Unit II: ASD & Cerebral Palsy (CP)

1. CP: Concept and definition

2. Characteristics of CP

3. Causes of CP

4. Types of CP

5. Educational implications for ASD children with CP


1. CP: Concept and definition

Cerebral palsy (commonly referred to as CP) affects normal movement in different parts of the body and has many degrees of severity.

CP causes problems with posture, gait, muscle tone and coordination of movement.

The word “cerebral” refers to the brain’s cerebrum, which is the part of the brain that regulates motor function. “Palsy” describes the paralysis of voluntary movement in certain parts of the body.


Cerebral Palsy is a group of conditions that are characterized by chronic disorders of movement or postures; it is cortical in origin, manifests itself early in life and is not the outcome of a progressive disease.

Cerebral Palsy is a syndrome as the following a combination of characteristics can be seen:

·      Motor Disorder.

·      Medical Conditions.

·      Sensory Impairments.

·      Hearing Disabilities.

·      Attention Deficits.

·      Language & Perceptual Deficits.

·      Behavioral Problems.

·      Mental Retardation.

Affected Areas of the Brain

The kinds of abnormal muscle tone and movement problems that a person with cerebral palsy experiences depend upon which area of the brain is injured.

Image result for affected area of the brain of cp


2. Characteristics of CP

Cerebral palsy is a disorder of the central regulation of mobility and development of mobility caused by damage to an immature brain.

Apart from delayed development of mobility skills like crawling or standing, decreased or increased muscle tension is another symptom.

Damage can occur during pregnancy, birth or in the first months of life.

The disease manifests itself in various forms, and disorders can appear gradually during the second and third year of life.

We distinguish between spastic and non-spastic cerebral palsy.

The spastic form is more common and its characteristic symptom is stiffness in affected muscles and permanently constricted (spasmed) muscles. This form results in weakening or paralysis in limbs.

In some cases, there are mental disorders, nervous seizures, sensory disorders, inability to communicate, sensation disorders and other issues present.

Cerebral palsy should not be mistaken for poliomyelitis. Polio is a viral infection disease and is transferable from human to human.

Cerebral palsy is neither infectious, nor hereditary. Its cause is most commonly insufficient oxygen supply in the brain tissue, but may also be a result of infection or after effects of toxic substances or medication.




These developmental movement disorders can be limited to: one side of the body, the legs, the arms, all four limbs or just one limb.


3. Causes of CP

Prenatal causes

·      Maternal infections. Example: rubella, herpes simplex

·      Inflammation of placenta (chorionamnionitis)

·      Rh incompatibility

·      Diabetes during pregnancy

·      Genetic causes

·      Exposure to radiation

·      Maternal jaundice

Peri-natal causes of cerebral palsy

·      Birth asphyxia.

·      Damage to the white master of the brain.

·      Severe untreated jaundice, hypoglycemia.

·      Sepsis (Meningitis, encephalitis).

·      Premature infant with complications.

·      Intracranial bleeding.

·      Multiple births.

Congenital causes of cerebral palsy

·      Malformation of the brain & blood vessels.

·      Neurological damage as a result of

1.     Intrauterine viral infections (torch).

2.     Pollution (affect of environmental toxins).

3.      Poor oxygenation of brain as a result of placental factors.

4.     Vascular factors (Congenital heart disease, sepsis, etc).

Post-natal causes

·      Infections (bacterial of viral).

·      Post-surgical vascular complications.

·      Asphyxia due to aspiration.

·      Traumatic brain injury.


4. Types of CP

Physiological Grouping

Spasticity is defined as a velocity-dependent increased muscle tone, determined by passively flexing and extending muscle groups across a joint. A satisfactory, reproducible system of grading muscle tone has never been developed, although the Ashworth and Tardieu scales are commonly used in research. Most physicians describe the tone as being normal, increased or decreased. Associated with spasticity are enhanced deep tendon reflexes, usually associated with clonus and extensor plantar responses. However, the latter are sometimes difficult to elicit in the infant and even in the older child with spastic CP.

Dyskinesia is defined as abnormal motor movements that become obvious when the patient initiates a movement. When the patient is totally relaxed, usually in the supine position, a full range of motion and decreased muscle tone may be found. Dyskinetic patients are subdivided into two subgroups.

• The hyperkinetic or choreo-athetoid children show purposeless, often massive involuntary movements with motor overflow, that is, the initiation of a movement of one extremity leads to movement of other muscle groups.

• The dystonic group manifest abnormal shifts of general muscle tone induced by movement. Typically, these children assume and retain abnormal and distorted postures in a stereotyped pattern. Both types of dyskinesia may occur in the same patient. Simply stated, spasticity you feel; dystonia you see.

Patients with ataxias have a disturbance of the coordination of voluntary movements due to muscle dyssynergia. These patients may be hypotonic during the first two or three years of life. They commonly walk with a wide-based gait and have a mild intention tremor (dysmetria).

The fourth category that is commonly used in the physiologic and motor classification is the mixed group. Patients in this category commonly have mild spasticity, dystonia, and/or athetoid movements. Ataxia may also be a component of the motoric dysfunction in patients placed in this group.


Anatomic Grouping

The distribution of cerebral palsy when the child is of low birth weight (less than 1500 grams) is as follows:

(a) Diplegia - 57%

(b) Quadriplegia - 22%

(c) Hemiplegia - 11%

(d) Mixed - 10%


The topographic classification of CP is monoplegia, hemiplegia, diplegia and quadriplegia; monoplegia and triplegia are relatively uncommon. There is a substantial overlap of the affected areas. In most studies, diplegia is the commonest form (30% – 40%), hemiplegiae is 20% – 30%, and quadriplegia accounting for 10% – 15%. In an analysis of 1000 cases of CP from India, it was found that spastic quadriplegia constituted 61% of cases followed by diplegia 22%.

Quadriplegic CP

This is the most severe form involving all four limbs, and the trunk upper limbs are more severely involved than the lower limbs, associated with acute hypoxic intrapartum asphyxia. However, this is not the only cause of spastic quadriplegia.5 Neuroimaging reveals extensive cystic degeneration of the brain – polycystic encephalomalacia and polyporencephalon MRI and a variety of developmental abnormalities such as polymicrogyria and schizencephaly. Voluntary movements are few; vasomotor changes of the extremities are common. Most children have psuedobulbar signs with difficulties in swallowing and recurrent aspiration of food material. Half the patients have optic atrophy and seizures. Intellectual impairment is severe in all cases.

 Hemiplegic CP

 Spastic hemiparesis is a unilateral paresis with upper limbs more severely affected than the lower limbs. It is seen in 56% of term infants and 17% of preterm infants. Pathogenesis is multifactorial. Voluntary movements are impaired with hand functions being most affected. Pincer grasp of the thumb, extension of the wrist and supination of the forearm are affected. In the lower limb, dorsiflexion and aversion of the foot are most impaired. There is increased flexor tone with hemiparetic posture, flexion at the elbow and wrist, knees and equines position of the foot. Palmer grasp may persist for many years. Sensory abnormalities in the affected limbs are common. Sterognosis impaired most frequently. 2 point discrimination and position sense is also defective. Seizures occur in more than 50%. Visual field defects, homonymous hemianopia, cranial nerve abnormalities most commonly facial nerve palsies are seen.

Diplegic CP

Spastic diplegia is associated with prematurity and low birth weight. Nearly all preterm infants with spastic diplegia exhibit cystic periventricular leukomalacia on neuroimaging. Periventricular leukomalacia (PVL) is the most common ischemic brain injury in premature infants. The ischemia occurs in the border zone at the end of arterial vascular distributions. The ischemia of PVL occurs in the white matter adjacent to the lateral ventricles. The diagnostic hallmarks of PVL are periventricular echo densities or cysts detected by cranial ultrasonography.

In this condition, lower limbs are more severely affected then the upper limbs. Mild cases may present with toe walking due to impaired dorsiflexion of the feet with increased tone of the ankles. In severe cases, there is flexion of the hips, knees and to a lesser extent elbows. When the child is held vertically, rigidity of lower limbs is most evident and adductor spasm of the lower extremities causes scissoring of the legs. Seizures are common. Fixation difficulties, nystagmus, strabismus, and blindness have been associated with PVL.


The Gross Motor Function Classification System (GMFCS)

The Gross Motor Function Classification System (GMFCS) is often used to diagnose the severity of a child’s motor impairment. Doctors can also use the GMFCS to make a prognosis and determine the likelihood of a child improving their gross motor skills (sitting without support, walking, etc.).

The GMFCS has five levels of motor impairment from least severe (Level I) to most severe (Level V). The level of severity a child is initially diagnosed with, can be a prognostic indicator of their future motor skills.

GMFCS – The 5 Levels of Severity in Cerebral Palsy


5. Educational implications for ASD children with CP

The connection between autism and cerebral palsy is not exactly direct – however, because of the similarities within developmental disorders, it is common for autism and cerebral palsy to co-occur.

Cerebral palsy is the result of brain damage that occurs before, during or shortly after birth. Autism is also a brain development disorder, but it tends to progress after age two or three when a child’s language and communication skills begin to show an obvious delay.

Due to both cerebral palsy and autism involving some kind of umbrella diagnosis of brain damage, children with CP can also display symptoms of autism. Both conditions have varying degrees of severity, which can make it difficult to form a clear diagnosis of co-existing autism and cerebral palsy during the early childhood years.

Treatment For Autism and Cerebral Palsy

The best way to determine if a child has both cerebral palsy and autism is by seeking an evaluation from a team of specialists experienced in the way that these conditions can co-exist.

If it is determined that a child has autism and cerebral palsy, there are various treatment options available to ensure that they are able to live life to the fullest, despite their diagnosis. A specific treatment plan will depend on the type of cerebral palsy and the type of autism a child has.

A treatment program will be put together by trained medical professionals who will examine a child’s mobility and cognitive abilities and determine the best course of action for their future.

Common treatment methods for co-existing autism and cerebral palsy are:

·       Physical therapy – This form of therapy can help improve coordination, balance and posture among children with CP and autism.

·       Speech therapy – Speech therapy can help articulation, language, vocabulary development and word comprehension.

·       Occupational therapy – Occupational therapy is used to help children with everyday activities and functions, such as eating, dressing, and using the bathroom.

·       Medications – There are medications available to help reduce common side-effects associated with cerebral palsy and autism, such as seizures.