1
|
Casseus M, Cheng J, Reichman NE. Clinical and functional characteristics of children and young adults with cerebral palsy and co-occurring attention-deficit/hyperactivity disorder. RESEARCH IN DEVELOPMENTAL DISABILITIES 2024; 151:104787. [PMID: 38924957 DOI: 10.1016/j.ridd.2024.104787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Emerging research shows that children and young adults (CYAs) with cerebral palsy (CP) are at higher risk for attention-deficit/hyperactivity disorder (ADHD). However, little is known about the clinical and functional characteristics of CYAs with these co-occurring disorders. AIM To estimate associations between a diagnosis of ADHD among CYAs with CP and clinical and functional characteristics. METHODS This retrospective, cross-sectional study used data from the electronic health records of CYAs (aged 4-26 years) with CP (n = 1145). We used bivariate and multivariable analyses to estimate associations between an ADHD diagnosis, CP type, Gross Motor Function Classification System (GMFCS) level, speech or language disorder, and intellectual disability. RESULTS 18.1 % of CYAs with CP had a diagnosis of ADHD. CYAs with spastic-bilateral CP had lower odds of ADHD (adjusted odds ratio [AOR] = 0.58; 95 % confidence interval [CI], 0.35-0.96). Odds of having ADHD were significantly lower for those with GMFCS levels III-V (AOR = 0.10; 95 % CI, 0.06-0.15). CONCLUSIONS Our study found that a diagnosis of ADHD among CYAs with CP was associated with greater clinical and functional impairments compared to counterparts without ADHD. Findings highlight the need to screen for both conditions because of the high comorbidity rates in this population.
Collapse
Affiliation(s)
- Myriam Casseus
- Division of Population Health, Quality, and Implementation Sciences, Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Child Health Institute of New Jersey, New Brunswick, NJ, USA.
| | - JenFu Cheng
- Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Nancy E Reichman
- Division of Population Health, Quality, and Implementation Sciences, Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Child Health Institute of New Jersey, New Brunswick, NJ, USA
| |
Collapse
|
2
|
Price K, Clarke MT, Swettenham J. Assessing aspects of early social communication in non-speaking children with bilateral cerebral palsy. Disabil Rehabil 2024:1-9. [PMID: 38975724 DOI: 10.1080/09638288.2024.2376339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 06/29/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Research suggests that rates for autism may be higher in cerebral palsy than in the general population. For those with severe bilateral physical impairment (GMFCS level IV and V) and little or no speech, describing a profile of social communication skills has been difficult because there are currently no assessments for early social communication specifically tailored for these children. Our aim was to explore the assessment of aspects of joint attention and social reciprocity in this group of children with CP. METHODS We compared the performance of children with bilateral CP on carefully designed assessments of joint attention and social responsiveness with groups of children with Down syndrome and autism. All three groups were matched for chronological age and mental age. RESULTS Approximately 30% of the children with bilateral CP had early social communication scores similar to the autistic children. The remaining 70% of children with CP had a range of early social communication scores similar to the children with Down syndrome. CONCLUSION It is possible to assess key early social communication skills in non-speaking children with bilateral motor disability. This could provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.
Collapse
Affiliation(s)
- Katie Price
- Division of Psychology and Language Science, University College London, UK
| | - Michael T Clarke
- Department of Speech, Language and Hearing Sciences, San Francisco State University, San Francisco, CA, USA
| | - John Swettenham
- Division of Psychology and Language Science, University College London, UK
| |
Collapse
|
3
|
Xu Y, Li Y, Richard SA, Sun Y, Zhu C. Genetic pathways in cerebral palsy: a review of the implications for precision diagnosis and understanding disease mechanisms. Neural Regen Res 2024; 19:1499-1508. [PMID: 38051892 PMCID: PMC10883492 DOI: 10.4103/1673-5374.385855] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/02/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT Cerebral palsy is a diagnostic term utilized to describe a group of permanent disorders affecting movement and posture. Patients with cerebral palsy are often only capable of limited activity, resulting from non-progressive disturbances in the fetal or neonatal brain. These disturbances severely impact the child's daily life and impose a substantial economic burden on the family. Although cerebral palsy encompasses various brain injuries leading to similar clinical outcomes, the understanding of its etiological pathways remains incomplete owing to its complexity and heterogeneity. This review aims to summarize the current knowledge on the genetic factors influencing cerebral palsy development. It is now widely acknowledged that genetic mutations and alterations play a pivotal role in cerebral palsy development, which can be further influenced by environmental factors. Despite continuous research endeavors, the underlying factors contributing to cerebral palsy remain are still elusive. However, significant progress has been made in genetic research that has markedly enhanced our comprehension of the genetic factors underlying cerebral palsy development. Moreover, these genetic factors have been categorized based on the identified gene mutations in patients through clinical genotyping, including thrombosis, angiogenesis, mitochondrial and oxidative phosphorylation function, neuronal migration, and cellular autophagy. Furthermore, exploring targeted genotypes holds potential for precision treatment. In conclusion, advancements in genetic research have substantially improved our understanding of the genetic causes underlying cerebral palsy. These breakthroughs have the potential to pave the way for new treatments and therapies, consequently shaping the future of cerebral palsy research and its clinical management. The investigation of cerebral palsy genetics holds the potential to significantly advance treatments and management strategies. By elucidating the underlying cellular mechanisms, we can develop targeted interventions to optimize outcomes. A continued collaboration between researchers and clinicians is imperative to comprehensively unravel the intricate genetic etiology of cerebral palsy.
Collapse
Affiliation(s)
- Yiran Xu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- National Health Council (NHC) Key Laboratory of Birth Defects Prevention, Henan Key Laboratory of Population Defects Prevention, Zhengzhou, Henan Province, China
| | - Yifei Li
- Department of Human Anatomy, School of Basic Medicine and Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Seidu A Richard
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yanyan Sun
- Department of Human Anatomy, School of Basic Medicine and Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
4
|
Gong C, Liu X, Fang L, Liu A, Lian B, Qi X, Chen S, Li H, Zhao M, Guo J, Zhou S. Prevalence of cerebral palsy comorbidities in China: a systematic review and meta-analysis. Front Neurol 2023; 14:1233700. [PMID: 37840931 PMCID: PMC10568468 DOI: 10.3389/fneur.2023.1233700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/25/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives This systematic review aimed to comprehensively understand the comorbidity of cerebral palsy (CP) in China. Methods We searched through databases in both Chinese and English until December 2022 to gather cross-sectional studies on the comorbidity of CP in China. After two reviewers independently screened the articles, collected the data, and assessed the bias risk, a meta-analysis was conducted using the Stata 17.0 software. Results A total of 73 articles were included. Of these, 16 articles reported total comorbidity, with a prevalence of 79.7% (95% CI: 73.8-85.7%); 56 articles reported epilepsy, with a prevalence of 17.9% (95% CI: 15.4-20.4%); 48 articles reported intellectual disability, with a prevalence of 58.0% (95% CI: 51.8-64.3%); 32 articles reported speech disorders, with a prevalence of 48.0% (95% CI: 41.6-54.4%); 41 articles reported hearing disorders, with a prevalence of 17.2% (95% CI: 13.0-21.4%); and 35 articles reported vision disorders, with a prevalence of 23.1% (95% CI: 16.3-29.8%). The topographical type of CP was the primary source of heterogeneity in the prevalence of epilepsy. Diagnostic criteria for CP, clinical type of CP, GMFCS, publishing time, and topographical type of CP were the primary sources of heterogeneity in the prevalence of intellectual disability. Clinical type of CP and topographical type were the primary sources of heterogeneity in the prevalence of speech disorders. Finally, the region was the primary source of heterogeneity in the prevalence of hearing disorders. Conclusion The prevalence of comorbidities in CP is high in China. Comorbidities are related to the characteristics, severity, and risk factors of brain insult and have a particular relationship with regional economic development and medical and health levels.
Collapse
Affiliation(s)
- Chao Gong
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Xiaopei Liu
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
- Jiamusi University Affiliated No. 3 Hospital, Jiamusi, China
| | - Liya Fang
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Annan Liu
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Beibei Lian
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Xunzhong Qi
- Jiamusi University Affiliated No. 1 Hospital, Jiamusi, China
| | - Shuyue Chen
- College of Basic Medicine, Jiamusi University, Jiamusi, China
| | - Huiqing Li
- College of Basic Medicine, Jiamusi University, Jiamusi, China
| | - Ming Zhao
- College of Public Health, Jiamusi University, Jiamusi, China
| | - Jin Guo
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
- Jiamusi University Affiliated No. 3 Hospital, Jiamusi, China
| | - Shaobo Zhou
- School of Science, Faculty of Engineering and Science, University of Greenwich, Medway Campus Central Avenue, Chatham Maritime, Kent, England
| |
Collapse
|
5
|
Gong C, Liu A, Lian B, Wu X, Zeng P, Hao C, Wang B, Jiang Z, Pang W, Guo J, Zhou S. Prevalence and related factors of epilepsy in children and adolescents with cerebral palsy: a systematic review and meta-analysis. Front Pediatr 2023; 11:1189648. [PMID: 37576141 PMCID: PMC10416728 DOI: 10.3389/fped.2023.1189648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To study the worldwide prevalence and associated factors of epilepsy in children and adolescents with Cerebral Palsy (CP) and to analyze the differences between various subgroups. Method We identified all potential studies on the prevalence of epilepsy in children and adolescents with CP from PubMed, Web of Science, and Embase. The search time was from the establishment of the database to November 2022. Randomized effects meta-analysis models were used to calculate the prevalence of epilepsy in CP. Subgroup analysis and meta-regression were utilized to further explore heterogeneity between articles and prevalence disparities between subgroups. The funnel plot and Egger's test were used to investigate potential publication bias. Results Seventy-two articles, comprising 53,969 children and adolescents with CP, were included in this study. The results indicated a total epilepsy prevalence of 38.0% (95% CI: 34.8%-41.2%) in CP. The prevalence of epilepsy was 46.4% (95% CI: 41.4%-51.5%) in clinical sample-based studies and 31.6% (95% CI: 28.7%-34.5%) in population-based studies. Meta-regression demonstrated that the sample source, neonatal seizure, family history of epilepsy, EEG or cranial imaging abnormalities, intellectual/cognitive impairment, and topographical types of CP were heterogeneous contributors to the epilepsy prevalence in CP. Conclusion Approximately one-third of children and adolescents with CP have epilepsy, and the sample source can significantly impact the total prevalence of epilepsy. Neonatal seizures, family history of epilepsy, EEG abnormalities, cranial imaging abnormalities, severe intellectual disability, and quadriplegia may be contributing factors to epilepsy comorbid in CP. Further study is required to verify the strength of these associations with epilepsy. This study aids in identifying the clinical characteristics of young people with CP at risk of developing epilepsy, which may assist clinicians in the early prevention and diagnosis of epilepsy within this population.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367766, identifier CRD42022367766.
Collapse
Affiliation(s)
- Chao Gong
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Annan Liu
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Beibei Lian
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Xixi Wu
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Pei Zeng
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Chaoli Hao
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Bobo Wang
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
| | - Zhimei Jiang
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
- Jiamusi University Affiliated No.3 Hospital, Jiamusi, China
| | - Wei Pang
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
- Jiamusi University Affiliated No.3 Hospital, Jiamusi, China
| | - Jin Guo
- College of Rehabilitation Medicine, Jiamusi University, Jiamusi, China
- Jiamusi University Affiliated No.3 Hospital, Jiamusi, China
| | - Shaobo Zhou
- School of Science, Faculty of Engineering and Science, University of Greenwich, Medway Campus Central Avenue, Chatham Maritime, Kent, England
| |
Collapse
|
6
|
Gonzalez-Mantilla PJ, Hu Y, Myers SM, Finucane BM, Ledbetter DH, Martin CL, Moreno-De-Luca A. Diagnostic Yield of Exome Sequencing in Cerebral Palsy and Implications for Genetic Testing Guidelines: A Systematic Review and Meta-analysis. JAMA Pediatr 2023; 177:472-478. [PMID: 36877506 PMCID: PMC9989956 DOI: 10.1001/jamapediatrics.2023.0008] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/29/2022] [Indexed: 03/07/2023]
Abstract
Importance Exome sequencing is a first-tier diagnostic test for individuals with neurodevelopmental disorders, including intellectual disability/developmental delay and autism spectrum disorder; however, this recommendation does not include cerebral palsy. Objective To evaluate if the diagnostic yield of exome or genome sequencing in cerebral palsy is similar to that of other neurodevelopmental disorders. Data Sources The study team searched PubMed for studies published between 2013 and 2022 using cerebral palsy and genetic testing terms. Data were analyzed during March 2022. Study Selection Studies performing exome or genome sequencing in at least 10 participants with cerebral palsy were included. Studies with fewer than 10 individuals and studies reporting variants detected by other genetic tests were excluded. Consensus review was performed. The initial search identified 148 studies, of which 13 met inclusion criteria. Data Extraction and Synthesis Data were extracted by 2 investigators and pooled using a random-effects meta-analysis. Incidence rates with corresponding 95% CIs and prediction intervals were calculated. Publication bias was evaluated by the Egger test. Variability between included studies was assessed via heterogeneity tests using the I2 statistic. Main Outcomes and Measures The primary outcome was the pooled diagnostic yield (rate of pathogenic/likely pathogenic variants) across studies. Subgroup analyses were performed based on population age and on the use of exclusion criteria for patient selection. Results Thirteen studies were included consisting of 2612 individuals with cerebral palsy. The overall diagnostic yield was 31.1% (95% CI, 24.2%-38.6%; I2 = 91%). The yield was higher in pediatric populations (34.8%; 95% CI, 28.3%-41.5%) than adult populations (26.9%; 95% CI, 1.2%-68.8%) and higher among studies that used exclusion criteria for patient selection (42.1%; 95% CI, 36.0%-48.2%) than those that did not (20.7%; 95% CI, 12.3%-30.5%). Conclusions and Relevance In this systematic review and meta-analysis, the genetic diagnostic yield in cerebral palsy was similar to that of other neurodevelopmental disorders for which exome sequencing is recommended as standard of care. Data from this meta-analysis provide evidence to support the inclusion of cerebral palsy in the current recommendation of exome sequencing in the diagnostic evaluation of individuals with neurodevelopmental disorders.
Collapse
Affiliation(s)
| | - Yirui Hu
- Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
| | - Scott M. Myers
- Autism & Developmental Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Brenda M. Finucane
- Autism & Developmental Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | - Christa L. Martin
- Autism & Developmental Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Andres Moreno-De-Luca
- Autism & Developmental Medicine Institute, Geisinger, Danville, Pennsylvania
- Department of Radiology, Geisinger, Danville, Pennsylvania
- Diagnostic Medicine Institute, Geisinger, Danville, Pennsylvania
| |
Collapse
|
7
|
Callahan M, Matson JL, Tevis C. Developmental Functioning of Infants and Toddlers with Neurodevelopmental Disorders. Dev Neurorehabil 2023; 26:89-100. [PMID: 36628488 DOI: 10.1080/17518423.2023.2166615] [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] [Indexed: 01/12/2023]
Abstract
PURPOSE The current study aimed to investigate developmental functioning in infants and toddlers with autism spectrum disorder (ASD), seizures, cerebral palsy (CP), and atypical development. METHODS An ANOVA was utilized to investigate the differences between neurodevelopmental group on BDI-2 developmental quotient and a MANOVA was used to investigate the differences between the groups and five developmental domains. RESULTS The results indicated statistically significant differences in overall developmental functioning and each subdomain of the BDI-2. DISCUSSION These findings provide the basis for further research to investigate comorbidities of the three neurodevelopmental disorders and parse out the impact of intellectual disability (ID).
Collapse
Affiliation(s)
- Megan Callahan
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| | - Johnny L Matson
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| | - Celeste Tevis
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| |
Collapse
|
8
|
Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics 2022; 150:e2022060055. [PMID: 36404756 DOI: 10.1542/peds.2022-060055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.
Collapse
Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| | - Lynn Davidson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Steingass
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| |
Collapse
|
9
|
Delobel-Ayoub M, Ehlinger V, Klapouszczak D, Duffaut C, Arnaud C, Sentenac M. Prevalence and characteristics of children with cerebral palsy according to socioeconomic status of areas of residence in a French department. PLoS One 2022; 17:e0268108. [PMID: 35588131 PMCID: PMC9119545 DOI: 10.1371/journal.pone.0268108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/23/2022] [Indexed: 11/19/2022] Open
Abstract
Aim
To study the association between the socioeconomic environment of area of residence and prevalence and characteristics of children with cerebral palsy (CP).
Method
Data on 8-year-old children with CP born in 2000–2011 (n = 252) were extracted from a regional population-based register in France. The European Deprivation Index (EDI), available at census block level, characterised socioeconomic deprivation in the child’s area of residence at age of registration. The prevalence of CP was estimated in each group of census units defined by EDI distribution tertiles in the general population. The association between deprivation level and CP severity was assessed according to term/preterm status.
Results
CP prevalence differed between deprivation risk groups showing a J-shaped form with the prevalence in the most deprived tertile (T3) being the highest but not significantly different of the prevalence in the least deprived one (T1). However, the prevalence in the medium deprivation tertile (T2) was significantly lower than that in the most deprived one with a prevalence risk ratio (PRR) of: PRRT2/T3 = 0.63 95% CI [0.44–0.89]). Prevalences of CP with associated intellectual disability (ID) and CP with inability to walk were significantly higher in the most deprived tertile compared to the least deprived one (respectively PRRT3/T1 = 1.86 95% CI [1.19–2.92] and PRRT3/T1 = 1.90 95% CI [1.07–3.37]). Compared to children living in the least deprived areas, children with CP born preterm living in the most deprived areas had more severe forms of motor impairment, such as an inability to walk or a combination of an inability to walk and moderate to severe impairment of bimanual function. They also had more associated intellectual disability. No associations were observed among term-born children.
Interpretation
A significant association between area deprivation group and CP severity was observed among preterm children but not among term-born children.
Collapse
Affiliation(s)
- Malika Delobel-Ayoub
- CERPOP, UMR1295 Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
- CHU Toulouse, Registre des Handicaps de l’Enfant en Haute-Garonne, Toulouse, France
- * E-mail:
| | - Virginie Ehlinger
- CERPOP, UMR1295 Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
- CHU Toulouse, Registre des Handicaps de l’Enfant en Haute-Garonne, Toulouse, France
| | - Dana Klapouszczak
- CERPOP, UMR1295 Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
- CHU Toulouse, Registre des Handicaps de l’Enfant en Haute-Garonne, Toulouse, France
| | - Carine Duffaut
- CERPOP, UMR1295 Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
| | - Catherine Arnaud
- CERPOP, UMR1295 Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
- CHU Toulouse, Registre des Handicaps de l’Enfant en Haute-Garonne, Toulouse, France
- Clinical Epidemiology Unit, University Hospital, Toulouse, France
| | - Mariane Sentenac
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Paris, France
| |
Collapse
|
10
|
Posar A, Visconti P. Early Motor Signs in Autism Spectrum Disorder. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020294. [PMID: 35205014 PMCID: PMC8870370 DOI: 10.3390/children9020294] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 12/02/2022]
Abstract
A growing number of literature data suggest the presence of early impairments in the motor development of children with autism spectrum disorder, which could be often recognized even before the appearance of the classical social communication deficits of autism. In this narrative review, we aimed at performing an update about the available data on the early motor function in children with autism spectrum disorder. Early motor impairment in these children can manifest itself both as a mere delay of motor development and as the presence of atypicalities of motor function, such as a higher rate and a larger inventory, of stereotyped movements both with and without objects. In the perspective of a timely diagnosis, the presence of early motor signs can be an important clue, especially in an individual considered at high risk for autism. Motor and communication (both verbal and non-verbal) skills are connected and a pathogenetic role of early motor dysfunctions in the development of autism can be hypothesized. From this, derives the importance of an early enabling intervention aimed at improving motor skills, which could also have favorable effects on other aspects of development.
Collapse
Affiliation(s)
- Annio Posar
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI Disturbi dello Spettro Autistico, 40139 Bologna, Italy;
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40126 Bologna, Italy
- Correspondence: ; Tel.: +39-051-6225111
| | - Paola Visconti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI Disturbi dello Spettro Autistico, 40139 Bologna, Italy;
| |
Collapse
|
11
|
Abdel Malek S, Mesterman R, Switzer L, DiRezze B, deVeber G, Fehlings D, Lunsky Y, Phoenix M, Gorter JW. Exploring demographic, medical, and developmental determinants of adaptive behaviour in children with hemiplegic cerebral palsy. Eur J Paediatr Neurol 2022; 36:19-25. [PMID: 34823070 DOI: 10.1016/j.ejpn.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022]
Abstract
Hemiplegic cerebral palsy (CP), the most common subtype, is characterized by high levels of mobility. Despite this, children with hemiplegic CP can face challenges functioning in and adapting to situations of everyday life. The purpose of this cross-sectional study (Hemi-NET database) was to identify factors associated with adaptive behaviour in 59 children with hemiplegic CP (ages 4-18; GMFCS I-IV). Using multivariate regression analyses, the relationship between demographic, medical, and developmental factors and adaptive behaviour (measured by the Adaptive Skills Composite score of the BASC-2) was explored. Results indicate that 34% of children had impaired adaptive skills. An autism diagnosis and lower communication functioning were significantly associated with poorer adaptive skills (R2 = 0.42, F(4, 43) = 7.87, p < 0.001), while factors such as IQ scores and GMFCS level were not. The results contribute to the growing literature that suggests that clinicians and researchers need to look beyond motor functioning when working with individuals with CP.
Collapse
Affiliation(s)
- Sandra Abdel Malek
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 403, Hamilton, Ontario, L8S 1C7, Canada; CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 408, Hamilton, Ontario, L8S 1C7, Canada.
| | - Ronit Mesterman
- Department of Paediatrics, McMaster University, 1280 Main Street West, Health Sciences Centre, 3A, Hamilton, Ontario, L8S 4K1, Canada
| | - Lauren Switzer
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Road, Toronto, Ontario, M4G 1R8, Canada
| | - Briano DiRezze
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 403, Hamilton, Ontario, L8S 1C7, Canada; CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 408, Hamilton, Ontario, L8S 1C7, Canada
| | - Gabrielle deVeber
- Division of Neurology, Hospital for Sick Children, 555 University Avenue, Neurology Clinic, 6C Atrium, Toronto, Ontario, M5G 1X8, Canada
| | - Darcy Fehlings
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Road, Toronto, Ontario, M4G 1R8, Canada; Department of Pediatrics, University of Toronto, 555 University Avenue, Black Wing Room 1436, Toronto, Ontario, M5G 1X8, Canada; Rehabilitation Sciences Institute, University of Toronto, 500 University Avenue, Suite 160, Toronto, Ontario, M5G 1V7, Canada
| | - Yona Lunsky
- Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario, M5T 1R8, Canada; Azrieli Centre for Adult Neurodevelopmental Disabilities, CAMH, McCain Complex Care & Recovery Building, 1025 Queen Street West, Toronto, Ontario, M6K 1H4, Canada
| | - Michelle Phoenix
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 403, Hamilton, Ontario, L8S 1C7, Canada; CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 408, Hamilton, Ontario, L8S 1C7, Canada; Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Road, Toronto, Ontario, M4G 1R8, Canada
| | - Jan Willem Gorter
- School of Rehabilitation Science, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 403, Hamilton, Ontario, L8S 1C7, Canada; CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street West, Institute for Applied Health Sciences, Room 408, Hamilton, Ontario, L8S 1C7, Canada; Department of Paediatrics, McMaster University, 1280 Main Street West, Health Sciences Centre, 3A, Hamilton, Ontario, L8S 4K1, Canada
| |
Collapse
|
12
|
Haffner DN, Bartram LR, Coury DL, Rice CE, Steingass KJ, Moore-Clingenpeel M, Maitre NL. The Autism Detection in Early Childhood Tool: Level 2 autism spectrum disorder screening in a NICU Follow-up program. Infant Behav Dev 2021; 65:101650. [PMID: 34653736 DOI: 10.1016/j.infbeh.2021.101650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 09/16/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Children born preterm are at increased risk for autism spectrum disorder (ASD). However, early diagnosis of ASD is challenging because conventional screening Level 1 tools are less reliable in this population. We sought to determine whether the Autism Detection in Early Childhood (ADEC) and Child Behavior Checklist (CBCL) could accurately identify children at risk for ASD in a NICU Follow-up setting and thus facilitate referral for formal ASD evaluation. METHOD Children aged 18-36 months were recruited from a NICU Follow-up program. All children received presumptive diagnoses based on DSM-5 criteria and were screened for ASD risk with the ADEC and CBCL. Children scoring in the "at risk" range on either tool were referred for a full diagnostic ASD evaluation. RESULTS Sixty-nine patients (median birth weight 1140 g; median gestational age 28 weeks) were included with 18 designated "at risk" for ASD. Nine (13 %) scored "at risk" on the ADEC and 12 (17 %) on the CBCL. Thirteen children underwent diagnostic ASD evaluation with 9 receiving a formal diagnosis of ASD. The ADEC demonstrated the best performance (sensitivity 89 %, specificity 98 %). The CBCL was less sensitive (sensitivity 50 %, specificity 90 %). Requiring elevated scores on both the CBCL and ADEC was specific but not sensitive (sensitivity 33 %, specificity 100 %). CONCLUSION The ADEC performed well in identifying children at risk for ASD within this high-risk NICU cohort, adding benefit as an autism-specific screening tool over the CBCL alone.
Collapse
Affiliation(s)
- Darrah N Haffner
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Lindsay R Bartram
- Department of Pediatrics, Division of Developmental Behavioral Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel L Coury
- Department of Pediatrics, Division of Developmental Behavioral Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Courtney E Rice
- Department of Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, OH, USA
| | - Katherine J Steingass
- Department of Pediatrics, Division of Developmental Behavioral Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Melissa Moore-Clingenpeel
- Biostatistics Core, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Nathalie L Maitre
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | |
Collapse
|
13
|
Påhlman M, Gillberg C, Himmelmann K. Autism and attention-deficit/hyperactivity disorder in children with cerebral palsy: high prevalence rates in a population-based study. Dev Med Child Neurol 2021; 63:320-327. [PMID: 33206380 PMCID: PMC7894137 DOI: 10.1111/dmcn.14736] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/27/2022]
Abstract
AIM To assess a total population of school-age children with cerebral palsy (CP) for autism and attention-deficit/hyperactivity disorder (ADHD) with a view to determining their prevalence and to relate findings to motor function, intellectual disability, and other associated impairments. METHOD Of 264 children, born between 1999 and 2006, from the CP register of western Sweden, 200 children (109 males, 91 females, median age at assessment 14y, range 7-18y) completed comprehensive screening and further neuropsychiatric clinical assessments. RESULTS Ninety children (45%) were diagnosed with autism, ADHD, or both, 59 (30%) were diagnosed with autism, and 60 (30%) were diagnosed with ADHD. Intellectual disability was present in 51%. Two-thirds had autism, ADHD, and/or intellectual disability. In regression models, autism was mainly predicted by intellectual disability (odds ratio [OR]=4.1) and ADHD (OR=3.2), and ADHD was predicted by intellectual disability (OR=2.3) and autism (OR=3.0). Autism was more common in children born preterm (OR=2.0). Gross motor function was not associated with autism. ADHD prevalence was low in children with severe motor impairment, possibly due to diagnostic limitations. INTERPRETATION Autism and ADHD were common in this population of children with CP and were mainlyindependent of motor severity and CP type. The strongest predictor of autism/ADHD was intellectual disability. Assessment for autism and ADHD is warranted as part of the evaluation in CP. WHAT THIS PAPER ADDS Forty-five percent of the children with cerebral palsy also had autism, attention-deficit/hyperactivity disorder (ADHD), or both. Autism and ADHD were predicted mainly by intellectual disability. Established diagnostic instruments worked well for all but the most disabled group of children.
Collapse
Affiliation(s)
- Magnus Påhlman
- Gillberg Neuropsychiatry CentreInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Regional Rehabilitation CentreQueen Silvia Children’s HospitalGothenburgSweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry CentreInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kate Himmelmann
- Regional Rehabilitation CentreQueen Silvia Children’s HospitalGothenburgSweden,Department of PediatricsInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| |
Collapse
|
14
|
Himmelmann K, Horber V, Sellier E, De la Cruz J, Papavasiliou A, Krägeloh-Mann I. Neuroimaging Patterns and Function in Cerebral Palsy-Application of an MRI Classification. Front Neurol 2021; 11:617740. [PMID: 33613420 PMCID: PMC7887285 DOI: 10.3389/fneur.2020.617740] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/17/2020] [Indexed: 01/02/2023] Open
Abstract
Background: Cerebral palsy (CP) is a disorder of movement and posture and every child with CP has a unique composition of neurological symptoms, motor severity, and associated impairments, constituting the functional profile. Although not part of the CP definition, magnetic resonance imaging (MRI) sheds light on the localization, nature, and severity of brain compromise. The MRI classification system (MRICS), developed by the Surveillance of Cerebral Palsy in Europe (SCPE), describes typical MRI patterns associated with specific timing of vulnerability in different areas of the brain. The classification has proven to be reliable and easy to use. Aims: The aim of this study is to apply the MRICS on a large dataset and describe the functional profile associated with the different MRI patterns of the MRICS. Materials and Methods: Data on children with CP born in 1999-2009 with a post-neonatal MRI from 20 European registers in the JRC-SCPE Central Registry was included. The CP classification and the MRICS was applied, and The Gross Motor Function Classification (GMFCS) and the Bimanual Fine Motor Function (BFMF) classification were used. The following associated impairments were documented: intellectual impairment, active epilepsy, visual impairment, and hearing impairment. An impairment index was used to characterize severity of impairment load. Results: The study included 3,818 children with post-neonatal MRI. Distribution of CP type, motor, and associated impairments differed by neuroimaging patterns. Functional profiles associated with neuroimaging patterns were described, and the impairment index showed that bilateral findings were associated with a more severe outcome both regarding motor impairment and associated impairments than unilateral compromise. The results from this study, particularly the differences in functional severity regarding uni- and bilateral brain compromise, may support counseling and service planning of support of children with CP.
Collapse
Affiliation(s)
- Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Veronka Horber
- Department of Paediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Elodie Sellier
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France.,RHEOP, Grenoble, France
| | - Javier De la Cruz
- Research Institute (i+12), SAMID, University Hospital "12 Octubre", Madrid, Spain
| | | | | | | |
Collapse
|
15
|
Leader G, Molina Bonilla P, Naughton K, Maher L, Casburn M, Arndt S, Mannion A. Complex Comorbid Presentations are Associated with Harmful Behavior Problems among Children and Adolescents with Cerebral Palsy. Dev Neurorehabil 2021; 24:25-34. [PMID: 32508226 DOI: 10.1080/17518423.2020.1770353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: Frequency and relationship between gastrointestinal symptoms, sleep problems, internalizing and externalizing symptoms, behavior problems and autism spectrum disorder (ASD) symptoms, and predictors of behavior problems were examined in children and adolescents with Cerebral Palsy (CP). Method: Parents of 104 children and adolescents with CP completed the Gastrointestinal Symptom Inventory, Children's Sleep Habits Questionnaire, Child Behavior Checklist, Social Communication Questionnaire and the Behavior Problem Inventory-Short Form. Results: High frequency of behavior problems (88.5%), gastrointestinal symptoms (81.7%), sleep problems (81%) ASD symptoms (48%) and internalizing and externalizing symptoms (31.7%) were found. Relationships were found between gastrointestinal symptoms and sleep problems, and gastrointestinal symptoms and internalizing and externalizing symptoms. Relationships were found between sleep problems and behavior problems. Intellectual disability, sleep problems, internalizing and externalizing symptoms, and ASD symptoms predicted behavior problems. Conclusion: Findings highlights the frequency of comorbidities that exist in CP and how these comorbidities affect one another.
Collapse
Affiliation(s)
| | | | | | - Leanne Maher
- National University of Ireland , Galway, Ireland
| | - Mia Casburn
- National University of Ireland , Galway, Ireland
| | - Sophia Arndt
- National University of Ireland , Galway, Ireland
| | | |
Collapse
|
16
|
Abstract
INTRODUCTION While the overall prevalence of autism is 1.7% in the United States of America, research has demonstrated a two- to five-fold increase in CHD. The Cardiac Neurodevelopmental Outcome Collaborative recommends screening for autism from infancy through adolescence. This study investigated the frequency of autism concerns at a single Cardiac Neurodevelopmental Program and examined current clinical practice as a way to improve quality of care. MATERIALS AND METHODS Patients (n = 134; mean age = 9.0 years) included children with high-risk CHD who completed a neurodevelopmental evaluation following a formalised referral to the Cardiac Neurodevelopmental Program between 2018 and 2019. Retrospective chart review included parent report on the Behaviour Assessment System for Children-3 and Adaptive Behaviour Assessment System-3. Descriptive and correlation analyses were completed. RESULTS In this sample, 11.2% presented with autism-related concerns at referral, 2 were diagnosed with autism, 9 were referred to an autism specialist (6 confirmed diagnosis; 3 not completed). Thus, at least 5.9% of the sample were diagnosed with autism following thorough clinical evaluation. Analyses showed atypicality, along with deficient adaptability, leisure, social, and communication skills. Frequency of early intervention, school supports, and relation with comorbidities are reported. DISCUSSION Prior to assessment recommendations by the Cardiac Neurodevelopmental Outcome Collaborative, autism screening may not be completed systematically in clinical care for CHD. The current sample demonstrates a high frequency of autism in the typically referred clinical sample. Commonly used parent-report measures may reveal concerns but will not help diagnosis. Systematic use of an autism screener is essential.
Collapse
|
17
|
Påhlman M, Gillberg C, Wentz E, Himmelmann K. Autism spectrum disorder and attention-deficit/hyperactivity disorder in children with cerebral palsy: results from screening in a population-based group. Eur Child Adolesc Psychiatry 2020; 29:1569-1579. [PMID: 31927764 PMCID: PMC7595991 DOI: 10.1007/s00787-020-01471-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/03/2020] [Indexed: 12/13/2022]
Abstract
Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are more common in children with cerebral palsy (CP) than in the general population, but may still be underdiagnosed. This study aimed to estimate screen-positive ASD and ADHD in a population-based group of 264 school-aged children with CP born 1999-2006 from the CP register of western Sweden. Validated parent-completed questionnaires were used at a median age of 12 years 11 months (range 8-17 years). Three different scales were used to detect signs of ASD and ADHD, respectively. Response rate was 88% (232/264). In 19 children, all in the most disabled group, the screening procedure was not feasible due to too few questionnaire items completed, leaving 213 for analyses. One third (74/213) of the children screened positive for ASD and half of the children (106/213) for ADHD, which was about twice as often as ASD/ADHD diagnoses had been clinically identified. Children with intellectual disability, epilepsy and/or impaired speech ability more often screened positive for ASD as well as ADHD. Severe motor impairment was more frequently associated with screen-positive ASD, but not ADHD. Neither sex nor CP type was associated with screen-positive ASD/ADHD. In conclusion, school-aged children with CP very often screened positive for ASD and/or ADHD. The prevalence of ASD and ADHD is most likely underestimated in children with CP. These screening findings require further investigations.
Collapse
Affiliation(s)
- Magnus Påhlman
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Regional Rehabilitation Centre, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elisabet Wentz
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kate Himmelmann
- Regional Rehabilitation Centre, Queen Silvia Children’s Hospital, Gothenburg, Sweden ,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
18
|
Kurjak A, Spalldi Barišić L, Stanojević M, Antsaklis P, Panchal S, Honemeyer U, Moreira Neto R, Tinjić S, Vladareanu R, Esin S, Bomba-Opon D, Međedović E, Hata T. Multi-center results on the clinical use of KANET. J Perinat Med 2019; 47:897-909. [PMID: 31677378 DOI: 10.1515/jpm-2019-0281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/21/2019] [Indexed: 12/21/2022]
Abstract
An extensive review of the literature on the diagnostic and clinical accuracy of Kurjak's antenatal neurodevelopmental test (KANET) and the summarized results of the multi-center study involving 10 centers revealed that four-dimensional ultrasonography (4D US) has become a powerful tool and KANET a valuable test that empowers the clinicians worldwide to evaluate the fetal behavior in a systematic way and contribute to the detection of fetuses that might be at high risk for neurological impairments and in particular cerebral palsy (CP). After 10 years of clinical use, many published papers and multi-center studies, hundreds of trained physicians and numerous tests performed all over the world, KANET has proven its value and has been showing encouraging results so far. The aim of this paper is to show the results from the studies done so far and to reveal the clinical value of the KANET. We expect that data from the larger ongoing collaborative study, the short- and long-term postnatal follow-up will continue to improve our knowledge. Ultimately, we all strive to prevent the CP disorders, autism spectrum disorder (ASD) and other neurological impairments and we are convinced that KANET might be helpful in the realization of this important aim.
Collapse
Affiliation(s)
- Asim Kurjak
- Department of Obstetrics and Gynecology, Medical School University of Zagreb, Zagreb, Croatia.,University Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Lara Spalldi Barišić
- University Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Specialist, Department of Obstetrics and Gynecology, Private Clinic Veritas, Zagreb, Croatia
| | - Milan Stanojević
- Neonatal Unit, Department of OBGYN, Medical School University in Zagreb, University Hospital Sveti Duh, Zagreb, Croatia
| | - Panagiotis Antsaklis
- Fetal and Maternal Medicine, Alexandra Maternity Hospital, Medical School, University of Athens, Athens, Greece
| | - Sonal Panchal
- University Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Dr Nagori's Institute for Infertility and IVF, Ahmedabad, Gujarat, India
| | | | - Raul Moreira Neto
- Clinical Ultrasound and Fetal Medicine Unit - Ecomoinhos, Porto Alegre, Brazil
| | - Suada Tinjić
- University Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Department of Infertility and IVF, Polyclinic "Korak do Života", Tuzla, Bosnia and Herzegovina
| | - Radu Vladareanu
- Department of Obstetrics and Gynecology, UMF Carol Davila, Elias Emergency University Hospital, Bucharest, Romania
| | - Sertaç Esin
- Baskent University, Perinatal Medicine Center, Ankara, Turkey
| | - Dorota Bomba-Opon
- 1st Department of OBGYN, 1st Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Edin Međedović
- Department of Obstetrics and Gynecology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Toshyuki Hata
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Kagawa, Japan
| |
Collapse
|
19
|
Påhlman M, Gillberg C, Himmelmann K. One-third of school-aged children with cerebral palsy have neuropsychiatric impairments in a population-based study. Acta Paediatr 2019; 108:2048-2055. [PMID: 31077607 DOI: 10.1111/apa.14844] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 11/29/2022]
Abstract
AIM To describe motor function and associated impairments, particularly autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), in school-aged children with cerebral palsy (CP). METHODS Population-based study of all children with CP born 1999-2006 from the county of Västra Götaland, Sweden; 264 children (141 males, 123 females). Information was obtained from the CP Register of western Sweden (data collected at 4-8 years of age) and all medical records at 10-17 years of age. RESULTS Cerebral palsy was spastic in 76%, dyskinetic in 17% and ataxic in 7% of all children. Sixty-three per cent were independent walkers. Associated impairments were present in 75%. Vision was impaired in 19%, hearing in 8% and speech in 54%. Intellectual disability (ID) was present in 53% and epilepsy in 41%. ID had increased from 42% to 53% since preschool-age. Neuropsychiatric impairments were present in 32% of the children; ASD in 18%; and ADHD in 21%. All impairments, except for ASD and ADHD, increased with more severe motor impairment. CONCLUSION Three in four school-aged children with CP have associated impairments, underscoring the need to broadly assess every child. The high rate of ASD and ADHD points to the importance of in-depth studies of such impairments in CP.
Collapse
Affiliation(s)
- Magnus Påhlman
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
- Regional Rehabilitation Centre, Queen Silvia Children’s Hospital Gothenburg Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
| | - Kate Himmelmann
- Regional Rehabilitation Centre, Queen Silvia Children’s Hospital Gothenburg Sweden
- Department of Pediatrics, Institute of Clinical Sciences Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
| |
Collapse
|
20
|
Bertoncelli CM, Altamura P, Vieira ER, Bertoncelli D, Thummler S, Solla F. Identifying Factors Associated With Severe Intellectual Disabilities in Teenagers With Cerebral Palsy Using a Predictive Learning Model. J Child Neurol 2019; 34:221-229. [PMID: 30665307 DOI: 10.1177/0883073818822358] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Intellectual disability and impaired adaptive functioning are common in children with cerebral palsy, but there is a lack of studies assessing these issues in teenagers with cerebral palsy. Therefore, the aim of this study was to develop and test a predictive machine learning model to identify factors associated with intellectual disability in teenagers with cerebral palsy. METHODS This was a multicenter controlled cohort study of 91 teenagers with cerebral palsy (53 males, 38 females; mean age ± SD = 17 ± 1 y; range: 12-18 y). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, communication abilities, behaviors, motor skills, eating, and drinking abilities were collected between 2005 and 2015. Intellectual disability was classified as "mild," "moderate," "severe," or "profound" based on adaptive functioning, and according to the DSM-5 after 2013 and DSM-IV before 2013, the Wechsler Intelligence Scale for Children for patients up to ages 16 years, 11 months, and the Wechsler Adult Intelligence Scale for patients ages 17-18. Statistical analysis included Fisher's exact test and multiple logistic regressions to identify factors associated with intellectual disability. A predictive machine learning model was developed to identify factors associated with having profound intellectual disability. The guidelines of the "Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis Statement" were followed. RESULTS Poor manual abilities (P ≤ .001), gross motor function (P ≤ .001), and type of epilepsy (intractable: P = .04; well controlled: P = .01) were significantly associated with profound intellectual disability. The average model accuracy, specificity, and sensitivity was 78%. CONCLUSION Poor motor skills and epilepsy were associated with profound intellectual disability. The machine learning prediction model was able to adequately identify high likelihood of severe intellectual disability in teenagers with cerebral palsy.
Collapse
Affiliation(s)
- Carlo M Bertoncelli
- Department of Pediatric Orthopaedic Surgery, Lenval University Pediatric Hospital of Nice, Nice, France
- EEAP H. Germain Fondation Lenval-Children's Hospital, Nice, France
| | - Paola Altamura
- Department of Medicinal Chemistry and Pharmaceutical Technology, University of Chieti, Chieti, Italy
| | - Edgar Ramos Vieira
- Department of Physical Therapy, Florida International University, Miami, FL, USA
| | - Domenico Bertoncelli
- Department of Information Engineering, Computer Science and Mathematics, University of L'Aquila, Italy
| | - Susanne Thummler
- Children's Hospitals of Nice CHU-Lenval, Child and Adolescent Psychiatry, Nice, France
| | - Federico Solla
- Department of Pediatric Orthopaedic Surgery, Lenval University Pediatric Hospital of Nice, Nice, France
| |
Collapse
|
21
|
Licari MK, Finlay-Jones A, Reynolds JE, Alvares GA, Spittle AJ, Downs J, Whitehouse AJO, Leonard H, Evans KL, Varcin K. The Brain Basis of Comorbidity in Neurodevelopmental Disorders. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2019. [DOI: 10.1007/s40474-019-0156-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
22
|
A systematic review of comorbidity between cerebral palsy, autism spectrum disorders and Attention Deficit Hyperactivity Disorder. Eur J Paediatr Neurol 2019; 23:31-42. [PMID: 30446273 DOI: 10.1016/j.ejpn.2018.10.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/17/2018] [Accepted: 10/26/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this systematic review was to examine the incidence and prevalence of comorbidity between Cerebral Palsy (CP), Autism spectrum disorders (ASDs) and Attention-Deficit/Hyperactivity Disorder (ADHD). METHODS We searched for articles indexed in PubMed, EBSCOhost, Scopus, Web of Science and other potentially relevant internet sources using a combination of expressions including "cerebral palsy" AND "autism" OR "ASD" OR "pervasive development disorder" AND "Attention Deficit Hyperactivity Disorder" OR "ADHD". RESULTS We identified 2542 studies on CP and ASD and 998 studies on CP and ADHD. After screening titles and abstracts and removing duplicated studies, 47 full papers (CP and ASD n = 28; CP and ADHD n = 19) were downloaded and screened for eligibility. Twenty-eight (CP and ASD n = 16; CP and ADHD n = 12) studies were identified in the peer-review literature. Based on this systematic review, ASD and ADHD seem to be more common in people with CP than in the general population, yet the gold standard methods for diagnosing ASD or ADHD are not suitable for children with motor problems. CONCLUSIONS Assessing the occurrence of ASD and ADHD would improve the significant cost of healthcare, therapies, and overall daily living for families with children affected by CP. However, psychometric studies are needed in the future to promote development of measures suitable for individuals with CP. In addition, this review highlights the paucity of peer-reviewed studies investigating the occurrence of ASD and ADHD in children with different CP subtypes or functional abilities, and there are still some open questions about pathogenic mechanisms common to CP, ASD and ADHD.
Collapse
|
23
|
Hata T, Kanenishi K, Mori N, AboEllail MAM, Hanaoka U, Koyano K, Kato I, Kusaka T. Prediction of postnatal developmental disabilities using the antenatal fetal neurodevelopmental test: KANET assessment. J Perinat Med 2018; 47:77-81. [PMID: 30098288 DOI: 10.1515/jpm-2018-0169] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/28/2018] [Indexed: 11/15/2022]
Abstract
Objective To assess the usefulness of the antenatal fetal neurodevelopmental test for the prediction of postnatal developmental disabilities. Methods Fetal behavior was assessed with Kurjak's antenatal neurodevelopmental test (KANET) using four-dimensional ultrasound between 28 and 38 weeks of gestation. A score range of 0-5 was characterized as abnormal, from 6 to 9 was considered borderline, and 10-16 was normal. After birth, follow-up was conducted for at least 2 years in all fetuses. Results There were 337 normal (95.47%) and 16 borderline (4.53%) cases among the 353 cases studied, whereas there was no abnormal case. Five cases with postnatal developmental disabilities (one case of Werdig-Hoffmann disease diagnosed just after delivery, one case of autism spectrum disorder diagnosed at 24 months, one case of Ullrich congenital muscular dystrophy diagnosed at 9 months and two cases of developmental disorders diagnosed at age 3 and 18 months) were noted among the 337 normal cases (1.48%), whereas three cases with developmental disabilities (one case of motor development delay diagnosed at 6 months, one case of Duchenne muscular dystrophy diagnosed at 18 months and one case of autism spectrum disorder diagnosed at age 30 months) were found among the 16 borderline cases (18.75%). There was a significant difference in the prevalence of postnatal developmental disabilities between the normal and borderline KANET groups (P<0.001). Conclusion Our results suggest that the KANET assessment may be a useful diagnostic modality for the prediction of postnatal developmental disabilities.
Collapse
Affiliation(s)
- Toshiyuki Hata
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | - Kenji Kanenishi
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | - Nobuhiro Mori
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | | | - Uiko Hanaoka
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | - Kosuke Koyano
- Department of Pediatrics, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | - Ikuko Kato
- Department of Pediatrics, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan
| |
Collapse
|
24
|
Korzeniewski SJ, Slaughter J, Lenski M, Haak P, Paneth N. The complex aetiology of cerebral palsy. Nat Rev Neurol 2018; 14:528-543. [PMID: 30104744 DOI: 10.1038/s41582-018-0043-6] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.
Collapse
Affiliation(s)
- Steven J Korzeniewski
- Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Jaime Slaughter
- Department of Health Systems and Sciences Research and Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
| | - Madeleine Lenski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Peterson Haak
- Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Nigel Paneth
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| |
Collapse
|
25
|
Geier DA, Kern JK, Sykes LK, Geier MR. Mercury-associated diagnoses among children diagnosed with pervasive development disorders. Metab Brain Dis 2018; 33:949-960. [PMID: 29512044 DOI: 10.1007/s11011-018-0211-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/25/2018] [Indexed: 12/27/2022]
Abstract
Nelson and Bauman (Pediatrics 111:674-679, 2003) previously hypothesized that pervasive developmental disorder (PDD) was not associated with mercury (Hg) exposure because the medical conditions associated with Hg exposure were not associated with PDD. A hypothesis-testing longitudinal case-control study evaluated the frequency of medically diagnosed conditions previously associated with Hg poisoning, including: epilepsy, dysarthria, failure to thrive, cerebral palsy, or contact dermatitis and other eczema among children preceding their eventual PDD diagnosis (cases) compared to controls. A retrospective examination of medical records within the Vaccine Safety Datalink (VSD) was undertaken. Cases diagnosed with PDD (n = 534) were born from 1991 to 2000 and continuously enrolled until their PDD diagnosis. Controls (n = 26,367) were born from 1991 to 1993 and continuously enrolled from birth for 7.22 years. Within the first 5 years of life, cases compared to controls were significantly (p < 0.0001) more likely to be assigned a diagnosis of contact dermatitis and other eczema (odds ratio (OR) = 2.033), dysarthria (OR = 23.992), epilepsy (OR = 5.351), failure to thrive (OR = 25.3), and cerebral palsy (OR = 4.464). Similar results were observed when the data were separated by gender. Overall, the results of the present study and recently published studies provide direct evidence supporting a link in twelve of twelve categories (100%) of Hg poisoning associated symptoms as defined by Nelson and Bauman (Pediatrics 111:674-679, 2003) and symptoms observed in those with a PDD diagnosis. The results of this study support the biological plausibility of Hg poisoning to induce PDD diagnoses and rejection of the Nelson and Bauman (Pediatrics 111:674-679, 2003) hypothesis because those with a PDD diagnosis have an increased frequency of conditions previously associated with Hg poisoning.
Collapse
Affiliation(s)
- David A Geier
- The Institute of Chronic Illnesses, Inc, 14 Redgate Ct, Silver Spring, MD, USA
| | - Janet K Kern
- The Institute of Chronic Illnesses, Inc, 14 Redgate Ct, Silver Spring, MD, USA.
- CoMeD, Inc, Silver Spring, MD, USA.
- CONEM US Autism Research Group, Allen, TX, USA.
| | | | - Mark R Geier
- The Institute of Chronic Illnesses, Inc, 14 Redgate Ct, Silver Spring, MD, USA
| |
Collapse
|
26
|
Downs J, Blackmore AM, Epstein A, Skoss R, Langdon K, Jacoby P, Whitehouse AJO, Leonard H, Rowe PW, Glasson EJ. The prevalence of mental health disorders and symptoms in children and adolescents with cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 2018; 60:30-38. [PMID: 28914445 DOI: 10.1111/dmcn.13555] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 11/30/2022]
Abstract
AIM Mental health conditions and problems are often reported in children and adolescents with cerebral palsy (CP). A systematic review was undertaken to describe their prevalence. METHOD MEDLINE and PsycINFO databases from 1996 to 2016 were searched and reference lists of selected studies were reviewed. Studies were included if they reported point prevalence of mental health diagnoses or symptoms in a general population of children and/or adolescents with CP. Pooled prevalence for mental health symptoms was determined using a random effects meta-analysis. RESULTS Of the 3158 studies identified, eight met the inclusion criteria. Mental health disorders were diagnosed by psychiatric interview in one study, giving a prevalence of 57% (32 out of 56 children). The remaining seven studies (n=1715 children) used parent-report mental health screening tools. The pooled prevalence for mental health symptoms using the Strengths and Difficulties Questionnaire (n=5 studies) was 35% (95% confidence interval [CI] 20-61) and using the Child Behavior Checklist (n=2 studies) was 28% (95% CI 22-36). Evidence was characterized by a moderate level of bias. INTERPRETATION More studies are needed to ascertain the prevalence of mental health disorders. Mental health symptoms are common and mental health evaluations should be incorporated into multidisciplinary assessments for these children. WHAT THIS PAPER ADDS Children with cerebral palsy and intellectual disability have a higher risk of mental health symptoms. The prevalence of mental health symptoms for age and severity groups is unclear.
Collapse
Affiliation(s)
- Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | | | - Amy Epstein
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Rachel Skoss
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Katherine Langdon
- Paediatric Rehabilitation, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Peter Jacoby
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Peter W Rowe
- Department of Neurology, Princess Margaret Hospital for Children, Perth, WA, Australia.,Department of Health, Child Development Service, Perth, WA, Australia
| | - Emma J Glasson
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | |
Collapse
|
27
|
Sigafoos J, Carnett A, McNamee S, Lancioni GE, O’Reilly MF. Helping a Man With Cerebral Palsy Access Preferred Internet Content Using Assistive Technology and a Participant-Directed Support Model. Clin Case Stud 2017. [DOI: 10.1177/1534650117732831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A man with cerebral palsy was helped to access preferred Internet content through a treatment program involving assistive technology and support from research staff. The assistive technology included an individually configured Apple iPad® and a head pointer that enabled the man to directly select screen icons linked to preferred websites. Staff supported the man by setting up the technology and responding to his instructions and requests for assistance and by performing general troubleshooting operations (e.g., starting up, positioning, rebooting, and charging the iPad® as necessary). Twelve treatment sessions, one per week, provided opportunities for the man to practice using the iPad®. Progress was assessed by rating his (a) degree of independence, (b) level of participation, (c) performance, (d) satisfaction with performance, and (e) overall satisfaction with the head pointer, the iPad®, and the treatment program. The man actively participated in each treatment session and reported better performance over the course of treatment. He was also generally satisfied with the program. The present combination of assistive technology and staff support appeared acceptable and effective in increasing participation. The approach illustrates how aspects of self-determination can be incorporated into assistive technology interventions for adults with cerebral palsy.
Collapse
|
28
|
VAN NAARDEN BRAUN KIM. Understanding cerebral palsy: the power of population-based surveillance. Dev Med Child Neurol 2017; 59:676-677. [PMID: 28485499 PMCID: PMC6038123 DOI: 10.1111/dmcn.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- KIM VAN NAARDEN BRAUN
- National Center on Birth Defects and Developmental Disabilities,
Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|