As expecting parents, we often let ourselves indulge in daydreams of what raising our child will be like once they arrive. But sometimes complications occur that create a reality exactly the opposite of what we once envisioned. We try to enjoy every little moment of our child’s infancy and toddler years – and then we notice that things are not exactly right. Learning your child has a disability is a seriously challenging and disheartening moment in any parent’s life.
How Is Cerebral Palsy Classified?
Cerebral palsy (CP) is a disorder that causes movement and muscle control malfunction in the body. CP is caused by damage to the brain in utero, during delivery or shortly after the birth of a child. The types of cerebral palsy are designated by severity level, which parts of the body are affected, and the child’s gross motor abilities.
CP is often difficult to diagnose because it can be easy to confuse an infant or toddler’s normal developmental responses with cerebral palsy symptoms. If your baby is missing major developmental milestones, please address this with your pediatrician. When combined with other factors, this could be a sign your child has CP.
- Section 1 Severity Level
- Section 2 Topographical Distribution
- Section 3 Motor Function
- Section 3a Spastic (Pyramidal) Cerebral Palsy
- Section 3b Non-Spastic (Extrapyramidal) Cerebral Palsy
- Section 3c Mixed Cerebral Palsy
- Section 4 Gross Motor Classification System
- Section 5 Manual Ability Classification System
- Section 6 Communication Function Classification System
There are many levels of classification for cerebral palsy. As a starting point, classification is first defined by level of severity. These are:
- Mild: your child has full mobility and their daily activities are not impacted by the disorder.
- Moderate: your child will need assistive devices; such as braces or medication to manage CP.
- Severe: your child will require significant caregiver assistance and a wheelchair.
To better understand cerebral palsy, classification is further diagnosed by where and to what extent CP manifests in the body of the child affected.
Doctors use the term “paresis” is used to define weakness, while the term “pelgia” or “plegic” means paralysis. Topographical distribution of cerebral palsy includes:
- Monoplegia/monoparesis means only one limb is affected.
- Diplegia/diparesis indicates two limbs are affected, specifically the lower extremities.
- Hemiplegia/hemiparesis means the arm and leg on one side of the body are affected.
- Paraplegia/paraparesis indicates the legs and lower half of the body area affected.
- Triplegia/triparesis occurs when three limbs are affected, or one upper extremity and the face.
- Double hemiplegia/hemiparesis affects all four limbs, but on one side more than the other.
- Tetraplegia/tetraparesis also affects all four limbs, but one limb is more affected than the others.
- Pentaplegia/pentaparesis indicates all four limbs, the head and the neck are affected.
Cerebral palsy is caused by brain injury. The parts of the brain that are damaged correlate to the child’s ability to control their body, also known as motor function. Classification based on motor function further divides CP into two groups: Spastic (Pyramidal) and Non-Spastic (Extrapyramidal).
In spastic forms of cerebral palsy, the motor cortex has been damaged. The system of nerves that connect the motor cortex to the spinal cord nerves are called the pyramidal tract. They relay messages from the brain to the spinal cord. The pyramidal tract is responsible for muscle movement of the face and body.
There are five types of spastic CP. They describe the type of movement disorder and the area of the body affected. Types of spastic CP are:
- Spastic hemiplegia: indicates the arm and/or leg on one side of the body is affected. Seizures are common, as is speech delay. Intellectual disability is usually mild or non-existent.
- Spastic diplegia: causes stiffness in the legs and clumsiness of the upper extremities. Muscle tightness in the legs cause them to move much like a Christmas nutcracker, so a child may need to use braces or a walker to help with mobility. Intellectual and language disability may be present.
- Spastic quadriplegia: the most severe form of CP, in which all limbs are drastically stiff and the neck is floppy. Children with this level of cerebral palsy often have intellectual disability, along with speech and language difficulties, and frequent seizures.
- Spastic Monoplegia: affects one of the limbs, either the leg or arm. The symptoms for this type of CP are generally mild, such as decreased joint motion, and are typically non-painful. If symptoms do not subside as a child gets older, spastic monoplegia will affect body function throughout a lifetime.
- Spastic Triplegia: three limbs are affected, which could be a combination of arms and legs or could involve two extremities and the face. Typically, the most common pattern is impairment of one arm and both legs.
Non-Spastic (Extrapyramidal) Cerebral Palsy
This type of CP is characterized by a decrease in muscle tone caused by a brain injury outside the pyramidal tract. Depending on the injury location, seizures and mental impairment are not as likely. The main impairment is involuntary movement that is often repetitive and in some instances, rhythmic. There are two categories of non-spastic CP: ataxic and dyskinetic, which make up 20 percent of all CP cases.
Ataxia cerebral palsy is the least common form of CP and causes difficulty with depth perception, gait, posture, walking, swallowing and even breathing. Fine motor skills, required for hand-eye coordination, are also challenging.
Dyskinetic cerebral palsy is a form of extrapyramidal CP, so named for the extrapyramidal tract that commands involuntary movement in the body. Dyskinetic CP describes the kinds of movement expressed by the person affected, these can be separated into two groups: dystonia (dystonic) CP ( the child experiences twisting, repetitive movements and athetoid CP (movements are slow and turbulent).
Sometimes dyskinesia and spasticity occur together. A child with these symptoms would be diagnosed with mixed cerebral palsy. This is experienced as muscle stiffness, involuntary movements and pain in the limbs affected. Due to the unpredictable presentation of symptoms, mixed CP is the most difficult to treat.
Gross Motor Classification System
Cerebral palsy affects children all over the world. To create a system of universal understanding across borders, the World Health Organization (WHO) and the Surveillance of Cerebral palsy in Europe (SCPE) developed the Gross Motor Function Classification System (GMFCS).
The GMFCS sheds a positive light on the capabilities of a child with CP by focusing on what activities they will be able to perform despite their diagnosis. The GMFCS has five levels, they are:
- Level I: the child is fully independent, able to walk normally with occasional occupational therapy sessions to strengthen gait and balance.
- Level II: the child can walk independently for the most part, but may need a walker or braces in the early learning stages.
- Level III: the child is able to sit and stand with little support, but needs assistive devices to walk, especially when outdoors.
- Level IV: the child is able to move independently in a wheelchair and sit up with some support.
- Level V: the child needs constant assistive technology, a dedicated caregiver and a motorized wheelchair.
By understanding the GMFCS classification, parents are better able to foresee the kinds of resources their child with CP requires as they grow.
Manual Ability Classification System
Cerebral palsy is diagnosed between 9 months and 4 years of age. By the time children have their fourth birthday, their level of independence changes dramatically. Personality traits are beginning to solidify and they’re preparing for kindergarten.
The Manual Ability Classification System was designed to assist parents, teachers and caregivers assess the capacity of a child with CP to handle objects in their environment.
MACS is used for school-aged children, ages 4-18 years old. MACS levels are as follows:
- Handles objects successfully. This means a child experiences little to no difficulty handling objects and has full independence in daily activities.
- Handles objects with reduced quality and/or speed of achievement. A child at this level may use alternative solutions in performance but usually retains independence in daily tasks.
- Handles objects with difficulty. At this level, task achievement is slow and activities will have to be set up or adapted.
- Handles a limited set of easily managed objects in adapted situations. Level 4 requires continuous support, assistance and adaptive technologies to perform an activity.
- Does not handle objects and has severely limited ability to perform even simple actions. A child at this level will require complete assistance.
Communication Function Classification System
Difficulty with communication occurs in about 58% of cerebral palsy cases. The Communication Function Classification System (CFCS) was created to assist healthcare professionals, parents, teachers and children with CP better understand and address the level of interaction that child can manage.
Although originally designed for those with cerebral palsy, the CFCS is now used to identify communication barriers in those with any kind of disability.
The CFCS is also broken into 5 levels, they are:
- Level I: Effective sender and receiver with unfamiliar and familiar partners. This means a child has little to no issues communicating at a comfortable pace with close friends and family as well as acquaintances or strangers.
- Level II: Effective but slower paced sender and/or receiver with unfamiliar and familiar partners. A person communicating at this level may have a little lag time between creating, understanding and responding to conversation.
- Level III: Effective sender and receiver with familiar partners. At this level, the person alternates sender and receiver roles with those they know well. However, communication patterns are not consistent with those they are less comfortable with.
- Level IV: Inconsistent sender and receiver with familiar partners. Here, a person would be inconsistent and ineffective in either sender or receiver roles, with one role occasionally overpowering the other.
- Level V: Seldom effective sender or receiver with familiar partners. At this level, a person would be exceedingly difficult to understand, even with people who care for them on a regular basis.
It’s important to keep in mind that the MACS and CFCS are not tests. They are tools to guide caregivers in choosing appropriate adaptive technologies and environments to provide the child afflicted with cerebral palsy the best choices to improve their future.
What Are My Next Steps?
Learning your child has a disability can cause parents a lot of grief and heartache. It requires adjustments across all areas of life, from day-to-day functions, to long-term outcomes like prom or college and beyond. Increasing your knowledge of cerebral palsy is a great first step in the process of deciding how to best address the needs of your differently abled child.
A thorough investigation into your child’s cerebral palsy may reveal that medical malpractice or negligence is responsible for your child’s condition. If your child suffers with cerebral palsy, please contact the law firm of Oshman & Mirisola. As attorneys experienced in birth injury cases, we may be able to help you bring those accountable to justice and compensate your family for physical and emotional damages. Contact us today at (800) 400-8182 or you can contact us online for a free case evaluation.