Development and face validity of a cerebral visual impairment motor questionnaire for children with cerebral palsy

Clinimetric properties of visuo-perceptual and visuo-cognitive assessment tools used for children with cerebral visual impairment and cerebral palsy or developmental delay: a systematic review

PURPOSE

The aim of this systematic review is to evaluate the psychometrics and clinical utility of visuo-perceptual and visuo-cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP) or neurodevelopmental delay (DD).

MATERIALS AND METHODS

Five databases (PubMed, EMBASE, SCOPUS, CINAHL, and Cochrane Database) were comprehensively searched from 1970 till June 2021. The PRISMA checklist was utilised to report on the process of selecting eligible papers. The methodological quality of included studies was evaluated using COnsenus-based Standards for the selection of health Measurement INstrument (COSMIN) checklist.

RESULTS

Of the 26 assessment tools identified, only seven tools had psychometric evidence supporting their use. Based on COSMIN guidelines, 60% of included studies were rated as inadequate or doubtful for their methodological quality of measurement properties, with equal number being rated as indeterminate on the overall rating.

CONCLUSIONS

Cerebral visual impairment due to its varied clinical presentation is often missed in children with CP and DD. There is a paucity of studies reporting on the validity and reliability of functional vision tools. Further studies are needed to conduct high-quality psychometric reporting using the updated COSMIN guidelines to identify appropriate functional vision tools for children with CP or DD.Implications for rehabilitationThere are paucity of studies evaluating the validity and reliability of existing perceptual and cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP).Development of age-appropriate assessment tools evaluating all aspects of functional vision will assist in providing more holistic child-centric rehabilitation programs.A combination of detailed perinatal history, direct observation, and clinical assessments of functional vision are important to recognise CVI in children with CP.

Validation and endorsement of health system performance measures for opioid use disorder in British Columbia, Canada: A Delphi panel study

Background

Limited data exists on the performance of the healthcare system in opioid use disorder (OUD). We evaluated the face validity and potential risks of a set of health system performance measures for OUD collaboratively with clinicians, policymakers and people with lived experience of opioid use (PWLE) in the interest of establishing an endorsed set of measures for public reporting.

Methods

Through a two-stage Delphi-panel approach, a panel of clinical and policy experts validated and considered 102 previously constructed OUD performance measures for endorsement using information on measurement construction, sensitivity analyses, quality of evidence, predictive validity, and feedback from local PWLE. We collected quantitative and qualitative survey responses from 49 clinicians and policymakers, and 11 PWLE. We conducted inductive and deductive thematic analysis to present qualitative responses.

Results

A total of 37 measures of 102 were strongly endorsed (9/13 cascade of care, 2/27 clinical guideline compliance, 17/44 healthcare integration, and 9/18 healthcare utilization measures). Thematic analysis of responses revealed several themes regarding measurement validity, unintended consequences, and key contextual considerations. Overall, measures related to the cascade of care (excluding opioid agonist treatment dose tapering) received strong endorsements. PWLE highlighted barriers to accessing treatment, undignified aspects of treatment, and lack of a full continuum of care as their concerns.

Conclusion

We defined 37 endorsed health system performance measures for OUD and presented a range of perspectives on their validity and use. These measures provide critical considerations for health system improvement in the care of people with OUD.

Exploring the Need for Education on Cortical Visual Impairment Among Occupational Therapy Professionals and Teachers of Students With Visual Impairments

Introduction: Cortical or cerebral visual impairment (CVI) is the leading cause of bilateral visual impairment in developed countries. The goals of this study were to explore the CVI education and training received by occupational therapy practitioners and teachers of students with visual impairments and to quantify the confidence of these professionals to evaluate and work with children who are diagnosed with CVI. Methods: An Internet-based survey was conducted with a volunteer sample that included occupational therapists, certified occupational therapy assistants, and certified teachers of students with visual impairments who practice in 50 U.S. states; Washington, D.C.; and Canada. The survey was posted on professional organizations and social media websites, as well as emailed to colleagues at organizations such as the Association for the Education and Rehabilitation of the Blind and Visually Impaired, schools for students who are blind, and local universities. Data collection occurred between June 2019 and November 2019. Results: Surveys were completed by 205 respondents from 43 U.S. states; Washington, D.C.; and Canada. Occupational therapy practitioners consistently reported lower rates of formal education in CVI, with only 25% of occupational therapists and 47% of certified occupational therapy assistants receiving education on CVI in their academic programs. Less than 23% of occupational therapists received training on CVI assessments, whereas 75% of teachers of students with visual impairments had training in CVI assessments. Additionally, respondents indicated reduced satisfaction with their knowledge and skills for treating or teaching children with CVI. Discussion: The results indicate a gap in formal CVI education for occupational therapy practitioners and, to a lesser extent, teachers of students with visual impairments. Due to the increasingly high prevalence of CVI, the gap in formal education on CVI is significant. Implications for Practitioners: Results indicate the need to increase formal and continuing education for occupational therapy practitioners and teachers of students with visual impairments.

The Multidisciplinary Guidelines for Diagnosis and Referral in Cerebral Visual Impairment

Introduction

Cerebral visual impairment (CVI) is an important cause of visual impairment in western countries. Perinatal hypoxic-ischemic damage is the most frequent cause of CVI but CVI can also be the result of a genetic disorder. The majority of children with CVI have cerebral palsy and/or developmental delay. Early diagnosis is crucial; however, there is a need for consensus on evidence based diagnostic tools and referral criteria. The aim of this study is to develop guidelines for diagnosis and referral in CVI according to the grade method.

Patients and Methods

We developed the guidelines according to the GRADE method 5 searches on CVI (children, developmental age ≤ 18 years) were performed in the databases Medline, Embase, and Psychinfo, each with a distinct topic.

Results

Based on evidence articles were selected on five topics: 1. Medical history and CVI-questionnaires 23 (out of 1,007). 2. Ophthalmological and orthoptic assessment 37 (out of 816). 3. Neuropsychological assessment 5 (out of 716). 4. Neuroradiological evaluation and magnetic resonance imaging (MRI) 9 (out of 723). 5. Genetic assessment 5 (out of 458).

Conclusion

In medical history taking, prematurity low birth weight and APGAR (Appearance, Pulse, Grimace, Activity, Respiration) Scores (<5) are important. Different questionnaires are advised for children under the age of 3 years, older children and for specific risk groups (extremely preterm). In ophthalmological examination, eye movements, specially saccades, accommodation, crowding, contrast sensitivity and visual fields should be evaluated. OCT can show objective signs of trans-synaptic degeneration and abnormalities in fixation and saccades can be measured with eye tracking. Screening of visual perceptive functioning is recommended and can be directive for further assessment. MRI findings in CVI in Cerebral Palsy can be structured in five groups: Brain maldevelopment, white and gray matter lesions, postnatal lesions and a normal MRI. In children with CVI and periventricular leukomalacia, brain lesion severity correlates with visual function impairment. A differentiation can be made between cortical and subcortical damage and related visual function impairment. Additional assessments (neurological or genetic) can be necessary to complete the diagnosis of CVI and/or to reveal the etiology.

Higher Visual Function Deficits in Children With Cerebral Visual Impairment and Good Visual Acuity

In clinical practice Cerebral Visual Impairment (CVI) is typically diagnosed by observation of abnormal visually guided behaviors which indicate higher visual function deficits (HVFDs) suggesting abnormal brain development or brain damage in a child with a suitable clinical history. HVFDs can occur even in the presence of good visual acuity and may remain undiagnosed because the good visual acuity does not prompt further investigation. This leads to a lack of understanding of the child's visual perceptual difficulties. In a prospective study, we determined the spectrum of HVFDs in a group of children with history suggestive of brain damage or disruption of brain development and an independent diagnosis of CVI in comparison with typically developing children with a structured 51 question inventory, the Higher Visual Function Question Inventory (HVFQI-51) adapted from the Cerebral Vision Impairment Inventory, CVI-I. Here, we show that the HVFQI-51 can detect a range of HVFDs in children with CVI with good visual acuity and clearly distinguishes these children from typically developing children. HVFDs in our study group could mostly be attributed to dorsal stream visual processing dysfunction though the spectrum varied between children. We report on the inclusion of the "not applicable" response option in analysis providing a picture of HVFDs more in tune with the overall disability of each child. We also propose a subset of 11 questions (Top-11) which discriminate between children with CVI vs. behaviors seen in typical children: this provides both a potential screening tool for initial assessment of HVFDs and a measure of CVI-related impairment, and needs further validation in a secondary independent sample.

Perceptual visual dysfunction in children - An Indian perspective

Perceptual visual dysfunction (PVD) comprises a group of vision disorders resulting from dysfunction of the posterior parietal and/or temporal lobes. Often, affected children have normal/near normal visual acuities and/or visual fields, but have difficulties in activities of daily living involving the use of vision. PVDs are known to be common among children with risk factors such as a history of prematurity and/or neurodevelopmental disorders. The inferior temporal lobes and ventral stream transform visual signals into perception, while the posterior parietal lobes and dorsal stream transform visual signals to non-consciously map the scene to guide action and facilitate attention. Dysfunction of these can lead to specific visual impairments that need to be identified during history taking, triggering ascertainment of further details by a structured inventory approach. Clinical tests to elicit dorsal and ventral stream visual dysfunctions have good specificity but low sensitivity. Neuropsychologists are rarely available in the developing world to perform detailed assessments, but there are a few tests that can be used by eye care professionals with some training. Optical coherence tomography (OCT) showing thinning of the ganglion cell layer and retinal nerve fiber layer is being explored as a potential tool for rapid assessment in the clinic. The behavioral outcomes of PVD can mimic psychological conditions including autism spectrum disorder, attention deficit hyperactivity disorder, specific learning disability, and intellectual impairment, and one needs to be aware of overlap among these differential diagnoses. A practical functional approach providing working solutions for each child's set of difficulties in day-to-day activities is needed.

Measure of Early Vision Use: development of a new assessment tool for children with cerebral palsy

PURPOSE

To report the development of an assessment tool to describe "how vision is used" for children with cerebral palsy.

METHOD

Measurement development consisted of three steps: (i) an online survey to explore the relevance and comprehensiveness of visual behaviours identified in a previous conceptualisation study; (ii) construction of items and a rating scale for the new measure; and (iii) cognitive interviews to explore comprehensibility and refine the measure in preparation for field testing. Survey respondents were 130 parents of children with cerebral palsy, eight adults with cerebral palsy, and 108 clinicians (n = 246). Nine parents participated in the interviews.

RESULTS

The new tool, the Measure of Early Vision Use, is a 14-item descriptive measure of typical performance of visual behaviours observable in everyday activities, as rated by parent/caregiver observation. Each item is rated on a 4-point ordinal scale.

CONCLUSIONS

This new measure is conceptually grounded within the Activity level domain of the International Classification of Functioning, Disability and Health as a measure of a single visual ability construct. The target population is children with cerebral palsy, and using parent report the Measure of Early Vision Use describes both strengths and limitations in using vision. This study addressed the selection of items and response options for the new scale, and provides evidence to support content relevance, comprehensiveness and comprehensibility from key stakeholders. Further research will explore psychometric properties and clinical utility.Implications for rehabilitationThe ability to use vision in daily activities is relevant to the development and learning of all children, so the availability of a method for describing visual abilities has potential for diverse research and clinical purposes.The Measure of Early Vision Use is a parent-report tool that provides a criterion-referenced method for quantifying and describing how children use vision in typical daily activities to support intervention planning.Clinicians and parents wishing to measure vision use in children with cerebral palsy can be confident about the rigorous methods used to develop this tool, including consultation with key stakeholders.

Cerebral Visual Impairment and Clinical Assessment: The European Perspective

This paper summarizes the multidisciplinary pediatric assessment methods of 3 European centers for identifying and assessing cerebral visual impairment in childhood. It describes a comprehensive neurodevelopmental assessment evaluation in which visual aspects play an important part. Developmental trajectories and the heterogeneity of the clinical picture are emphasized. Multidisciplinary ophthalmology and neurodisability/neurology teamwork together with the parent and teachers, to reach an integrated and individualized perspective for the individual child, are described. This comprehensive assessment is the starting point for habilitation programs and interventions, that can support and meet the child's needs and help them reach their optimal potential. Future developments in classification of the cerebral visual impairment conditions, building on the child's individual assessment profile, will further enhance the direction of clinical, educational, and research progress.

Profiling Children With Cerebral Visual Impairment Using Multiple Methods of Assessment to Aid in Differential Diagnosis

Cerebral (cortical) visual impairment (CVI), the primary cause of visual impairment in children in high-income countries, is increasing globally due to improved life-saving measures for premature and full-term infants. Yet the consequences of this condition are only beginning to be understood and addressed. According to the topography, site, and the extent of the pathology, the deficit may variably concern central visual functions, visual field, perception of movement, visual analysis, visual exploration, attention, or visual memory, as well as visual guidance of movement. Each affected child has a unique clinical picture, which needs to be identified and individually profiled. This is probably the underlying reason that CVI is commonly underdiagnosed or misdiagnosed, especially in children, and, as a consequence, the full range of potential behavioral outcomes are not identified and adequately addressed. The present paper shows how the use of multiple methods of assessment can improve understanding of children with CVI.

Towards population screening for Cerebral Visual Impairment: Validity of the Five Questions and the CVI Questionnaire

Introduction

Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the developed world and appears to be more prevalent in children with additional support needs (ASN). There is an urgent need for routine screening for CVI, particularly in children with ASN, however, current screening questionnaires for CVI have limited validation. The aim of this study was to evaluate two screening tools: the Five Questions and the CVI Questionnaire. Additionally, the distribution of CVI across neurodevelopmental disorders is unknown. This too was investigated.

Methods

An online survey was completed by 535 parents. The survey was advertised via social media, CVI websites and parent email systems of four schools. The survey comprised of the Five Questions, the CVI Questionnaire and additional questions regarding the child’s diagnoses. Whether or not a child had a diagnosis of CVI and/or additional neurodevelopmental disorders was based on parental report.

Results

Based on parent reports, both the screening tools accurately screened for CVI diagnoses in children. The Five Questions and the CVI Questionnaire have construct validity (as determined through factor analysis), high internal consistency (as determined by Cronbach’s alpha) and convergent validity (as determined by correlation analysis of the raw scores of each questionnaire). This study also highlights that among children with neurodevelopmental disorders, a large proportion have parent-reported CVI (23%-39%) and potential CVI (6.59–22.53%; as identified by the questionnaires).

Conclusion

The current study demonstrates that the Five Questions and CVI Questionnaire have good convergent validity, internal consistency and a reliable factor structure and may therefore be suitable as screening tools. The study also highlights that reported or potential CVI is evident in a large proportion of children with neurodevelopmental disorders.

Cognitive functioning in dyskinetic cerebral palsy: Its relation to motor function, communication and epilepsy

BACKGROUND

Cerebral palsy (CP) is a disorder of motor function often accompanied by cognitive impairment. There is a paucity of research focused on cognition in dyskinetic CP and on the potential effect of related factors.

AIM

To describe the cognitive profile in dyskinetic CP and to assess its relationship with motor function and associated impairments.

METHOD

Fifty-two subjects with dyskinetic CP (28 males, mean age 24 y 10 mo, SD 13 y) and 52 typically-developing controls (age- and gender-matched) completed a comprehensive neuropsychological assessment. Gross Motor Function Classification System (GMFCS), Communication Function Classification System (CFCS) and epilepsy were recorded. Cognitive performance was compared between control and CP groups, also according different levels of GMFCS. The relationship between cognition, CFCS and epilepsy was examined through partial correlation coefficients, controlling for GMFCS.

RESULTS

Dyskinetic CP participants performed worse than controls on all cognitive functions except for verbal memory. Milder cases (GMFCS I) only showed impairment in attention, visuoperception and visual memory. Participants with GMFCS II-III also showed impairment in language-related functions. Severe cases (GMFCS IV-V) showed impairment in intelligence and all specific cognitive functions but verbal memory. CFCS was associated with performance in receptive language functions. Epilepsy was related to performance in intelligence, visuospatial abilities, visual memory, grammar comprehension and learning.

CONCLUSION

Cognitive performance in dyskinetic CP varies with the different levels of motor impairment, with more cognitive functions impaired as motor severity increases. This study also demonstrates the relationship between communication and epilepsy and cognitive functioning, even controlling for the effect of motor severity.