Cerebral Palsy

(Orthopedic Impairment)

DEFINITION

Our nation’s special education law, the Individuals with Disabilities Education Act (IDEA) includes cerebral palsy under "orthopedic impairment," which means…

“…a severe orthopedic impairment that adversely affects a child's educational performance. The term includes impairments caused by congenital anomaly, impairments caused by disease (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures).”

[34 Code of Federal Regulations §300.8(c) (8)]

OTHER DEFINITIONS

The term cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement, muscle coordination, and balance. CP affects the part of the brain that controls muscle movements. The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. The early signs of cerebral palsy usually appear before a child reaches 3 years of age. The most common are a lack of muscle coordination when performing voluntary movements (ataxia); stiff or tight muscles and exaggerated reflexes (spasticity); walking with one foot or leg dragging; walking on the toes, a crouched gait, or a “scissored” gait; and muscle tone that is either too stiff or too floppy. Other neurological symptoms that commonly occur in individuals with CP include seizures, hearing loss and impaired vision, bladder and bowel control issues, and pain and abnormal sensations. A small number of children have CP as the result of brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse. The disorder isn't progressive, meaning that the brain damage typically doesn't get worse over time. Risk factors associated with CP do not cause the disorder but can increase a child's chance of being born with the disorder. CP is not hereditary.

(National Institute of Neurological Disorders and Stroke, NINDS, 2019)

TYPES

Cerebral palsy is an umbrella term for a group of disorders. It is the most common physical disability in childhood. It is a condition that is permanent, but not unchanging. Cerebral palsy can be described by the way it affects people’s movement, the part of the body affected and by how severe the affects are.

  • Spastic – too much muscle tone or tightness; movements are stiff, especially in the legs, arms, and/or back. Children with this form of CP move their legs awkwardly, turning in or scissoring their legs as they try to walk. This form of CP is the most common and occurs in about 70% to 80% of all cases.
  • Dyskinetic (also called Athetoid) – can affect movements of the entire body. Characterized by involuntary body movements and low muscle tone that makes it hard for a person to sit straight and walk; occurs in about 6% of all cases.
  • Ataxic CP – involves poor coordination, balance, and depth perception; occurs in about 6% of all cases.
  • Mixed CP – a combination of the symptoms listed above; a child with mixed CP has both high and low tone muscle. Some muscles are too tight, and others are too loose, creating a mix of stiffness and involuntary movements.

More types that described by the parts of the body affected:

  • Diplegia – only legs are affected
  • Hemiplegia – one half of the body (such as right arm and leg) are affected
  • Quadriplegia – both arms and legs are affected, sometimes including facial muscles and torso

(Center for Parent Information Resources, CPIR, 2017) 
(Cerebral Palsy Alliance Research Foundation, CPARF, 2018)

FACTS AND STATS

Every hour a baby is born with cerebral palsy (CP). It is estimated that 1 out of every 323 newborn children will be diagnosed with cerebral palsy. This frequency has remained relatively constant for more than four decades, even with significant advances in the medical care of newborns. Cerebral palsy, except in its mildest forms, can be evident in the first 12-14 months. Of all children with cerebral palsy, 40% were born prematurely and 60% born at term. Cerebral palsy is the most common physical disability in childhood. Spastic hemiplegia, where one half of the body has difficulty with voluntary movement, is the most common presentation of cerebral palsy with approximately 40% of people with CP having hemiplegia. Approximately half of the children with CP have intellectual impairments. Globally, approximately 17 million people have cerebral palsy.

(CPARF, 2018)

CAUSES

Cerebral palsy is the result of a combination of events either before, during, or after birth that can lead to an injury in a baby’s developing brain. There is no single cause of cerebral palsy. For many babies born with cerebral palsy, the cause remains unknown or not well understood.

Researchers now know that only a very small percentage of cases of cerebral palsy are due to complications at birth (e.g. asphyxia or lack of oxygen). Today, it is accepted that cerebral palsy usually arises from a series of events that when combined can cause or accelerate injury to the developing brain. Stroke is the most common cause in babies who acquire cerebral palsy after one month of age. The stroke may occur spontaneously or arise from surgical or heart complications.

Some risk factors for cerebral palsy include:

  • Premature (early) birth
  • Low birth weight
  • Twins, triplets, and higher multiple births
  • Blood clotting problems
  • Brain injury after birth (i.e., stroke, car injury, shaken-baby syndrome)
  • Inability of the placenta to provide the developing fetus with oxygen and nutrients
  • RH or A-B-O blood type incompatibility between mother and infant
  • Infection of the mother with German measles or other viral diseases in early pregnancy
  • Bacterial infection of the mother, fetus, or infant that directly or indirectly attack the infant's central nervous system
  • Prolonged loss of oxygen during the birthing process
  • Severe jaundice shortly after birth
  • There are more males with cerebral palsy (57%) than females (43%)

Familial cerebral palsy is uncommon with approximate 1% of people with cerebral palsy having a sibling with the condition. It is even uncommon in twins – when one has cerebral palsy, 90% of co-twins will not have cerebral palsy. However small these statistics, there is enough suggestion that there might be some genetic factors involved in cerebral palsy. Researchers believe that a genetic predisposition to certain characteristics, i.e. prematurity or heart problems, may encourage a change of events that can increase the risk of a child having cerebral palsy.

(CPARF, 2018)

CHARACTERISTICS

There are some signs that may indicate a child has cerebral palsy. Not all signs are visible at birth and may become more obvious as babies develop.

  • Low muscle tone (baby feels “floppy” when picked up)
  • Unable to hold up head while lying on stomach or in a supported position
  • Muscle spasms or feeling stiff
  • Poor muscle control, reflexes, or posture
  • Delayed development (sitting up, independently rolling, walking, speaking, etc.)
  • Feeding or swallowing difficulties
  • Preference to use one side of the body

People with cerebral palsy may also have a range of associated physical and cognitive struggles. Mobility, communication, eating and drinking, sleep, and bladder/bowel control may all be affected by cerebral palsy. Additionally, people with cerebral palsy may also be at risk for having an intellectual disability, learning difficulties, a hearing impairment, a vision impairment, behavioral problems, or epilepsy.

(CPARF, 2018)

PREVENTION

Certain medical advances (such as vaccines) as well as better prenatal care and nutrition have lowered the number of babies born with CP in poorer countries. During pregnancy a woman can take precautions to prevent CP. These include:

  • Rh Factor Test: if a woman is found to be Rh negative, she can be immunized within 72 hours after birth to help reduce the risk of CP. If the woman who is Rh negative has not been immunized, and has a baby, the newborn can be given a transfusion to help prevent blood incompatibilities. If a newborn baby has jaundice, he or she can be treated with phototherapy (light therapy) in the hospital nursery.
  • Immunizations: immunization against measles for at-risk women who might get pregnant.
  • Prenatal care: receive proper prenatal care during pregnancy to prevent premature birth.

TREATMENT

Cerebral palsy can't be cured, but treatment will often improve a child's capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. Treatment may include physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms, and alleviate pain; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; wheelchairs and rolling walkers; and communication aids such as computers with attached voice synthesizers.

(NINDS, 2019)

PROGNOSIS

Cerebral palsy doesn't always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might only be slightly awkward and require no special assistance. Many children with cerebral palsy have average to above average intelligence and attend the same schools as other children their age. Supportive treatments, medications, and surgery help many individuals improve their motor skills and ability to communicate with the world.

(NINDS, 2019)

A review of different treatments (interventions for movement, communication, epilepsy, sleep disorders and other issues) can be found on pages at the Cerebral Palsy Alliance Research Foundation.

(CPARF, 2018)

Also see The Case for Inclusion 2020: Key Findings Report which, a comprehensive assessment of how well programs in all 50 states and the District of Columbia are serving people with intellectual and developmental disabilities.

(United Cerebral Palsy, UCP, 2019).

EDUCATIONAL IMPLICATIONS

A child with CP can face many challenges in school and is likely to need individualized help. Fortunately, states are responsible for meeting the educational needs of children with disabilities.

For school-aged children, including preschoolers, special education and related services will be provided through the school system. School staff will work with the child's parents to develop individualized education programs (IFSPs, IEPs) to meet each child's unique needs and the services that have been designed to meet those needs. Special education and related services, which can include PT, OT, and speech-language pathology, are provided at no cost to parents.

In addition to therapy services and special equipment, children with CP may need assistive technology (AT). Collaborate with special educators and speech pathologists who are well aware of alternative communication systems and other AT equipment and devices.

Examples of assistive technology include:

  • Communication devices, which can range from the simple to the sophisticated (e.g., Communication boards, which have pictures, symbols, letters, or words attached. The child communicates by pointing to or gazing at the pictures or symbols. Augmentative communication devices are more sophisticated and include voice synthesizers that enable the child to "talk" with others.)
  • Computer technology, which can range from electronic toys with special switches to sophisticated computer programs operated by simple switch pads or keyboard adaptations.

The ability of the brain to find new ways of working after an injury is remarkable. Even so, it can be difficult for parents to imagine what their child's future will be like. With the right mix of support, equipment, extra time, and accommodations, all children with CP can be successful learners and full participants in life.

Tips for Teachers

  • Learn more about CP. The resources and organizations at the end of this publication will help you.
  • This may seem obvious, but sometimes the "look" of CP can give the mistaken impression that a child who has CP cannot learn as much as others. Focus on the individual child and learn firsthand the child’s needs and capabilities.
  • Be inventive. Ask yourself (and others), "How can I adapt this lesson for this child to maximize active, hands-on learning?"
  • Learn to love assistive technology. Find experts within and outside your school to help you. Assistive technology can mean the difference between independence for your student or not.
  • Always remember, parents are experts, too. Talk candidly with your student's parents. They can tell you a great deal about their daughter or son's special needs and abilities.
  • Effective teamwork for the child with CP needs to bring together professionals with diverse backgrounds and expertise. The team must combine the knowledge of its members to plan, implement, and coordinate the child's services.

(CPIR, 2017)

Also see the many descriptions of Resources on pages for United Cerebral Palsy (UCP, 2019).

ORGANIZATIONS & RESOURCES

United Cerebral Palsy Associations, Inc. (UCP) 
https://ucp.org
1825 K Street NW, Suite 600 
Washington DC 20006 
202.776.0406

Since 1949, United Cerebral Palsy (UCP) has been committed to change and progress for persons with disabilities. The national organization and its nationwide network of affiliates strive to ensure the inclusion of persons with disabilities in every facet of society—from the Web to the workplace, from the classroom to the community. As one of the largest health charities in America, the mission of United Cerebral Palsy is to advance the independence, productivity and full citizenship of people with disabilities through an affiliate network. UCP recently published a useful report available to download. The Case for Inclusion 2020: Key Findings Report is a comprehensive assessment of how well programs in all 50 states and the District of Columbia are serving people with intellectual and developmental disabilities.

Cerebral Palsy Alliance Research Foundation (CPARF) 
https://cparf.org 
142 W 57th Street, Floor 11 
New York, NY 10019 
646.340.1209

The Cerebral Palsy Alliance Research Foundation was established in 2015 to fund the world’s best research to treat, prevent, and ultimately find a cure for cerebral palsy. They seek to accomplish these goals through support of research to improve therapies and interventions for people living with cerebral palsy, support high quality evidence-based research into the prevention of cerebral palsy, share the direction of future research, and build careers dedicated to investigating cerebral palsy research.

Children's Hemiplegia and Stroke Association (CHASA) 
https://chasa.org 
4101 West Green Oaks, Suite 305 #149 
Arlington, TX 76016

Online Support for Children with Hemiplegia or Hemiplegic Cerebral Palsy. Includes local support groups and an e-mail discussion group to keep parents of children with CP connected.

Last updated March 2020.