ACQ Vol 13 no 2 2011

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ACQ Volume 13, Number 2 2011 69
Body structures
The Body Structures component of the ICF-CY is closely
related to the Body Functions level as it identifies structural
deficits underlying the physiological impairments. Body
Structures is defined as the “anatomical parts of the body
such as organs, limbs, and their components” (WHO, 2007,
p. 107). An example of this relating to children with CP
includes large ranges of jaw movement and impaired
velopharyngeal closure (Kent & Netsell, 1978). Chapters
within this component relevant to children with CP include
Structures involved in voice and speech (e.g., hard/soft
palate, tongue, lips); Structures of the nervous system (e.g.,
basal ganglia, cerebellum); The eye, ear and related
structures (e.g., middle/inner ear); Structures of the
cardiovascular, immunological and respiratory systems (e.g.,
muscles of respiration); Structures related to the digestive,
metabolic and endocrine systems (e.g., salivary glands,
oesophagus); and Structures related to movement (e.g.,
muscles of the head and neck region, structure of the
trunk).
The qualifiers used at the Body Functions level also apply
to the Body Structures component to indicate the severity
of the impairment. Two additional qualifiers may also be
used at this level: one uses a 10-point scale to indicate the
nature of the change in the body structure (e.g., no change
in structure, partial absence, deviating position), while the
remaining qualifier can be used to indicate the location of
the impairment (e.g., right, left, or bilateral).
Considering that up to 90% of children with CP
demonstrate oral motor impairments (Reilly, Skuse, &
Poblete, 1996), assessment of the oral structures at rest
and during movement is an important component of the
clinical assessment of children. Children with sufficient
cognitive abilities may be able to complete commonly used
standardised oral motor assessments such as the Verbal
Motor Production Assessment for Children (Hayden &
Square, 1999). Formally assessing the oral motor abilities of
children with severe intellectual disabilities may be difficult
and speech pathologists may need to rely on informal
observations of the child at rest and during feeding.
Activities and participation
While Body Functions and Structures address the
impairment level, the Activities and Participation component
aims to identify possible limitations or restrictions in the
child’s ability to function. The ICF-CY defines Activities as
the “execution of a task or action by an individual” (WHO,
2007, p. 9), while Participation relates to a child’s
“involvement in a life situation” (WHO, 2007, p. 9).
All of the Activity and Participation domains are important
to consider for children with CP with a speech and/
or language impairment. These include Learning and
applying knowledge (e.g., thinking and problem-solving
skills); General tasks and demands (e.g., performing
single/multiple tasks, following routines); Communication
(e.g., receiving and producing spoken and nonverbal
messages), Mobility (e.g., gross and fine motor skills);
Self-care (e.g., eating and drinking); Domestic life (e.g.,
maintaining assistive devices); Interpersonal interactions
and relationships (e.g., interacting with family members
and peers); Major life areas (e.g., engagement in play and
school activities); and Community, social and civic life (e.g.,
engagement in community activities).
Due to poor consensus in differentiating between
domains relating to Activities versus Participation (WHO,
respiratory systems (to document deficits in respiration for
speech); Functions of the digestive, metabolic and
endocrine systems (for recording feeding/swallowing
impairments and excessive drooling); and
Neuromusculoskeletal and movement related functions (for
classifying the physical abilities of children).
The following qualifiers are used to classify the severity
of an impairment at the Body Functions level: 0: no
impairment; 1: mild impairment; 2: moderate impairment;
3: severe impairment; and 4: complete impairment (WHO,
2007).
When determining the most appropriate speech and/
or language assessment to administer to a child, speech
pathologists must take into consideration the child’s
motor, cognitive, visual, hearing, and communicative
abilities. Commonly used articulation assessments may
be administered (where appropriate) with no motor
modifications, although visual modifications (e.g.,
positioning test stimuli close to the child’s face) may be
necessary in some cases.
Formally assessing the language abilities of children with
impaired upper limb function may prove to be more difficult
considering the high reliance on fine motor movements
(e.g., object manipulation, pointing) to indicate responses.
Hustad, Gorton, and Lee (2010) reported that only 32%
(11/34) of their sample involving children aged four years
with varying types and severity of CP were able to complete
a standardised comprehension assessment. Yet Love,
Hagerman, and Taimi (1980) found that most children
and adults (i.e., 78%, 47/60) aged 3 to 26 years, who
varied in gross motor abilities, were able to complete the
Peabody Picture Vocabulary Test (Dunn, 1965). Even if a
child is capable of completing standardised assessments,
establishing the reliability of a child’s score may be
complicated by difficulties in determining whether a child’s
inability to respond to a task represents a true receptive
language deficit or reflects a child’s inability to execute the
physical component of the task (Hustad et al., 2010).
Unfortunately, commonly used language assessments
are not specifically designed to be used with children
with physical impairments. Modifications to assessment
procedures are often necessary for children with severe
speech and physical impairments. Results obtained using
adapted procedures need to be interpreted with caution,
however, as they may alter the psychometric properties of
the assessment, reduce the child’s motivation (Geytenbeek
et al., 2010), and increase the cognitive load of the task
(Pennington, 2008).
Recently, Geytenbeek et al. (2010) conducted a
systematic review to determine the most appropriate
comprehension test to use with children with CP who
demonstrate severe dysarthria (defined as unintelligible
speech) or anarthria (i.e., the absence of speech). The
authors reviewed 12 standardised tests and found that no
test was sufficiently suitable to use with this population. Of
the tests reviewed, the Peabody Picture Vocabulary Test
– Revised (Dunn & Dunn, 1981) was the most commonly
used instrument and most feasible to administer to children
over 9 years of age, although it may be used with younger
children provided that modifications are made for those with
reduced upper limb mobility. The authors concluded that
there was a need for the development of an assessment
measuring comprehension specifically designed for children
with severe CP and dysarthria or anarthria (Geytenbeek et
al., 2010).