Using the Communication Function Classification System (CFCS)

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Using the Communication Function Classification
System (CFCS)

• Mary Jo Cooley Hidecker, PhD, CCC-A/SLP 

Speech-Language Pathology University of Central
Arkansas Email MJCHidecker_at_uca.edu
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Cerebral Palsy Definition

• describes a group of permanent disorders of the
  development of movement and posture, causing
  activity limitations, that are attributed to
  non-progressive disturbances that occurred in the
  developing fetal or infant brain.
• The motor disturbances of cerebral palsy are
  often accompanied by disturbances of sensation,
  perception, cognition, communication, and
  behaviour, by epilepsy, and by secondary
  musculoskeletal problems Rosenbaum, et al.
  (2007)

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Cerebral Palsy Definition

• Annotations of each term follow, including
  sensation Vision, hearing and other sensory
  modalities may be affected, both as a function of
  the primary disturbance(s) to which CP is
  attributed, and as a secondary consequence of
  activity limitations that restrict learning and
  perceptual development experiences.
  communication Expressive and/or receptive
  communication and/or social interaction skills
  may be affected, both as a function of the
  primary disturbance(s) to which CP is
  attributed, and as a secondary consequence of
  activity limitations that restrict learning and
  perceptual development experiences.
  Rosenbaum, et al. (2007)

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How many individuals with CP have communication
problems?

• Few recent studies conducted by SLPs and
  audiologists
• Many citations are based on published U.S.
  research in 1950s and 1960s
• Need for CP epidemiological studies of
  communication and eating
• In U.S., no national registry of individuals with
  CP
• Expensive research to carry out and maintain
• Need for multidisciplinary teams

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How many individuals with CP have communication
problems?

• No consensus on operational definitions
• 58 with communication problem 7 with
  hearing problem Bax et al (2006)
• Cerebral palsy registries (n26) Hidecker et al
  (2009)
• 11 speech definitions used by 22 registries
• 8 language definitions used by 11 registries
• 14 hearing definitions used by 25 registries
• 6 AAC definitions used by 6 registries

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How many individuals with CP have communication
problems?

• Norway CP Registry (Andersen, et al. 2010)
• 51 of 564 children had speech problems
• Speech problems indistinct or no speech
• 54 of children with speech problems had AAC
• 58 of the children with speech problems used
  graphic AAC
• 33 of the children with speech problems used
  hand signs

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Few Communication Measures in CP Studies

• Need Better measures of speech, language, and
  hearing within existing CP epidemiological
  studies.
• Challenge Quick, multidisciplinary measure of
  communication
• Hope More SLPs and audiologists will be included
  on CP research teams

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WHO ICF Model

• The World Health Organizations (WHO)
  International Classification of Functioning,
  Disability and Health (ICF)

Health Condition (Disorder or Disease)
Body Functions Structures
Participation
Activity
Environmental Factors
Personal Factors
WHO, 2001
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WHO ICF Model 3 perspectives on assessment and
intervention

1. body structure and function anatomy
   physiology includes language subsystems
2. daily activities carrying out tasks such as
   communication
3. participation in home, school, work and/or
   community

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Also consider interactions with

• personal factors
• (e.g., age, motivation, desires) and
• environmental factors
• (e.g., settings of home or community, familiarity
  with communication partner)

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ICF Body/Structure Function Level
Denes Pinson, p.5
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The Communication Model ICF Activities/Participa
tion Levels
Message
Sender
Receiver
Communication Environment
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Functional Limitations in Daily Activities

• Mobility Palisano et al., 1997
• Gross Motor Function Classification System
  (GMFCS)
• www.canchild.ca/Portals/0/outcomes/pdf/GMFCS
  -ER.pdf
• Handling Objects Eliasson et al., 2006
• Manual Ability Classification System (MACS) for
  children with cerebral palsy 4-18 years
  www.macs.nu/
• Communication Hidecker et al., under development
• Communication Function Classification System
  (CFCS) www.cfcs.us/
• Eating/Drooling Sellers et al., under development
  Manchester U.K.

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Comparison of Classification Tools
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Purpose of CFCS

• Communication classification tool in CP clinical
  and research settings
• Grounded in SLP and audiology literature
• Understandable to all interested in CP
• Valid and reliable
• Easily administered with other protocols
• Will not replace existing communication
  assessments

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Method 4 Phases

1. Development
2. Nominal Groups
3. Delphi Surveys
4. Reliability

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CFCS Development

• 8 Stakeholder groups
• Adults with CP
• Educators
• Neurologist
• Occupational Therapists
• Parents of children with CP
• Pediatricians
• Physical Therapists
• Speech-Language Pathologists

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Participants
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Results
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Reliability

• Professional inter rater (n69)
• Parent-professional inter rater
• Parents/Family members (n68)
• Professionals (n61)
• Test-retest (n48 professionals)

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Professional Inter rater Reliability
Professional 1 Professional 1 Professional 1 Professional 1 Professional 1 Professional 1
CFCS I II III IV V
I 5 2
II 2 3
III 3 5 7 6
IV 1 2 2 17 1
V 4 13
Professional 2
Weighted kappa.66 (95 CI. 55-.77) Increases to
.77 for kids gt 4 years
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Parent-Professional Inter rater Reliability
Professional Professional Professional Professional Professional Professional
CFCS I II III IV V
I 10 4 3 2
II 7 9 9 12 1
III 6 9 7 6
IV 1 4 24 11
V 2 11
Parent
Weighted kappa.49 (95 CI .39-.58)
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Professional Test-Retest Reliability
Time 2 Time 2 Time 2 Time 2 Time 2 Time 2
CFCS I II III IV V
I 11 2 1 1
II 7 3 2
III 11 7
IV 21 3
V 20
Time 1
Weighted kappa.82 (95 CI .74-.90)
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(No Transcript)
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Current CFCS Draft
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CFCS Level Identification Chart
Hidecker et al.
Please do not use
without permission
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Clinical Implications

• Accessible, common tool that can be used by both
  parents and professionals.
• Useful when talking with families and other
  professionals.
• Support understanding among various members of
  multidisciplinary teams.

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Clinical Implications examples

• Knowing a persons CFCS classification may
  suggest a starting point for intervention (we
  still need clinical research evidence)
• Level I Any activity or participation
  limitations? Decrease any residual speech sound
  errors?
• Level II Any ways to speed up communication,
  especially with unfamiliar partners? Can repair
  strategies be improved? Can AAC access/composing
  methods be faster?

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Clinical Implications examples

• Level III Increase communication partners?
  Improve communication repair strategies? Add AAC?
• Level IV Increase sender and/or receiver
  skills? Add AAC?
• Level V Improve partner recognition of gestures
  and unconventional messages?
• Focus on communication partner training.
• Create a communication dictionary of these
  unconventional message.
• Pair AAC message with unconventional message.

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Current research directions

• Measure the CFCS stability across the life span.
• Need research partners who serve individuals with
  CP from age 2 to 21
• Will classify CFCS and collect additional data
  over the course of 4 years

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Current research directions

• CFCS to cerebral palsy registries data?
• Surveillance of CP in Europe (SCPE)
• Translate/validate CFCS in languages
• Currently underway
• Arabic
• Dutch
• Turkish
• Need Spanish partners

• Translation Interests
• ?????

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Future research directions

• Create a snapshot of a persons functional levels
  by reporting the CFCS in conjunction with GMFCS
  MACS.
• Correlate the CFCS level to quality of life
  and/or participation measures.

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Future research directions

• Validate the CFCS in other populations including
  those with autism, Down syndrome, and
  post-stroke.
• Study the possible effect of additional AAC
  components and operational competencies on CFCS
  Levels.

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Acknowledgements

• Thank you to the individuals who participated
• In addition to those who chose to contribute
  anonymously,
• Development Team Sally Bucrek, Kipp Chillag, DO,
  Ann-Christin Eliasson, PhD, Maria S. French, PhD,
  Lisa Herren, Rebecca Jones, PhD, Lena
  Krumlinde-Sundholm, PhD
• Nominal Group Deena Agree, George Baker, Lisa
  Bardach, Lehua Beamon, Susan Davenport, Denise
  Fitzpatrick, Elizabeth A. Fox, Barb Galuppi,
  Jonathon Gold, Clare Jorgensen, Marilyn Kertoy,
  John Lawton, Michael Livingston, Rhonda Massa,
  Jeanette Miller, Chris Morris, Nancy Novakoski,
  Krista Richardson, Cindy J. Russell, Dianne
  Russell, Geraldine Schram, Dennis Schroeder,
  Becky Schroeder, Yakov Sigal, Nancy
  Thomas-Stonell, David VanDyke, Lynna M. Walta,
  Kristin J. Whitfield
• Delphi Survey Janet H. Allaire, Ilona
  Autti-Rämö, Rita L. Bailey, Simona Bar-Haim,
  David Bauer, Kristie Bjornson, PhD, PT, Timothy J
  Brei, MD, Wendy Burdo-Hartman, MD, Megan Carter,
  Michael Collis, Cynthia Cress, Diane L. Damiano,
  Pamela K. De Loach, Leo V. Deal, Shelley Deegan,
  Steven T DeRoos, MD, Cindy DeYoung, Laura Drower
  M.S., SLP, Joseph R. Duffy, Stephanie Farnham
  OTR, James W. Fee, Jr., Iris Fishman, Deb
  Gaebler, Gay L. Girolami, PT, MS, Jan Willem
  Gorter, MD PhD, Kate Himmelmann, Megan M. Hodge,
  Tara Kehoe, Debora K. Kerr, Barbara A. Krampac,
  MS CCC/SLP-L, Nicole Lomerson, Mary Ann Lowe,
  Valerie Maples, Jill Meilahn, D.O., Michael E.
  Msall, MD, Susan Murr, Dana Overhake, Robert J.
  Palisano, Carol Palk, Lindsay Pennington, Judy
  Phelps, OTR, Matthew Phillips, Margaret R. Poore,
  SLP/AAC Specialist, Dinah Reddihough, Tom J Reed,
  Dr. Gina Rempel, James M Renuk, Bernadette
  Robertson, Cheryl Robins, Sharon Rogers, Lynn
  Rothman, Julie Scherz, Diane Dudas Sheehan, Kevin
  Vance, Candace Hill Vegter, Jo Watson, Ellen
  Wood, Marilyn Seif Workinger, PhD, Marshalyn
  Yeargin-Allsopp, MD
• Reliability Sites BC Centre for Ability
  (Vancouver, British Columbia), Helen DeVos
  Childrens Hospital (Grand Rapids, Michigan),
  Gillette Childrens Hospital (St. Paul,
  Minnesota), Marshfield Clinic (Marshfield,
  Wisconsin), Seattle Childrens Hospital (Seattle,
  Washington), Rehabilitation Institute of Chicago
  (Chicago, Illinois)
• Research Team Aliah Alsarraf, Megan Bigalke,
  Kenneth Chester, Stephanie Currier, Kristen
  Darga, Julie Fisk, Kelly Gowryluk, Carly Hanna,
  Brenda Johnson, Lauren Klee, Lauren Klier, Jenny
  Koivisto, Lauren Michalsen, Hye Sung Park, Sarah
  Parker, Tiffany Quast, Kristen Raabis, Marliese
  Sharp, Archie Soelaeman, Katie VanLandschoot,
  Lauren Werner, Jacqueline Wilson
• This research is supported in part by an NIH
  postdoctoral fellowship (NIDCD 5F32DC008265-02)
  as well as grants from the Cerebral Palsy
  International Research Foundation and The Hearst
  Foundation.

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References

• 1 World Health Organization. (2001) International
  classification of functioning, disability and
  health ICF. Geneva World Health Organization.
• 2 World Health Organization. (2007) International
  classification of functioning, disability, and
  health children youth version ICF-CY.
  Geneva World Health Organization.
• 3 Raghavendra P, Bornman J, Granlund M,
  Björck-Åkesson E. (2007) The World Health
  Organization's international classification of
  functioning, disability and health implications
  for clinical and research practice in the field
  of augmentative and alternative communication.
  Augmentative and Alternative Communication 23
  349 - 61.
• 4 Hidecker MJC, Paneth N, Rosenbaum P, Kent RD,
  Lillie J, Johnson B, Chester K. (2009)
  Development of the Communication Function
  Classification System (CFCS) for individuals with
  cerebral palsy. Developmental Medicine and Child
  Neurology 51(Suppl2) 48.
• 5 Palisano R, Rosenbaum P, Walter S, Russell D,
  Wood E, Galuppi B. (1997) Development and
  reliability of a system to classify gross motor
  function in children with cerebral palsy. Dev Med
  Child Neurol 39 214-23.
• 6 Eliasson AC, Krumlinde-Sundholm L, Rosblad B,
  Beckung E, Arner M, Ohrvall AM, Rosenbaum P.
  (2006) The Manual Ability Classification System
  (MACS) for children with cerebral palsy scale
  development and evidence of validity and
  reliability. Dev Med Child Neurol 48 549-54.
•  

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Contact us

• Mary Jo Cooley HideckerMJCHidecker_at_uca.edu
• Accepting graduate and postdoctoral students
• CFCS Websitehttp//cfcs.us
• Updated presentation slides will be posted
  athttp//faculty.uca.edu/mjchidecker