not ensure a child will develop cerebral palsy; it means chances are higher than if that risk factor was not present. The absence of risk factors does not ensure that a child will not develop cerebral palsy.

    Cerebral Palsy Risk Factors »

  • baby on blanket smiling

    Developmental delay

    It is worrisome to parents if their child is not progressing at the same rate as other. Developmental delays in motor skills are common in children with cerebral palsy. Once it’s determined that a child has impairment, early interventions, therapies, and treatments can make a difference in how he or she progresses.
    Developmental Delay »

  • doctor holding infant during exam

    Diagnosis and tests for cerebral palsy

    Parents are often disheartened to learn that there is no singular test that will accurately diagnose a child with cerebral palsy. Once a round of medical evaluations are initiated in order to form a diagnosis, parents prepare for a long and sometimes frustrating process that will, in time, provide answers about a child’s condition.
    Diagnosis and Tests for Cerebral Palsy »


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AAP urges doctors to diagnose early

doctor checking infant's reflexes

American Academy of Pediatrics Issues Clinical Report Urging Early Diagnosis of Cerebral Palsy

For decades, physicians have been overly cautious in diagnosing cerebral palsy and other motor delays. But recently, the American Academy of Pediatrics stressed the importance of early diagnosis in a clinical report.
AAP Clinical Report »

Clarifying terminology

doctor examining baby's feet

Signs vs. symptoms

Signs can be clinically substantiated; symptoms are subjective to an individual's personal experience. Signs are indicators of disease, disability or impairment detected through evaluation or testing administered by a medical professional.

Symptoms, however, are feelings experienced, perceived or expressed by the child as a result of a condition.

When diagnosing cerebral palsy, parents and doctors are typically looking at signs, especially in infants and toddlers, who do not have the capability yet to explain symptoms they are experiencing.

Signs

Signs are detected through medical evaluation, clinical tests, and practitioner observance. Although a parent may see signs of cerebral palsy when the child shows motor development delay, a doctor must rule out other conditions and formally diagnose the impairment.

The physician will also determine the extent, location and severity level of impairment, along with associative conditions or co-mitigating factors. Signs may vary by individual, depending on the brain injury or malformation and severity level. Examples of signs of cerebral palsy include:
  • Not blinking at loud noises by one month
  • Not sitting by seven months
  • Not turning head toward sounds by four months
  • Not verbalizing words by 12 months
  • Seizures
  • Walking with an abnormal gait

Symptoms

Symptoms are the effects of impairment an individual experiences. The child perceives and notices the symptoms, which are not necessarily visible to others. At such a young age, a child is limited in his or her ability to express symptoms and often relies on the careful observation of parents.

Symptoms, relayed to the medical practitioner, assists in the diagnosis process. Some symptoms of cerebral palsy include:
  • Choking
  • Difficulty grasping objects
  • Difficulty swallowing
  • Fatigue
  • Inability to focus on objects
  • Inability to hear
  • Pain

Is your child developmentally delayed?

baby on blanket smiling

Signs of developmental delay

Doctors look for visible signs of brain injury when they evaluate children for cerebral palsy. Development delay, which occurs when an infant does not reach a milestone at the expected time, is often the first sign in most children. Doctors will also look for anatomic signs, such as evidence of excessively stiff or loose limbs. Radiological signs of cerebral palsy are visible in the brain through neuroimaging techniques like MRIs, CT scans, and cranial ultrasound.

Certain milestones are reached at predictable times. Reaching these milestones later than expected does not necessarily indicate cause for concern; many infants develop at their own pace. However, delay does suggest the possibility of a problem, especially when combined with other risk factors and anatomic or radiological signs.

Examples of milestones important for motor development include:

  • Smiling at around six weeks
  • Rolling onto back at around four months
  • Reaching for toys at three to four months
  • Sitting without assistance at six to seven months
  • Walking at 10 to 14 months
If developmental delay is suspected the ensuing evaluation is broken into two parts:
  • Developmental screening is used to detect whether possible impairment of the child’s development exists. Doctors ask parents questions and interact with the child to gauge capabilities, reflexes and responses. If delay is detected, the process moves onto the second part.
  • Developmental evaluation is performed by a specialist, such as a developmental psychologist, developmental pediatrician, or pediatric neurologist. It is a very thorough exam used to determine whether the child is lagging behind. Tests may be performed at this stage to rule out conditions, or to diagnose.
Failure to thrive is a condition diagnosed when the child does not meet age and weight appropriate standards. Failure to thrive often describes children who fall below the third to fifth percentile in weight, or a child who experiences an extreme decrease in his or her growth rate. The child could have a digestive or dietary concern, or an orthopedic condition which makes it difficult to swallow or consume foods properly.

Anatomical signs

Cerebral palsy often affects limbs. Signs, although not always present early in an infant’s life, may appear as the child develops. Doctors look for impairment of a child’s limbs, usually in the form of hypertonia or hypotonia. Other signs include impaired torso support and control, difficulty in balancing, and infant reflexes that either do not develop, or persist after they should have disappeared.

Radiological signs

Cerebral palsy is caused by an injury to the brain. The injury or malformation is detected through modern neuroimaging techniques. Cranial ultrasounds can be used on extremely young infants but are not as reliable as CT scans and MRIs (although the latter requires infants to lie still, which can be problematic.) As many as 83% of children with cerebral palsy will present with a detectable injury to the brain. Radiological exams can be an important step in diagnosing cerebral palsy.

Is your child meeting all the developmental milestones?

underweight baby in NICU

Developmental milestones

Developmental milestones are the points in time when a child learns to accomplish a specific task. A significant delay in reaching developmental milestones is often the first indicator a child may have cerebral palsy.

Although children grow and develop at their own pace, these milestones are established to mark the average age moments most children learn the specific task. Reaching these milestones late is a sign that a child may have cerebral palsy or another development disability, especially if other signs are present. These should be discussed with a child’s doctor.

Important developmental milestones charts:

Source: Complements of Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, as of February 16, 2012. Adapted from Source: CARING FOR YOUR BABY AND YOUNG CHILD: BIRTH TO AGE 5 by Steven Shelov, Robert E. Hannermann, © 1991, 1993, 1998, 2004 by the American Academy of Pediatrics. Used permission of Bantam Books, a division of Random House, Inc.

Resources

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