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May D, Kponee-Shovein K, Neul JL, Percy AK, Mahendran M, Downes N, Chen G, Watson T, Pichard DC, Kennedy M, Lefebvre P. Characterizing the journey of Rett syndrome among females in the United States: a real-world evidence study using the Rett syndrome natural history study database. J Neurodev Disord 2024; 16:42. [PMID: 39061009 PMCID: PMC11282812 DOI: 10.1186/s11689-024-09557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND With the advent of the first targeted therapy for Rett Syndrome (RTT), a comprehensive assessment of the journey of RTT is needed to elucidate on present unmet needs in this population. This study characterized females with RTT in the United States and their disease journey with respect to longitudinal treatment patterns, RTT-related outcomes, and changes in disease severity. METHODS This retrospective cohort study used registry data of females with RTT from the 5211 RTT Natural History Study (RNHS) (November 2015-July 2021). Pharmacological and supportive therapy use, RTT-related outcomes, and RTT severity, as measured by the Clinical Severity Scale and Motor Behavioral Assessment scale, were evaluated following the first RNHS visit. Analyses were conducted overall and in subgroups by RTT type (classic and atypical RTT) and age at first visit (pediatric and adult). RESULTS A total of 455 females with RTT were included in the study, of whom 90.5% had classic RTT and 79.8% were pediatric individuals. Over a median follow-up of 4 years, use of pharmacological therapies, including prokinetic agents (42.7% vs. 28.3%), and supportive therapies, including physical therapy (87.3% vs. 40.2%) and speech-language therapy (86.8% vs. 23.9%), were more common in pediatric than adult individuals (all p < 0.05). Nearly half (44.6%) of all individuals had a hospital or emergency room visit, with a higher proportion of visits in individuals with classic RTT than atypical RTT and pediatric than adult individuals (both p = 0.001). An increasing trend in clinical severity was observed in pediatric individuals (mean change per year: 0.24; 95% confidence interval [CI]: 0.03, 0.44), while an increasing trend in motor-behavioral dysfunction was observed in pediatric individuals (mean change per year: 1.12; 95% CI: 0.63, 1.60) and those with classic RTT (mean change per year: 0.97; 95% CI: 0.53, 1.41). CONCLUSIONS Findings from this study highlight the considerable burden of RTT across disease subtype and age. Despite reliance on supportive therapies and healthcare encounters, individuals with RTT experience increasing disease severity and motor-behavioral dysfunction in childhood and adolescence, underscoring the unmet needs of this population and the value of early intervention to manage RTT in the long-term.
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Affiliation(s)
- Damian May
- Acadia Pharmaceuticals, San Diego, CA, USA.
| | | | - Jeffrey L Neul
- Vanderbilt Kennedy Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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Berger TD, Fogel Berger C, Gara S, Ben-Zeev B, Weiss B. Nutritional and gastrointestinal manifestations in Rett syndrome: long-term follow-up. Eur J Pediatr 2024:10.1007/s00431-024-05668-3. [PMID: 38960904 DOI: 10.1007/s00431-024-05668-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Rett syndrome is a rare neurodevelopmental disorder associated with methyl CpG binding protein 2 (MECP2) gene mutations. We aimed to characterize the long-term nutritional and gastrointestinal course of Rett syndrome in a large national patient population. METHODS We conducted a retrospective cohort study of patients followed during 1991-2021 at a national center for Rett syndrome. The data retrieved included clinical features, laboratory and genetic analyses. Continuous anthropometric measurements were calculated for the closest visit to the median ages: 2.5, 7.5, 12.5 and 17.5 years. Kaplan Meier curves were used to describe the appearance of clinical manifestations during the follow up period. Generalized estimating equation models were used to compare repeated measurements. RESULTS Included were 141 patients (139 females), the median age at the first visit was 3.2 years (interquartile range [IQR] 2.3-5.7), and the median length of follow-up was 94.5 months (IQR 28.6-153.3). Mean weight, height and BMI Z-scores were -1.09, -1.03 and -0.56, respectively, at median age 2.5 years; and deteriorated to -3.95, -3.01 and -1.19, respectively, at median age 17.5 years (P < 0.001). Gastrointestinal features included constipation (47.5%, 67/141) and chewing/feeding difficulties (20%, 28/141) at presentation; and an additional 47 (33.3%) and 24 (17.0%), respectively, during follow up. Twenty-eight patients (20%) developed aerophagia and 44 (31.2%) gastroesophageal reflux. No relation was found between genetic mutation types and clinical manifestations. GI manifestations were more prevalent in patients with typical form of Rett syndrome. CONCLUSIONS Anthropometric parameters were shown to deteriorate with age, regardless of the specific genetic mutation. Chewing/feeding difficulties, constipation and gastroesophageal reflux are common in Rett patients.
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Affiliation(s)
- Tal David Berger
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel.
| | - Chen Fogel Berger
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
| | - Sewar Gara
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
| | - Bruria Ben-Zeev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Neurology, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vilvarajan S, McDonald M, Douglas L, Newham J, Kirkland R, Tzannes G, Tay D, Christodoulou J, Thompson S, Ellaway C. Multidisciplinary Management of Rett Syndrome: Twenty Years' Experience. Genes (Basel) 2023; 14:1607. [PMID: 37628658 PMCID: PMC10454341 DOI: 10.3390/genes14081607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Over the last 20 years, the understanding and natural history of Rett syndrome has advanced, but to date no cure has emerged, with multidisciplinary management being symptomatic and supportive. This study provides a comprehensive review of the clinical features, comorbidities and multidisciplinary management of a well-characterized cohort of females with classical Rett syndrome. We aim to improve awareness and understanding of Rett syndrome amongst pediatricians, pediatric subspecialists and allied health professionals to enable early diagnosis and a streamlined enrolment approach for future clinical trials. Rett syndrome, a complex X-linked condition, affecting mainly females, is due to pathogenic variants of the MECP2 gene in most affected individuals. The Rett syndrome Multidisciplinary Management clinic at The Children's Hospital at Westmead, Sydney, Australia, was established in 2000. This retrospective analysis of individuals who attended the clinic from 2000 to 2020 was performed to identify the incidence and predicted age of onset of Rett syndrome related comorbidities, disease progression and to review management principles. Data collected included age of Rett syndrome diagnosis, MECP2 genotype, clinical features and medical comorbidities, such as sleep disturbance, seizures, breathing irregularities, scoliosis, mobility, hand stereotypies, hand function, constipation, feeding ability, use of gastrostomy, communication skills, QTc prolongation, anthropometry, and bruxism. Analysis of 103 girls who fulfilled the clinical diagnostic criteria for classical Rett syndrome with a pathogenic variant of the MECP2 gene showed a median age of diagnosis of 3 years. The most frequent MECP2 variant was c.502 C>T.
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Affiliation(s)
| | | | - Lyndal Douglas
- Department of Clinical Genetics, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Jessica Newham
- Department of Physiotherapy, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Robyn Kirkland
- Department of Occupational Therapy, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Gloria Tzannes
- Department of Speech Pathology, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Diane Tay
- Department of Dentistry, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - John Christodoulou
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, NSW 2006, Australia
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, VIC 3052, Australia
| | - Susan Thompson
- Faculty of Medicine, Sydney University, Sydney, NSW 2006, Australia
- Genetic Metabolic Disorders Service, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Carolyn Ellaway
- Faculty of Medicine, Sydney University, Sydney, NSW 2006, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, NSW 2006, Australia
- Genetic Metabolic Disorders Service, Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
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Improving clinical trial readiness to accelerate development of new therapeutics for Rett syndrome. Orphanet J Rare Dis 2022; 17:108. [PMID: 35246185 PMCID: PMC8894842 DOI: 10.1186/s13023-022-02240-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/06/2022] [Indexed: 12/16/2022] Open
Abstract
Rett syndrome is associated with severe functional impairments and many comorbidities, each in urgent need of treatments. Mutations in the MECP2 gene were identified as causing Rett syndrome in 1999. Over the past 20 years there has been an abundance of preclinical research with some studies leading to human clinical trials. Despite this, few viable therapeutic options have emerged from this investment of effort. Reasons for this lack of success as they relate both to preclinical research and the clinical trial landscape are discussed. Considering what needs to be done to promote further success in the field, we take a positive and constructive approach and introduce the concept of clinical trial readiness and its necessary ingredients for Rett syndrome. These include: listening to the needs of families; support from advocacy groups; optimising use of existing clinic infrastructures and available natural history data; and, finally, the validation of existing outcome measures and/or the development and validation of new measures. We conclude by reiterating the need for a collaborative and coordinated approach amongst the many different stakeholder groups and the need to engage in new types of trial design which could be much more efficient, less costly and much less burdensome on families.
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Mendoza J, Downs J, Wong K, Leonard H. Determinants of quality of life in Rett syndrome: new findings on associations with genotype. J Med Genet 2020; 58:637-644. [PMID: 32843489 DOI: 10.1136/jmedgenet-2020-107120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/26/2020] [Accepted: 07/05/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rett syndrome is a genetically caused neurodevelopmental disorder associated with functional deficits and comorbidities. This study investigated relationships between genotype, functional abilities and comorbidities and quality of life in Rett syndrome. METHODS The International Rett Syndrome Database, InterRett, was used as a sampling frame for this observational study. Information was collected to describe functional abilities (walking and feeding), health (Sleep Disorder Scale for Children, the Rett Syndrome Behavioural Questionnaire), parental health (12-item Short Form Health Survey) sociodemographic factors (parental employment and education) and quality of life (Quality of Life Inventory-Disability) for 210 individuals with Rett syndrome. Univariate and multivariate regressions were used to analyse the relationships between the independent variables and quality of life. RESULTS Compared with individuals with the p.Arg270* mutation, those with the p.Arg294* mutation type had the poorest quality of life (coeff -12.81, 95% CI -23.49 to 2.12), despite this being recognised as a clinically milder genotype. Overall better walking and feeding skills and seizure parameters were more associated with better quality of life and poor sleep and behavioural difficulties with poorer quality of life. CONCLUSIONS These findings suggest that genotype, functioning and health each have implications for quality of life and should be considered when counselling families and planning clinical and support management strategies.
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Affiliation(s)
- Jonathan Mendoza
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia .,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
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Wong K, Glasson EJ, Jacoby P, Srasuebkul P, Forbes D, Ravikumara M, Wilson A, Bourke J, Trollor J, Leonard H, Nagarajan L, Downs J. Survival of children and adolescents with intellectual disability following gastrostomy insertion. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2020; 64:497-511. [PMID: 32319159 DOI: 10.1111/jir.12729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability. METHODS We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors. RESULTS Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2 years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion. CONCLUSIONS Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.
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Affiliation(s)
- K Wong
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - E J Glasson
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - P Jacoby
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - P Srasuebkul
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Sydney, Sydney, New South Wales, Australia
| | - D Forbes
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - M Ravikumara
- Department of Gastroenterology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - A Wilson
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- School of Paediatrics, The University of Western Australia, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - J Bourke
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - J Trollor
- Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Sydney, Sydney, New South Wales, Australia
| | - H Leonard
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
| | - L Nagarajan
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - J Downs
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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Giudice-Nairn P, Downs J, Wong K, Wilson D, Ta D, Gattas M, Amor D, Thompson E, Kirrali-Borri C, Ellaway C, Leonard H. The incidence, prevalence and clinical features of MECP2 duplication syndrome in Australian children. J Paediatr Child Health 2019; 55:1315-1322. [PMID: 30756435 DOI: 10.1111/jpc.14399] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 01/20/2019] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to assess the incidence and prevalence of MECP2 duplication syndrome in Australian children and further define its phenotype. METHODS The Australian Paediatric Surveillance Unit was used to identify children with MECP2 duplication syndrome between June 2014 and November 2017. Reporting clinicians were invited to complete a questionnaire. Clinician data (n = 20) were supplemented with information from the International Rett Syndrome Phenotype Database and from caregivers (n = 7). Birth prevalence and diagnostic incidence were calculated. RESULTS The birth prevalence of MECP2 duplication syndrome in Australia was 0.65/100 000 for all live births and 1/100 000 for males. Diagnostic incidence was 0.07/100 000 person-years overall and 0.12/100 000 person-years for males. The median age at diagnosis was 23.5 months (range 0 months-13 years). A history of pneumonia was documented in three quarters of the clinical cases, half of whom had more than nine episodes. Cardiovascular abnormalities were reported in three cases. A clinical vignette is presented for one child who died due to severe idiopathic pulmonary hypertension. The majority (13/15) of males had inherited the duplication from their mothers, and two had an unbalanced translocation. CONCLUSIONS MECP2 duplication syndrome is a rare but important diagnosis in children because of the burden of respiratory illness and recurrence risk. Pulmonary hypertension is a rare life-threatening complication. Array comparative genomic hybridisation testing is recommended for children with undiagnosed intellectual disability or global developmental delay. Early cardiac assessment and ongoing monitoring is recommended for MECP2 duplication syndrome.
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Affiliation(s)
- Peter Giudice-Nairn
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Dylan Wilson
- Leading Steps Paediatric Clinic, Gold Coast, Queensland, Australia
| | - Daniel Ta
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | | | - David Amor
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Thompson
- SA Clinical Genetics Service, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Cathy Kirrali-Borri
- Genetic Metabolic Disorders Service, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
| | - Carolyn Ellaway
- Genetic Medicine, and Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
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Mori Y, Downs J, Wong K, Leonard H. Longitudinal effects of caregiving on parental well-being: the example of Rett syndrome, a severe neurological disorder. Eur Child Adolesc Psychiatry 2019; 28:505-520. [PMID: 30151799 DOI: 10.1007/s00787-018-1214-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/13/2018] [Indexed: 01/14/2023]
Abstract
Little longitudinal research has examined parental well-being in those with a child with specific genetic developmental disorder although the associated severe neurological impairments and multiple physical comorbidities likely place substantial burden of caregiving on the parent. We aimed to examine longitudinally the well-being of parents of individuals included in the Australian Rett Syndrome Database over the period from 2002 to 2011 using the Short Form 12 Health Survey. Residential remoteness, the child being a teenager at baseline, having frequent sleep disturbances or behavioural problems, and the type of MECP2 gene mutation were each associated with later poorer parental physical well-being scores. Being a single parent or on a low income was also associated with later poorer physical well-being, while the child having enteral feeding was associated with later poorer emotional well-being. Both the physical and emotional well-being of the parent improved if the child was living in out-of-home care. Our findings suggest that some opportunities do exist for clinicians to help optimise parental well-being. Being alert to the possibility and need for management of a child's sleep or emotional disturbance is important as is awareness of the additional likely parental burden as the child moves through adolescence into early adulthood and their need for additional support at that time. However, the findings also highlight the complex nature of parental well-being over time in parents of children with a severe neurological disorder and how they may be affected by a range of inter-related family and child factors.
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Affiliation(s)
- Yuka Mori
- Telethon Kids Institute, 100 Roberts Road, Subiaco, WA, 6008, Australia.,The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.,Department of Home Medical Treatment and Pediatrics, Osaka Developmental Rehabilitation Center, 5-11-21 Yamasaka Higashi-Sumiyoshi-ku, Osaka, 546-0035, Japan
| | - Jenny Downs
- Telethon Kids Institute, 100 Roberts Road, Subiaco, WA, 6008, Australia.,The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Building 408, Brand Drive, Bentley, WA, 6102, Australia
| | - Kingsley Wong
- Telethon Kids Institute, 100 Roberts Road, Subiaco, WA, 6008, Australia.,The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Helen Leonard
- Telethon Kids Institute, 100 Roberts Road, Subiaco, WA, 6008, Australia. .,The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.
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