Cognitive profile in young Icelandic children with cerebral palsy

Nonverbal Cognitive Skills in Children With Aicardi Goutières Syndrome

BACKGROUND AND OBJECTIVES

Aicardi Goutières syndrome (AGS) is type I interferonopathy characterized by severe neurologic impairment. Although many children with AGS demonstrate motor and expressive language deficits, the magnitude of receptive language impairment is uncharacterized. We sought to characterize cognitive function in AGS-affected children using assessment tools with reduced dependence on motor abilities and compare cognitive testing outcomes with overall severity and parental assessment of adaptive behavior.

METHODS

We performed a cross-sectional study. Children were recruited as part of the Myelin Disorders Biorepository Project at the Children's Hospital of Philadelphia. We included individuals with a confirmed diagnosis of AGS. We administered the Leiter International Performance Scale, third edition (Leiter-3), and the Vineland Adaptive Behavior Scale, third edition (VABS-3), in the context of research encounters. Motor skills were categorized by AGS Severity Scale mobility levels. Descriptive statistics and Spearman's rank correlation were used to compare assessments. Mann-Whitney and Kruskal-Wallis tests with correction with Dunn's multiple comparison test were used to compare test performance between mobility groups.

RESULTS

Cognitive and adaptive behavior performance was captured in 57 children. The mean age at encounters was 8.51 (SD 5.15) years. The median (IQR) Leiter-3 score was 51 (interquartile range [IQR] 60), with administration failure in 20 of 57 (35%) individuals. On the VABS-3, the Motor Domain (median 29, IQR 36.25) was more impacted than the Communication (median 50, IQR 52), Daily Living Skills (median 52, IQR 31), and Socialization (median 54, IQR 40) Domains (p < 0.0001). The AGS Scale correlated with VABS-3 (r = 0.86, p < 0.0001) and Leiter-3 (r = 0.87, p < 0.0001). There was correlation between VABS-3 Domains and Leiter-3 (r-range 0.83-0.97). Gross motor and fine motor categories, respectively, correlated with VABS-3 (H = 39.37, p < 0.0001; U = 63, p < 0.0001) and Leiter-3 (H = 40.43, p < 0.0001; U = 66, p < 0.0001). Within each gross motor and fine motor category of the AGS Scale, a subset of children scored within normal IQ range.

DISCUSSION

Parental assessment of function by the VABS-3 correlated with directly assessed performance measures. Our data underscore the potential value of VABS-3 and Leiter-3 as tools to assess psychometric function in AGS. With a deeper understanding of our patients' abilities, we can better guide clinicians and families to provide appropriate support and personalized interventions to empower children with leukodystrophies to maximize their communication and educational potential.

Randomised controlled trial of an online cognitive training program in school-aged children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) experience deficits in nonverbal reasoning. The SMART online cognitive intervention has been associated with gains in IQ and nonverbal IQ in previous studies in typically developing school-aged children and children experiencing learning difficulties.

AIM

To assess the efficacy of an online cognitive intervention in school-aged children with CP.

METHODS AND PROCEDURES

21 children with CP (male n = 17; 76.2%), mean age 9 y 8 m, SD 1 y 1 month (range 8 y 3 m to 12 y 6 m) were randomised into the intervention group (n = 9) or a waitlist control group. A mixed-methods approach with an explanatory sequential design was used, with a randomised controlled trial followed by qualitative interviews. Participants were assessed on measures of intelligence, academic ability, attention and executive functioning, and social-emotional functioning at baseline, then after completing the training, or the waitlist period. Analyses included ANCOVAs and paired samples t tests. Semi-structured interviews explored participants' experiences with the training.

RESULTS AND OUTCOMES

Training completion was low with a mean of 16.9 modules completed out of 55 available. No significant effect of training was found for the primary outcome of intelligence, or for any secondary outcomes. Participants reported barriers and facilitators for accessing the program.

IMPLICATIONS

Cognitive training programs addressing relational framing ability may require significant modifications before they can be effectively tested with children with CP.

Hemiplegic (unilateral) cerebral palsy in northern Stockholm: Intellectual disability and epilepsy

PURPOSE

The purpose of this study was to describe intellectual disability and its association with epilepsy and brain imaging, in a population-based group of children with hemiplegic (unilateral) cerebral palsy, previously investigated and published in 2020.

MATERIALS AND METHODS

Forty-seven children of school age in northern Stockholm, fulfilling the Surveillance of Cerebral Palsy in Europe-criteria of hemiplegic (unilateral spastic) cerebral palsy, were invited to participate in the study. Twenty-one children consented to participate. A WISC (Wechsler Intelligence Scale for Children)-test was performed by an experienced psychologist.

RESULTS

In the study population of twenty-one children, 57 % (n 12) displayed uneven cognitive profiles, 38 % (n 8) intellectual disability and 62 % (n 13) had a normal IQ. 43 % (n 9) developed epilepsy. Children with extensive brain lesions had more severe intellectual disability.

CONCLUSIONS

In this study intellectual disability and/or epilepsy were associated with the type and extent of the underlying brain lesion. Intellectual disability and uneven cognitive profiles were common. We therefore recommend individual cognitive assessment to ensure an optimal school start.

Accommodations to cognitive assessment for a child with dyskinetic cerebral palsy: case study

PURPOSE

Despite the importance of having knowledge about a child's cognitive functioning, less than one-third of children with cerebral palsy (CP) are formally assessed. Consequently, the cognitive strengths of many children with severe CP may be underestimated or go overlooked. This case study aimed to test accommodations to cognitive assessment administration procedures to enable switch access.

METHODS

A 9-year-old boy with dyskinetic CP tested a suite of cognitive assessments with accommodations for single switch access and measures of user experience. The cognitive assessment included: receptive vocabulary; non-verbal reasoning; sustained attention; executive functions of problem solving and shifting; and visual perception skills.

RESULTS

The participant's ability to independently undertake assessment on the receptive vocabulary, non-verbal reasoning and the sustained attention measures indicates that accommodations made for single switch access were appropriate. Assessment took 1-2 h longer than expected for a typically developing child via standardised administration procedures, but was considerably faster than expected if undertaken via low-tech partner assisted scanning. Accessibility barriers continued to be present for the executive function and visual perception measures. Overall, the user experience was positive, both in regards to usability and cognitive load.

CONCLUSIONS

This case study provides emerging data for usability and accessibility of accommodations to a battery of cognitive assessment tasks. Further research is needed to devise appropriate accommodations for executive function and visual perception measures and to determine whether the accommodations are accessible more generally for children with motor and/or speech impairments. Implications for rehabilitationAccommodations can be successfully made to receptive vocabulary, non-verbal reasoning and sustained attention assessment administration procedures for switch technologies.Cognitive assessment with switch accommodations takes considerably longer to complete than standardised administration estimates for a typically developing child. Assessment may need to be scheduled over more than one session.User experience, including usability and cognitive load, of accommodations was positive.

Differential neuropsychological profiles in children and adolescents with motor disability in an inclusive educational setting

The aim of this study was to determine the potential cognitive impairment associated with motor disability in a group of children attending regular schools and to analyze whether there were different cognitive profiles according to the type of motor disability they presented. The study had 87 participants, 31 healthy and 56 with three types of motor disability: Neuromuscular Diseases (NMD Group), Cerebral Palsy-Hemiparesis (CP- HPx Group) and Cerebral Palsy-Diplegia (CP-DP). Ages ranged from 6 to 18 years and they had medium and medium-high socioeconomic and cultural levels. All participants attended regular state-funded and independent schools in an inclusive modality. The neuropsychological assessment included the following cognitive domains: processing speed, working memory, verbal and visual episodic memory, language, visuo-perception and constructive praxis and executive functioning. A second analysis was performed with the groups with CP: one based on the severity of gross motor impairment (GMFCS-E&R scale) and the other based on the levels of manual dexterity (MACS scale). ANCOVAs were performed controlling for age and processing speed in the three analyses. The group with CP-HPx was shown to be the most cognitively impaired of the three groups, with significant deficits in visuo-perception, verbal working memory, and visuo-spatial memory. Subjects with greater gross motor dysfunction (GMFCS-E&R) did not show the greatest cognitive impairment, while those with worse manual dexterity (MACS) exhibited greater cognitive impairment. Children and adolescents with motor disabilities, a priori cognitively normal, present different levels of cognitive impairment. This should be considered when planning educational adaptations for this infant-juvenile population.

Cognitive Functioning and Assessment in Adults with Cerebral Palsy: A Scoping Review

In this scoping review, we summarize the current knowledge of cognitive functioning in adults with cerebral palsy (CP), and identify the neuropsychological tests typically used in this population. 39 studies from the period January 1990 - August 2023 were included in the review, and they differ widely in their aims and approach to studying cognition. Very few studies have cognitive assessment as their core aim and use a neuropsychological test battery. The included studies show great variability in reported intelligence and cognitive functioning in adults with CP, and cognitive deficits have been reported in all cognitive domains. Most of the studies suffer from methodological limitations, and there is ample room for improvement within the field. We conclude by suggesting a number of recommendations that may contribute to increasing our understanding of cognitive impairments in adults with CP.

Provision of augmentative and alternative communication interventions to Norwegian preschool children with cerebral palsy: are the right children receiving interventions?

Preschool children with cerebral palsy (CP) with no or unintelligible speech need augmentative and alternative communication (AAC), but not all children needing AAC have access to it. This study describes the use and perceived benefit of AAC and explores factors associated with receiving AAC interventions. Using a cross-sectional design, we combined parent-reported data with data from the Norwegian Quality and Surveillance Registry for Cerebral Palsy (NorCP). Communication, speech and hand function was classified according to the Communication Function Classification System (CFCS), Viking Speech Scale (VSS), and Manual Ability Classification System (MACS), accordingly. The need for AAC was defined as Levels III-V on the CFCS, without simultaneous classification at VSS Level I, and/or Levels III-IV on VSS. Parents reported on child- and family-directed AAC interventions using the Habilitation Services Questionnaire. Of the 95 children (42 females) with CP (M = 39.4 months, SD = 10.3), 14 had communication aids. Of the 35 children (31.4%) defined as needing AAC, 11 had been provided with communication aids. Parents of children with a communication aid reported satisfaction with and frequent use of the aid. Children at MACS Level III-V (OR = 3.4, p = .02) or with epilepsy (OR = 8.9, p < .01) were most likely to have received an AAC intervention. The low proportion of children receiving communication aids indicates an unmet need for AAC interventions among preschool children with CP.

Prevalence, birth, and clinical characteristics of dyskinetic cerebral palsy compared with spastic cerebral palsy subtypes: A Norwegian register-based study

AIM

To study the prevalence, birth, and clinical characteristics of children with dyskinetic cerebral palsy (CP) in Norway compared with spastic quadriplegic CP and other spastic CP subtypes.

METHOD

Data on children born from 1996 to 2015 were collected from the Norwegian Quality and Surveillance Registry for Cerebral Palsy and the Medical Birth Registry of Norway.

RESULTS

One hundred and seventy (6.8%) children had dyskinetic CP. The birth prevalence decreased during 1996 to 2015 from 0.21 to 0.07 per 1000 livebirths (p < 0.001). Dyskinetic CP was more often associated with term/post-term birth, and motor and associated impairments were more severe compared with spastic bilateral and unilateral CP, but less severe than spastic quadriplegic CP. On neuroimaging, grey matter injuries were most prevalent in dyskinetic CP (mainly basal ganglia/thalamus) and spastic quadriplegic CP (mainly cortico-subcortical), white matter injuries in spastic bilateral, and white and grey matter injuries were equally common in spastic unilateral CP. Normal neuroimaging and brain maldevelopment were present in 25% of children with dyskinetic CP.

INTERPRETATION

The decrease in birth prevalence of dyskinetic CP was probably due to improved antenatal and perinatal care. Potential sentinel events at term were more common in dyskinetic CP than other spastic CP subtypes. However, probable antenatal aetiologies were most prevalent. Motor and associated impairments were less severe in children with dyskinetic CP compared with spastic quadriplegic CP.

WHAT THIS PAPER ADDS

Birth prevalence of those with dyskinetic and spastic bilateral cerebral palsy (CP) in Norway decreased between 1996 and 2015. Potential sentinel events at term were more common in dyskinetic CP. Nonetheless, probable antenatal aetiologies were most prevalent in dyskinetic CP. Basal ganglia/thalamus lesions were more common in dyskinetic than spastic quadriplegic CP. Motor and associated impairments were milder in dyskinetic than spastic quadriplegic CP.

Cognitive assessments among children with cerebral palsy in Sweden and the use of augmentative and alternative communication and interpreters: a cross-sectional registry study

PURPOSE

Children with cerebral palsy (CP) have an increased risk of cognitive difficulties and should be offered cognitive assessments. In Sweden, the CPCog protocol recommends children with CP undergo cognitive assessments at the start of primary and secondary school. To assess children with CP can be challenging, in particular when children are non-vocal or do not speak the local language. In such instances, augmentative and alternative communication (AAC) and qualified medical interpreters should be considered. The purpose of this study was to monitor the implementation and equitable delivery of the CPCog protocol in Sweden between the years 2017-2020.

MATERIALS AND METHODS

In this cross-sectional study, registry data were extracted from the combined follow-up program and national registry for individuals with CP (CPUP), and a convenience sample of psychologists responded to an online survey.

RESULTS AND CONCLUSIONS

Each year, less than 5% of eligible children had registered cognitive assessments in CPUP. There was underuse of AAC during assessments and a discrepancy between the registered versus reported use of interpreters. Psychologists perceived AAC as more reliable for cognitive assessments than interpreters. Greater availability of and capacity to offer cognitive assessments in other formats and languages could help increase test accessibility for all children with CP.Implications for RehabilitationThe cognitive assessment of children with cerebral palsy (CP) is a complex but important issue within disability and re/habilitation.Individualized cognitive assessments should be offered and carried out by psychologists.Rehabilitation centers should strive to be inclusive through reliable test adaptations for functional abilities, means of communication, and language.Greater availability of- and capacity to offer cognitive assessments in more formats and languages could help increase test accessibility for children with disabilities.

Sentence Length Effects on Intelligibility in Two Groups of Older Children With Neurodevelopmental Disorders

PURPOSE

The purpose of this study was to examine the impact of sentence length on intelligibility in two groups of older children with neurodevelopmental disabilities.

METHOD

Nine children diagnosed with cerebral palsy (CP) and eight children diagnosed with Down syndrome (DS), between the ages of 8 and 17 years, repeated sentences varying in length from two to seven words. Three hundred forty adult listeners (20 listeners per child) provided orthographic transcriptions of children's speech, which were used to calculate intelligibility scores.

RESULTS

There was a significant main effect of sentence length on intelligibility for children with CP. Intelligibility significantly increased from two- and three-word sentences to four-, five-, and six-word sentences, then significantly decreased from four-, five-, and six-word sentences to seven-word sentences. There was a main effect of sentence length on intelligibility for children with DS. Intelligibility significantly increased from two-word sentences to four-, five-, and six-word sentences.

CONCLUSIONS

The primary findings of this study include the following: (a) Unlike in typically developing children, sentence length continues to influence intelligibility well into adolescence for children with neurodevelopmental disorders, and (b) sentence length may influence intelligibility differently in children with CP than in children with DS; however, other factors besides the type of neurodevelopmental disorder (e.g., severity of speech motor involvement and/or cognitive-linguistic impairment) could play a role in the relationship between sentence length and intelligibility and must be investigated in future studies.

Working Memory Training in Norwegian Children with Cerebral Palsy (CP) Show Minimal Evidence of Near and No Far Transfer Effects

In children with cerebral palsy (CP), learning disabilities are well documented, and impairments in executive functions, such as attention, inhibition, shifting and working memory, represent significant burdens on patients, their families and the society. The aim of this study was to evaluate whether Cogmed RM working memory training could improve working memory in children with CP and investigate whether increased working memory capacity would generalize to other cognitive functions. Twenty-eight children completed the training and the results were compared to a waitlist control group (n = 32). The results yielded three main findings. First, children with CP improved with practice on trained working memory tasks. Second, the intervention group showed minimal near transfer effects to non-trained working memory tasks. Third, no effects on cognitive and behavioral far transfer measures were found.

Differential Impacts of Sentence Length on Speech Rate in Two Groups of Children With Neurodevelopmental Disorders

PURPOSE

The primary purpose of this study was to examine the effect of sentence length on speech rate and its characteristics, articulation rate, and pauses in children with neurodevelopmental disorders.

METHOD

Nine children diagnosed with cerebral palsy (CP) and seven children diagnosed with Down syndrome (DS) repeated sentences varying in length from two to seven words. Children were between the ages of 8 and 17 years. Dependent variables included speech rate, articulation rate, and proportion of time spent pausing.

RESULTS

For children with CP, there was a significant effect of sentence length for speech rate and articulation rate but not for the proportion of time spent pausing. In general, the longest sentences were produced with a faster speech and articulation rate than the shortest sentences. For children with DS, there was a significant effect of sentence length for the proportion of time spent pausing but not for speech rate or articulation rate. In general, children with DS spent significantly more time pausing in the longest sentences, particularly seven-word sentences, than in any other sentence length.

CONCLUSIONS

Primary findings include the following: (a) Articulation rate and pause time are differentially impacted by sentence length, and (b) children with CP and children with DS respond differently to increases in cognitive-linguistic load.

Psychometric properties of the English language version of the C-BiLLT evaluated in typically developing Canadian children

PURPOSE

This study aimed to 1) investigate the convergent and discriminant validity, internal consistency, and test-retest reliability of the Canadian English version of the Computer-Based instrument for Low motor Language Testing (C-BiLLT-CAN), and 2) explore feasibility of the C-BiLLT assessment for children with cerebral palsy (CP) and complex communication needs in the Canadian health care context.

METHODS

Eighty typically developing children between 1.5 and 8.5 years of age completed the C-BiLLT-CAN, the Peabody Picture Vocabulary Test-IV (PPVT-4), the receptive language sub-test of the New Reynell Developmental Language Scales (NRDLS), and/or the Raven's 2. Correlations between raw scores were calculated for estimates of convergent and discriminant validity. Internal consistency was calculated for all items and separately for items pertaining to vocabulary and grammar. To calculate the standard error of measurement (SEM) and intraclass correlation coefficient (ICC), 33 participants were re-tested with the C-BiLLT within three weeks. Feasibility was explored with nine participants with CP.

RESULTS

C-BiLLT-CAN's convergent validity was good to excellent (Spearman's rho >  0.78) and discriminant validity was higher than hypothesized (Spearman's rho >  0.8). Internal consistency (Cronbach's alpha = 0.96), test-retest reliability (ICC >  0.9), and measurement error (SEM <  5%) were excellent. The feasibility study could not be fully completed due to the COVID-19 pandemic. Preliminary data demonstrated some technical and practical barriers for using the C-BiLLT in children with CP in Canada.

CONCLUSION

The C-BiLLT-CAN demonstrates good to excellent psychometric properties in a sample of typically developing children, indicating that it is an adequate test for measuring language comprehension in English-speaking Canadian children. Further research is needed to investigate the feasibility of the C-BiLLT-CAN in children with CP.

Assessing IQ in adolescents with mild to moderate cerebral palsy using the WISC-V

Objective: To examine the influence of subtests that require fine motor responses on measures of intellectual ability, and compare three approaches to minimizing motor demands while assessing cognitive abilities in adolescents with cerebral palsy (CP) to the traditional method of the Wechsler Intelligence Scale for Children - Fifth edition (WISC-V). Method: Seventy adolescents with CP (M = 14 years 6 months, SD = 10 months) who were able to provide either a verbal or point response were assessed using the WISC-V administered via Q-interactive. The pencil-to-paper version of Coding was also administered. Performance on Block Design and pencil-to-paper Coding was compared to Visual Puzzles and Coding on Q-interactive, respectively. Full Scale IQ (FSIQ) scores derived according to the Traditional method of the WISC-V were compared to alternative estimates of FSIQ derived according to the Q-interactive, Nonmotor, and Motor-free methods, which minimized motor demands. Results: An additional 7-12% of participants were able to respond to Visual puzzles and Coding on Q-interactive compared to Block Design and pencil-to-paper Coding, respectively, and performance was marginally but significantly better. For 54 adolescents (Gross Motor Function Classification System (GMFCS) Level I-III) who were able to obtain FSIQ scores, the Traditional method underestimated FSIQ by 3-6 points compared to the alternative methods and the difference was most pronounced for those with more severe CP as measured by the GMFCS. Conclusion: Adolescents with CP are at an inherent disadvantage when cognitive ability is assessed using the Traditional method of the WISC-V. Findings suggest clinicians should employ the Nonmotor or Motor-free methods when assessing IQ in adolescents with CP.

A validation and acceptability study of cognitive testing using switch and eye-gaze control technologies for children with motor and speech impairments: A protocol paper

Despite the importance of knowing the cognitive capabilities of children with neurodevelopmental conditions, less than one-third of children with cerebral palsy participate in standardized assessments. Globally, approximately 50% of people with cerebral palsy have an intellectual disability and there is significant risk for domain-specific cognitive impairments for the majority of people with cerebral palsy. However, standardized cognitive assessment tools are not accessible to many children with cerebral palsy, as they require manual manipulation of objects, verbal response and/or speeded response. As such, standardised assessment may result in an underestimation of abilities for children with significant motor and/or speech impairment. The overall aim of the project is to examine and compare the psychometric properties of standardised cognitive assessment tools that have been accommodated for use with either a switch device or eye-gaze control technologies, with the specific aims to: (1) Examine the psychometric properties (measurement agreement and validity) of accommodated assessment tools by comparing the performance of typically developing children on six cognitive assessment tools administered via standardised versus accommodated (switch or eye-gaze control) administration; (2) Describe and compare the performance and user experience of children with cerebral palsy on six accommodated cognitive assessments administered via switch or eye-gaze control technologies. Secondary aims are to: (1) Describe the completion rates and time to complete assessments of participants in each group; (2) Within the group with cerebral palsy, examine the effects of condition-specific characteristics (type of cerebral palsy, functional levels, and pain) and demographics (age, socio-demographic) on participation. This protocol paper describes a two-phase validation and acceptability study that utilizes a mixed-model design. This study will collect concurrent data from 80 typically developing children and 40 children with cerebral palsy, who use switch or eye-gaze control technology as alternate access communication methods. The set of instruments will measure receptive vocabulary, fluid reasoning, sustained attention, vision perception, visuospatial working memory and executive functions. Data analyses will be conducted using SPSS v. 25 and R v 4.1.0. SPSS Sample Power 3 was used for power computation and allows for a 10% drop out rate. Quantitative descriptive statistics, measurement agreement data plotting, bivariate and multiple regressions analysis will be conducted using appropriate methods.

Relationship among four functional classification systems and parent interpredicted intelligence level in children with different clinical types of cerebral palsy

OBJECTIVE

To investigate the relationships between four functional classification systems in children with cerebral palsy (CP) and parent-interpredicted intelligence level, and the functional status in clinical types of CP.

METHODS

Two hundred and twenty-five children with CP ages between 2 and 18 (mean age 6.5 ± 4.4) years included using the Surveillance of CP in Europe (SCPE) database in Turkey. Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS) and Eating and Drinking Classification System (EDACS) levels were classified by clinical observation, and intelligence quotient (IQ) was determined by parent reports.

RESULTS

Correlations were found between all functional levels; the strongest were between GMFCS-MACS (r = 0.784, p < .001), CFCS-EDACS (r = 0.772, p < .001). Strong correlations were found for the IQ-CFCS (r = 0.762, p < .001) and IQ-EDACS (r = 0.634, p < .001). Correlations were stronger in children with bilateral CP and IQ level <70.

CONCLUSIONS

Taken together, these four classification systems and reported IQ levels can adequately describe overall functioning for children with CP. Our results can guide clinicians in the rehabilitation of children with CP.

The implementation of systematic monitoring of cognition in children with cerebral palsy in Sweden and Norway

PURPOSE

Children with cerebral palsy (CP) are at risk of cognitive impairments and need to be cognitively assessed to allow for individualized interventions, if applicable. Therefore, a systematic protocol for the follow-up of cognition in children with CP, CPCog, with assessments offered at five/six and 12/13 years of age, was developed. This report presents and discusses assessment practices in Sweden and Norway following the introduction of CPCog and a quality improvement project in Norway aimed at increasing the number of children offered cognitive assessments.

MATERIALS AND METHODS

A questionnaire investigating assessment practices was sent to pediatric habilitation centers in Sweden and Norway. In Norway, the habilitation centers also participated in a quality improvement project aimed at increasing adherence to the CPCog protocol.

RESULTS

Of the respondents, 64-70% report that they assess cognition in children with all degrees of motor impairment, and 70-80% assess at the ages recommended in CPCog. Following the quality improvement project in Norway, the percentage of children assessed increased from 34 to 62%.

CONCLUSIONS

The findings illustrate that the provision of information is not sufficient to change practice. Implementation of new re/habilitation procedures is aided by targeting health care practices individually.Implications for rehabilitationChildren with cerebral palsy (CP) have increased risk of cognitive impairments that require intervention.Assessments of cognition should be offered to all children with CP because the nature of cognitive impairments may vary.Introducing a follow-up protocol of how and when to perform cognitive assessments is a step towards ensuring equal access to the services for all children with CP.A quality improvement project might be a viable method for implementing a protocol into everyday clinical practice.

Risk factors for intellectual disability in children with spastic cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a non-progressive disorder of posture and movement caused by prenatal or perinatal lesions of the brain. Children with CP are also at increased risk of other disabilities, for example, intellectual disability. Previous studies suggest the risk of intellectual disability varies in complex ways according to the type of motor impairment and perinatal factors such as gestational age.

OBJECTIVE

To determine the patterns of risk of intellectual disability in children with spastic CP.

DESIGN

Cross-sectional, population-based study using the Northern Ireland Cerebral Palsy Register.

PARTICIPANTS

Persons born in 1981-2008 with congenital bilateral or unilateral spastic CP (N=1452).

OUTCOME MEASURE

The outcome measure was severe intellectual disability (IQ <50), as reported by clinicians known to the child. Data pertaining to CP subtype, sex, gestational age, birth weight and functional level were included in analyses.

RESULTS

Severe intellectual disability was significantly more prevalent in children with bilateral spastic CP (BSCP) compared with children with unilateral spastic CP (χ² (2)=162.60, p<0.001). Compared with very preterm infants with BSCP, the risk of intellectual disability increased in moderately preterm (OR=3.97, 95% CI 1.04 to 15.23) and at-term (OR=2.51, 95% CI 1.16 to 5.44) children with BSCP.

CONCLUSIONS

Children with BSCP are at increased risk of intellectual disability, with those born at term at the highest risk. The findings highlight the importance of early screening, particularly for children with BSCP born at term.

Cerebral Palsy in Very Preterm Infants: A Nine-Year Prospective Study in a French Population-Based Tertiary Center

OBJECTIVES

To describe the prevalence of cerebral palsy (CP) at age 2 years in infants born before 33 weeks of gestation and to analyze the fetal neuroprotective effect of the antenatal administration of magnesium sulfate (MgSO₄) treatment on CP.

STUDY DESIGN

Preterm infants born before 33 weeks of gestation and discharged from the Rouen University Hospital's Neonatal Intensive Care Unit between 2007 and 2015 were included. At age 2 years, pediatricians of the perinatal network of Eure and Seine-Maritime counties administered standardized questionnaires analyzing motor, cognitive, and behavioral items, derived from the Denver and Amiel-Tison scales. A routine protocol based on MgSO₄ infusion was introduced in 2010. The primary outcome measure was the occurrence of CP according to the Surveillance of Cerebral Palsy in Europe network definition.

RESULTS

A total of 1759 very preterm infants were included, among whom 138 (7.8%) died and 148 (9.1%) were lost to follow-up. Assuming that those lost to follow-up had no CP, at 2 years, 55 of 1621 infants (3.4%; 95% CI, 2.6%-4.4%) had CP. After statistical adjustment for birth term and antenatal corticosteroid use, a significant decrease in CP was observed after implementation of a protocol of MgSO₄ administration in mothers before imminent preterm birth at <33 weeks of gestation (aOR, 0.53; 95% CI, 0.29-0.98; P = .04).

CONCLUSIONS

The prevalence of CP at 2 years after very preterm birth was low. The implementation of a neuroprotective protocol with MgSO₄ was associated with reduced CP occurrence; however, several relevant limitations must be considered for interpretation.

Systematic Monitoring of Cognition for Adults With Cerebral Palsy-The Rationale Behind the Development of the CPCog-Adult Follow-Up Protocol

Cerebral palsy (CP) comprises a heterogeneous group of conditions recognized by disturbances of movement and posture and is caused by a non-progressive injury to the developing brain. Birth prevalence of CP is about 2-2.5 per 1,000 live births. Although the motor impairment is the hallmark of the diagnosis, individuals with CP often have other impairments, including cognitive ones. Cognitive impairments may affect communication, education, vocational opportunities, participation, and mental health. For many years, CP has been considered a "childhood disability," but the challenges continue through the life course, and health issues may worsen and new challenges may arise with age. This is particularly true for cognitive impairments, which may become more pronounced as the demands of life increase. For individuals with CP, there is no one-to-one correlation between cognition and functioning in other areas, and therefore, cognition must be individually assessed to determine what targeted interventions might be beneficial. To facilitate this for children with CP, a systematic follow-up protocol of cognition, the CPCog, has been implemented in Norway and Sweden. However, no such protocol currently exists for adults with CP. Such discontinuity in healthcare services that results from lack of follow-up of cognitive functioning and subsequent needs for adjustments and interventions makes transition from pediatric to adult healthcare services challenging. As a result, a protocol for the surveillance of cognition in adults with CP, the CPCog-Adult, has been developed. It includes assessment of verbal skills, non-verbal reasoning, visual-spatial perception, and executive functioning. It is recommended to perform these assessments at least once in young adulthood and once in the mid-fifties. This report describes the process of developing the CPCog-Adult, which has a three-fold purpose: (1) to provide equal access to healthcare services to enable the detection of cognitive impairments; (2) to provide interventions that increase educational and vocational participation, enhance quality of life, and prevent secondary impairments; and (3) to collect systematic data for research purposes. The consent-based registration of data in the well-established Swedish and Norwegian national CP registries will secure longitudinal data from childhood into adulthood.

WISC-V motor-free cognitive profile and predictive factors in adolescents with cerebral palsy

BACKGROUND

The most commonly used intelligence tests - the Wechsler Scales - do not provide standardised procedures for assessing children with motor impairment, and as a result, may underestimate the intelligence quotient (IQ) of young people with CP.

AIMS

To characterise a motor-free cognitive profile of adolescents with CP using the Wechsler Intelligence Scale for Children - Fifth edition (WISC-V) and explore the influence of clinical factors on cognitive abilities.

METHODS AND PROCEDURE

The WISC-V was used to assess cognitive abilities in 70 adolescents (M = 14 years 6 months, SD = 10 months). Sixty-six adolescents (Gross Motor Function Classification System (GMFCS) Level I, n = 26 ; II, n = 23; III, n = 15; IV, n = 1; V, n = 1) obtained either a Motor-free IQ or index score using the motor-free method.

OUTCOMES AND RESULTS

MFIQ and index scores fell below the normative data and rates of borderline and impaired cognitive abilities were significantly higher in the CP group. Scores showed an uneven cognitive profile with a relative strength in verbal abilities. Severity of motor impairment and small for gestational age (SGA) were associated with lower IQ scores. A history of seizures was related to lower verbal abilities.

CONCLUSIONS AND IMPLICATIONS

Cognitive abilities of adolescents with CP are significantly below expectation compared to normative data. Severity of motor impairment, SGA, and seizures need to be recognised by health professionals as risk factors for cognitive impairment. A substantial proportion of adolescents showed borderline cognitive abilities, constituting a group with CP which are relatively neglected in the literature.

FUNCTIONAL CLASSIFICATION OF CHILDREN WITH CEREBRAL PALSY IN KRAPINA-ZAGORJE COUNTY

The aim was to study functional abilities and to create functional classification of children with cerebral palsy (CP) in Krapina-Zagorje County, based on the classification of gross and fine motor skills and associated impairments. Classification was performed according to the SCPE (Surveillance of Cerebral Palsy in Europe) criteria. We used standardized and complementary functional classification systems for cerebral palsy to create a functional profile. Research included 44 children with CP in the age range of 4 to 18 years. The results showed that the majority of children had bilateral spastic CP (63.6%), followed by unilateral spastic (22.7%) while the representation of dyskinetic CP was 9.09% and ataxic CP 4.55%. Based on the classification of gross and fine motor skills, 43.2% of children had the ability to walk, 11% of children could walk with assistive mobility devices, while 45.4% of children had a low functional level. The study also analyzed the associated impairments where higher classification score of motor impairment correlated with the severity of impairment. The results showed that children with dyskinetic CP and severe motor impairment could have mild cognitive impairment. We systematically present the neuropsychological and functional profile according to the CP type.

Psychiatric disorders in adults with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is one of the most common neurological conditions in childhood. Individuals with CP often experience various secondary conditions, including intellectual disability (ID), medical conditions, and psychiatric issues. A large number of youth with CP have psychiatric disorders; however, few studies have examined the prevalence of psychiatric issues in adults with CP at the population-level.

AIMS

To investigate the prevalence and co-occurrence of psychiatric disorders at the population-level in adults with CP only, and adults with CP and ID.

METHOD AND PROCEDURES

Using clinical information from seven Canadian data sources, we conducted a retrospective cross-sectional analysis of adults with CP, with and without ID.

OUTCOMES AND RESULTS

Adults with CP were more likely than the general population to have a psychiatric diagnosis, independent of ID status. All psychiatric disorders were more common in individuals with CP than the general population, with the exception of addiction related disorders. In most cases, having an ID substantially increased the risk of having a psychiatric disorder.

CONCLUSIONS

Adults with CP are at heightened risk for experiencing psychiatric disorders. Current findings highlight the important role health care providers play in screening for psychiatric issues in individuals with CP.

Cortical oscillations that underlie working memory are altered in adults with cerebral palsy

OBJECTIVE

This investigation used magnetoencephalography (MEG) to identify the neurophysiological mechanisms contributing to the altered cognition seen in adults with cerebral palsy (CP).

METHODS

Adults with CP (GMFCS levels I-IV) and demographically-matched controls completed a Sternberg-type working memory task during MEG. Secondarily, they completed the National Institutes of Health (NIH) cognitive toolbox. Beamforming was used to image the significant MEG oscillatory responses and the resulting images were examined using statistical parametric mapping to identify cortical activity that differed between groups.

RESULTS

Both groups had a left-lateralized decrease in alpha-beta (11-16 Hz) power across the occipital, temporal, and prefrontal cortices during encoding, as well as an increase in alpha (9-13 Hz) power across the occipital cortices during maintenance. The strength of alpha-beta oscillations in the prefrontal cortices were weaker in those with CP during encoding. Weaker alpha-beta oscillation within the prefrontal cortex was associated with poorer performance on the NIH toolbox and a higher GMFCS level.

CONCLUSIONS

Alpha-beta aberrations may impact the basic encoding of information in adults with CP, which impacts their overall cognition. Altered alpha-beta oscillation might be connected with gross motor function.

SIGNIFICANCE

This experimental work highlights the aberrant alpha-beta during encoding as possible neurophysiological mechanism of the cognitive deficiencies.

Speech-Language Profile Groups in School Aged Children with Cerebral Palsy: Nonverbal Cognition, Receptive Language, Speech Intelligibility, and Motor Function

Purpose: To explore the relationship of intelligibility, receptive language, executive functioning, and motor skills to nonverbal cognitive skills among children with cerebral palsy (CP) in different speech-language profile groups. Method: Twenty-seven children with CP aged 10-12 years old participated in the study. They completed a battery of standard clinical assessments. The relationship of various skillsets with nonverbal cognitive ability was explored using correlational procedures. Additionally, we examined pairwise differences in nonverbal cognitive skills among profile groups. Cohen's Kappa and Chi-square tests were used to study the consistency of receptive language and nonverbal cognitive performance. Results: Children who showed better nonverbal cognitive abilities demonstrated better motor, receptive language, and intelligibility skills. Nonverbal cognition was generally consistent with receptive language. Conclusion: Nonverbal cognitive impairment often co-occurs with language and speech motor impairment among children with CP. Speech-language profile groups are a useful framework for describing both communication and cognitive abilities.

Adaptive Working Memory Training Can Improve Executive Functioning and Visuo-Spatial Skills in Children With Pre-term Spastic Diplegia

Pre-term spastic diplegia (pSD) due to periventricular leukomalacia is a form of cerebral palsy in which weaknesses in executive functions are reported beyond the core visuo-spatial deficits. The study aimed at improving executive functioning and visuo-spatial skills with an evidence-based training focused on working memory in children with pSD. The intervention study followed a stepped wedge design. 19 children with pSD (11 female and 8 male; age range: 4;1–13;1 years), mild to moderate upper limb impairment and Verbal Intelligence Quotient (VIQ) >80 participated to the study. The children were trained with a home-based adaptive working memory training (CogMed®) over a 5-week period. The primary outcome measure was the CogMed Improvement index; pre- and post-test explorative neuropsychological assessment was conducted with a subset of tests from the NEPSY-II battery. Working memory training in children with pSD significantly improved trained working memory abilities (CogMed indices) as well as non-trained skills, such as visuo-spatial skills, inhibition of automatic responses and phonological processing. The results suggest that standard rehabilitation schedules for children with pSD should be integrated with trainings on executive functions.

Evaluation of Risk Factors for Epilepsy in Pediatric Patients with Cerebral Palsy

Cerebral palsy (CP) is a set of etiologically diverse symptoms that change with the child's age. It is one of the most frequent causes of motor disability in children. CP occurs at a frequency of 1.5 to 3.0 per 1000 live-born children. CP often coexists with epilepsy, which is drug-resistant in a high number of cases. The aim of the present study was to analyze the associations between preconception, prenatal, perinatal, neonatal, and infancy risk factors for epilepsy in a group of pediatric patients with CP. We retrospectively analyzed 181 children with CP (aged 4-17 years at diagnosis), hospitalized at the Department of Pediatrics and Developmental Age Neurology in Katowice in the years 2008-2016. Division into particular types of CP was based on Ingram's classification. Data were analyzed using STATISTICA 13.0 (STATSOFT; Statistica, Tulsa, OK, USA). Epilepsy was diagnosed in 102 children (56.35%), of whom 44 (43%) had drug-resistant epilepsy; only in 15 cases (14.71%) was epilepsy susceptible to treatment. The incidence of epilepsy varied between the types of CP. It occurred significantly more often in children with tetraplegia (75%), ataxic form (83%), and mixed form (80%) in comparison to diplegia (32%) and hemiplegia (38%). Maternal hypertension was found to be a risk factor for epilepsy in CP patients (OR = 12.46, p < 0.001) as well as for drug-resistant epilepsy (the odds ratio (OR) = 9.86, p = 0.040). Delivery by cesarean section increased the risk of epilepsy in the CP patients over two-fold (OR = 2.17, p = 0.012). We observed also that neonatal convulsions significantly increased the risk for epilepsy (OR = 3.04, p = 0.011) as well as drug-resistant epilepsy (OR = 4.02, p = 0.002). In conclusion, maternal hypertension, neonatal convulsions, and delivery by cesarean section were the most important factors increasing the risk of epilepsy as well as drug-resistant epilepsy in the analyzed group of patients with CP.

Cognitive functioning in children with cerebral palsy

Children with cerebral palsy (CP) have an increased risk of cognitive impairments. This narrative review of the literature discusses assessment of cognition in children with CP, presents the most salient characteristics of cognitive functioning pertaining to each subtype, and discusses the relationships between brain injury, functioning, and intervention from a developmental perspective. A search for original studies of cognitive functioning in children with different subtypes of CP was performed. The search resulted in 81 unique hits. There were few studies with a representative sample of children with CP where all participants were individually assessed. Cognitive functioning in children with the most severe motor impairments were often assumed and not assessed. Furthermore, there was a confounding of IQ below 70 and intellectual disability, possibly leading to an overestimation of the prevalence of intellectual disability. Longitudinal neuropsychological studies, including also very young children and those with the most severe speech and motor impairments, as well as intervention studies, are called for. WHAT THIS PAPER ADDS: Few studies have assessed cognition in a representative sample of children with cerebral palsy. Cognition in children with severe motor impairment is often assumed, not assessed. Lack of assessment may lead to overestimating the prevalence of intellectual disability. Lowered cognitive functioning in older children highlights the need for longitudinal studies.

Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options

Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. According to the up-to-date definition, CP is a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The CP definition has evolved over time; the problem is aetiologically and clinically very heterogeneous. According to European data, the average frequency of CP is 2.08 per 1000 live births, but in the group of children born with a body weight below 1500 g, the frequency is 70 times higher when compared with the group of children with a body weight over 2500 g at birth. The risk factors for CP can be divided into pre-conception, prenatal, perinatal and postnatal ones. CP commonly co-exists with epilepsy, in particular drug-resistant epilepsy, but also with mental retardation, visual and hearing impairment, as well as feeding and behavioral disorders. The degree of motor problem varies from mild to very severe making the child totally dependent on caregivers. Cerebral palsy is divided into forms depending on the type of motor disorders which dominate the clinical presentation; the traditional classifications by Ingram and Hagberg have now been replaced by the Surveillance of Cerebral Palsy in Europe classification which divides CP into spastic, dyskinetic and ataxic forms. Although cerebral palsy is a clinical diagnosis, modern diagnostic imaging provides information that allows the division of the results of magnetic resonance imaging in children with cerebral palsy into five groups according to the magnetic resonance imaging classification system. Just as the clinical presentation and the factors predisposing for CP are very diverse, treatment is also a very complex problem. Modern treatment of spasticity includes both botulinum toxin therapies and surgical techniques, eg, rhizotomy. The authors present current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy.

Improving the Health of Individuals With Cerebral Palsy: Protocol for the Multidisciplinary Research Program MOVING ON WITH CP

Background

Cerebral palsy (CP) is one of the most common early onset disabilities globally. The causative brain damage in CP is nonprogressive, yet secondary conditions develop and worsen over time. Individuals with CP in Sweden and most of the Nordic countries are systematically followed in the national registry and follow-up program entitled the Cerebral Palsy Follow-Up Program (CPUP). CPUP has improved certain aspects of health care for individuals with CP and strengthened collaboration among professionals. However, there are still issues to resolve regarding health care for this specific population.

Objective

The overall objectives of the research program MOVING ON WITH CP are to (1) improve the health care processes and delivery models; (2) develop, implement, and evaluate real-life solutions for Swedish health care provision; and (3) evaluate existing health care and social insurance benefit programs and processes in the context of CP.

Methods

MOVING ON WITH CP comprises 9 projects within 3 themes. Evaluation of Existing Health Care (Theme A) consists of registry studies where data from CPUP will be merged with national official health databases, complemented by survey and interview data. In Equality in Health Care and Social Insurance (Theme B), mixed methods studies and registry studies will be complemented with focus group interviews to inform the development of new processes to apply for benefits. In New Solutions and Processes in Health Care Provision (Theme C), an eHealth (electronic health) procedure will be developed and tested to facilitate access to specialized health care, and equipment that improves the assessment of movement activity in individuals with CP will be developed.

Results

The individual projects are currently being planned and will begin shortly. Feedback from users has been integrated. Ethics board approvals have been obtained.

Conclusions

In this 6-year multidisciplinary program, professionals from the fields of medicine, social sciences, health sciences, and engineering, in collaboration with individuals with CP and their families, will evaluate existing health care, create conditions for a more equal health care, and develop new technologies to improve the health care management of people with CP.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13883

Inhibitory control and temporal perception in cerebral palsy

Prepotent response inhibition and temporal perception abilities were explored in a sample of individuals with cerebral palsy relative to typically developing peers. The extent to which inhibitory control difficulties might affect temporal processing was also investigated. For this purpose, two inhibitory control tasks and two duration estimation tasks were given to the groups of cerebral palsy and typically developing children. Results showed inhibition and temporal perception problems in the group with cerebral palsy. A relationship was found between inhibition and temporal estimation performances, which indicates that inhibitory control contributes, at least partially, to acquisition of the temporal processing ability.

Executive function and general intellectual functioning in dyskinetic cerebral palsy: Comparison with spastic cerebral palsy and typically developing controls

AIM

To comprehensively describe intellectual and executive functioning (EF) in people with dyskinetic cerebral palsy (DCP), by comparing their performance with that of: 1) age- and sex-matched typically developing controls (TDC); and 2) participants with spastic cerebral palsy (SCP) matched for age, sex, term/preterm and gross motor function classification system (GMFCS).

METHOD

This cross-sectional study was conducted by the University of Barcelona in collaboration with five institutions. Participants were people with DCP (n = 52; 24 females, median age 20.5 y: 5mo, interquartile range [IQR] = 13.75 y: 7mo; GMFCS I-V). As comparison groups, participants with SCP (n = 20; 10 females, median age = 20.5 y: 5.5mo, IQR = 13.75 y 9mo; GMFCS I-V) and TDC (n = 52; 24 females, median age = 20 y: 4mo, IQR = 12 y 7mo) were included. Intelligence and EF were assessed using common tests in all participants.

RESULTS

Both CP groups had lower intelligence than TDC and performed poorer in almost all EF tasks. Intelligence was higher in DCP than SCP (z = -2.51, p = 0.01). Participants with DCP also performed significantly better in goal-setting tasks (z = 2.27, p = 0.03) and information processing (z = -2.54, p = 0.01) than those with SCP.

CONCLUSION

People with DCP present lower general intellectual functioning and poorer EF across multiple domains than typically developing controls. People with DCP have higher general intellectual functioning and better EF than people with SCP when levels of motor severity are similar.

Sense of autonomy and daily and scholastic functioning among children with cerebral palsy

BACKGROUND

There is growing evidence that children's sense of autonomy is an important psychological need closely linked with the development of self-esteem and motivation. Among children with physical disabilities, motor or cognitive limitations may negatively affect child's sense of autonomy (CSA) and competency.

PURPOSE

To examine how sense of autonomy among children with cerebral palsy (CP) directly and indirectly relates to their activity of daily living (ADL) and scholastic performance.

METHODS

Seventy-three children with CP and their mothers participated in this study. Child's ADL skills and scholastic performance were assessed using the Pediatric Evaluation Disability Inventory (PEDI) and the Scholastic Skills Rating Scale (SSRS), respectively. Level of impairment was assessed using the Gross Motor Function Measure-66 (GMFM-66). CSA was established via videotaped mother-child interactions. Regression analyses were conducted to examine factors predicting child's functional level (ADL and scholastic). The overall model was tested for goodness-of-fit and test of mediation.

RESULTS

GMFM and CSA significantly predicted child's ADL and scholastic functioning. GMFM explained 15% of the variance for CSA, 84% for PEDI, and 24% for scholastic functioning. CSA positively mediated the association between GMFM and child's ADL skills. GMFM was positively associated with CSA.

CONCLUSION

Motor impairment has a substantial impact on child's level of functioning. However, child's functioning is a complex construct that is also affected by her or his sense of autonomy. Therefore, sense of autonomy can serve as a potential point of intervention to improve functioning among children with CP.

Intellectual disability in cerebral palsy: a population-based retrospective study

AIM

A population-based observational study design was used to describe the epidemiology of intellectual disability in cerebral palsy (CP) in terms of clinical and neuroimaging associations, and to report the impact of intellectual disability on utilization of health services and length of survival.

METHOD

Population CP registry data were used to retrospectively assess the frequency of intellectual disability and strength of associations between intellectual disability and mobility, epilepsy, vision, hearing, communication, and neuroimaging patterns (n=1141). Data linkage was undertaken to assess usage of hospital inpatient and emergency department services. Survival analysis was performed in a 30-year birth cohort (n=3248).

RESULTS

Intellectual disability, present in 45% of the cohort, was associated with non-ambulation (47% vs 8%), later walking (mean 2y 7mo vs 1y 9mo), hypotonic (8% vs 1%) or dyskinetic (9% vs 5%) CP, a quadriplegic pattern of motor impairment (42% vs 5%), epilepsy (52% vs 12%), more emergency and multi-day hospital admissions, and reduced 35-year survival (96% vs 71%). Grey matter injuries (13% vs 6%), malformations (18% vs 6%), and miscellaneous neuroimaging patterns (12% vs 4%) were more common in people with intellectual disability.

INTERPRETATION

Intellectual disability adds substantially to the overall medical complexity in CP and may increase health and mortality disparities.

WHAT THIS STUDY ADDS

Cerebral maldevelopments and grey matter injuries are associated with higher intellectual disability rates. Health care is more 'crisis-driven' and 'reactive' in children with co-occurring intellectual disability. Length of survival is reduced in individuals with CP and co-occurring intellectual disability.

Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study

Background

Motor outcomes of children with unilateral cerebral palsy are clearly documented and well understood, yet few studies describe the cognitive functioning in this population, and the associations between the two is poorly understood. Using two hands together in daily life involves complex motor and cognitive processes. Impairment in either domain may contribute to difficulties with bimanual performance. Research is yet to derive whether, and how, cognition affects a child’s ability to use their two hands to perform bimanual tasks.

Methods/Design

This study will use a prospective, cross-sectional multi-centre observational design. Children (aged 6–12 years) with unilateral cerebral palsy will be recruited from one of five Australian treatment centres. We will examine associations between cognition, bimanual performance and brain neuropathology (lesion type and severity) in a sample of 131 children. The primary outcomes are: Motor - the Assisting Hand Assessment; Cognitive - Executive Function; and Brain – lesion location on structural MRI. Secondary data collected will include: Motor - Box and Blocks, ABILHAND- Kids, Sword Test; Cognitive – standard neuropsychological measures of intelligence. We will use generalized linear modelling and structural equation modelling techniques to investigate relationships between bimanual performance, executive function and brain lesion location.

Discussion

This large multi-centre study will examine how cognition affects bimanual performance in children with unilateral cerebral palsy. First, it is anticipated that distinct relationships between bimanual performance and cognition (executive function) will be identified. Second, it is anticipated that interrelationships between bimanual performance and cognition will be associated with common underlying neuropathology. Findings have the potential to improve the specificity of existing upper limb interventions by providing more targeted treatments and influence the development of novel methods to improve both cognitive and motor outcomes in children with unilateral cerebral palsy.

Trial registration

ACTRN12614000631606; Date of retrospective registration 29/05/2014.

Neuropsychological profiles of children with cerebral palsy

PURPOSE

To explore factors contributing to variability in cognitive functioning in children with cerebral palsy (CP).

METHOD

A geographical cohort of 70 children with CP was assessed with tests of language comprehension, visual-spatial reasoning, attention, working memory, memory, and executive functioning. Mean age was 9;9 years (range 5;1-17;7), 54.3% were girls, and 50.0% had hemiplegic, 25.7% diplegic, 12.9% quadriplegic, and 11.4% dyskinetic CP. For the participants with severe motor impairments, assessments were adapted for gaze pointing. A cognitive quotient (CQ) was computed.

RESULTS

Mean CQ was 78.5 (range 19-123). Gross motor functioning, epilepsy, and type of brain injury explained 35.5% of the variance in CQ (F = 10.643, p = .000).

CONCLUSION

Twenty-four percent had an intellectual disability, most of them were children with quadriplegic CP. Verbal comprehension and perceptual reasoning scores did only differ for the 21% with an uneven profile, of whom two-thirds had challenges with perceptual reasoning.

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.

The Development of a Motor-Free Short-Form of the Wechsler Intelligence Scale for Children–Fifth Edition

Purpose. This study aimed to develop a motor-free short-form of the Wechsler Intelligence Scale for Children–Fifth Edition (WISC-V) that allows clinicians to estimate the Full Scale Intelligence Quotients of youths with motor impairments. Method. Using the reliabilities and intercorrelations of six WISC-V motor-free subtests, psychometric methodologies were applied to develop look-up tables for four Motor-free Short-form indices: Verbal Comprehension Short-form, Perceptual Reasoning Short-form, Working Memory Short-form, and a Motor-free Intelligence Quotient. Index-level discrepancy tables were developed using the same methods to allow clinicians to statistically compare visual, verbal, and working memory abilities. Results. The short-form indices had excellent reliabilities ( r = .92-.97) comparable to the original WISC-V. Conclusion. This motor-free short-form of the WISC-V is a reliable alternative for the assessment of intellectual functioning in youths with motor impairments. Clinicians are provided with user-friendly look-up tables, index level discrepancy tables, and base rates, displayed similar to those in the WISC-V manuals to enable interpretation of assessment results.

White matter integrity in dyskinetic cerebral palsy: Relationship with intelligence quotient and executive function

BACKGROUND

Dyskinetic cerebral palsy (CP) is one of the most disabling motor types of CP and has been classically associated with injury to the basal ganglia and thalamus. Although cognitive dysfunction is common in CP, there is a paucity of published quantitative analyses investigating the relationship between white matter (WM) microstructure and cognition in this CP type.

AIMS

This study aims (1) to compare brain WM microstructure between people with dyskinetic CP and healthy controls, (2) to identify brain regions where WM microstructure is related to intelligence and (3) to identify brain regions where WM microstructure is related to executive function in people with dyskinetic CP and (4) to identify brain regions where the correlations are different between controls and people with CP in IQ and executive functions.

PATIENTS AND METHODS

Thirty-three participants with dyskinetic CP (mean ± SD age: 24.42 ± 12.61, 15 female) were age and sex matched with 33 controls. Participants underwent a comprehensive neuropsychological battery to assess intelligence quotient (IQ) and four executive function domains (attentional control, cognitive flexibility, goal setting and information processing). Diffusion weighted MRI scans were acquired at 3T. Voxel-based whole brain groupwise analyses were used to compare fractional anisotropy (FA) and of the CP group to the matched controls using a general lineal model. Further general linear models were used to identify regions where white matter FA correlated with IQ and each of the executive function domains.

RESULTS

White matter FA was significantly reduced in the CP group in all cerebral lobes, predominantly in regions connected with the parietal and to a lesser extent the temporal lobes. There was no significant correlation between IQ or any of the four executive function domains and WM microstructure in the control group. In participants with CP, lower IQ was associated with lower FA in all cerebral lobes, predominantly in locations that also showed reduced FA compared to controls. Attentional control, goal setting and information processing did not correlate with WM microstructure in the CP group. Cognitive flexibility was associated with FA in regions known to contain connections with the frontal lobe (such as the superior longitudinal fasciculus and cingulum) as well as regions not known to contain tracts directly connected with the frontal lobe (such as the posterior corona radiata, posterior thalamic radiation, retrolenticular part of internal capsule, tapetum, body and splenium of corpus callosum).

CONCLUSION

The widespread loss in the integrity of WM tissue is mainly located in the parietal lobe and related to IQ in dyskinetic CP. Unexpectedly, executive functions are only related with WM microstructure in regions containing fronto-cortical and posterior cortico-subcortical pathways, and not being specifically related to the state of fronto-striatal pathways which might be due to brain reorganization. Further studies of this nature may improve our understanding of the neurobiological bases of cognitive impairments after early brain insult.

Intelligence, Functioning, and Related Factors in Children with Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is the most common significant motor impairment in childhood. CP is defined as a primary disorder of posture and movement; however, intellectual impairment is prevalent in children with CP. The purpose of this study was to examine the intelligence level associated with gross motor function and hand function, type of CP, the presence of comorbid disorders such as epilepsy, and other factors.

METHODS

In total, 107 children with CP were included. Age, gender, prenatal/natal/postnatal risk factors, type of CP, and presence of other neurodevelopmental disorders were recorded as demographic findings. Intellectual functions of the patients were determined by clinical assessment, adaptive function of daily life, and individualized, standardized intelligence testing. The gross motor function and hand function of the patients were classified using the "Gross Motor Function Classification System" and "Bimanual Fine Motor Function" measurements, respectively.

RESULTS

The mean age of the patients was 8.10±3.43 years (2-16 years). The study included 63 (58.9%) male patients and 44 (41.1%) female patients. During clinical typing, 80.4% of the patients were spastic, 11.2% were mixed, 4.7% were dyskinetic, and 3.7% were ataxic. Intellectual functioning tests found 26.2% of the children within the intellectual norm and that 10% of the children had a borderline intellectual disability, 16% of them had a mild intellectual disability, 17% of them had a moderate intellectual disability, and 30.8% of them had a severe intellectual disability. No significant relationship was determined between the CP type and intellectual functioning (p>0.05). Intellectual functioning was found to be significantly correlated with hand functions and motor levels (p<0.001). Factors related with intellectual functioning were neonatal convulsion, epilepsy, and speech disorders.

CONCLUSION

Intelligence assessment should be an essential part of CP evaluation and research. There is not enough reliable knowledge, unanimity regarding validity data, and population-specific norms in the intelligence assessments of children with CP. Research is required to assess properly intelligence for children with CP.

Pain assessment in the course of cerebral palsy - a review of methods used in the practice of a physiotherapist, doctor and psychologist

Cerebral palsy (CP) is a syndrome in which movement and posture disorders are progressive, along with the stationary nature of damage to the central nervous system. Despite the heterogeneity of clinical and functional status, patients with CP are a group of patients at high-risk of the occurrence of diverse pain. The aim of this study was to review literature on the phenomenon of pain in the course of cerebral palsy. An attempt was made to present the characteristics of the phenomenon of pain, and gather tools for its evaluation. A review of Polish and English language literature, in which the issue of pain in the course of cerebral palsy was discussed (in terms of epidemiology, characteristics and evaluation methods). Research papers and reports from the past 15 years included in the databases: PubMed, Medline and websites of Polish medical publishing houses, were analyzed. The works were searched using the key words: cerebral palsy, mental retardation, pain, pain assessment scales. Patients with cerebral palsy – due to their chronic health problems and performed diagnostic-treatment and physiotherapeutic treatments – are at risk of experiencing acute and chronic pain. There is a need to improve knowledge regarding the phenomenon of pain in patients with CP. The optimal course of therapy in this group of patients requires comprehensive and multi-faceted co-operation of doctors, physiotherapists, psychologists and patients as well as their immediate caregivers. Professionals working with patients suffering from CP should be aware of the potential pain causes, possess assessment tools and have the skills and, above all, the desire to use them. cerebral palsy, pain, pain assessment Received: 18.09.2016; accepted: 22nd Jan. 2017

Spastic diplegia in preterm-born children: Executive function impairment and neuroanatomical correlates

BACKGROUND

The neuropsychological literature on preterm-born children with spastic diplegia due to periventricular leukomalacia is convergent in reporting deficits in non-verbal intelligence and in visuo-spatial abilities. Nevertheless, other cognitive functions have found to be impaired, but data are scant and not correlated with neuroimaging findings.

AIMS

This study analyzes the neuropsychological strengths and weaknesses in preterm-born children with spastic diplegia (pSD) and their relationships with neuroanatomical findings, investigated by a novel scale for MRI classification.

METHODS AND PROCEDURES

Nineteen children with pSD, mild to moderate upper limb impairment and Verbal IQ>80, and 38 normal controls were evaluated with a comprehensive neuropsychological battery (NEPSY-II), assessing Attention/Executive Functioning, Language, Memory, Sensorimotor, Social Perception and Visuospatial Processing domains. The MRIs were quantitatively scored for lesion severity.

OUTCOMES AND RESULTS

The results showed that, beyond core visuo-spatial and sensory-motor deficits, impairments in attention and executive functions were present in more than half of the sample, particularly in children with damage to the anterior corpus callosum.

CONCLUSIONS AND IMPLICATIONS

The findings are discussed in terms of clinical and rehabilitative implications tailored for pSD subgroups diversified for neuropsychological and neuroanatomical characteristics.

Strengths and challenges faced by school-aged children with unilateral CP described by the Five To Fifteen parental questionnaire

PURPOSE

The purpose of this study was to describe motor and non-motor (e.g. cognitive, social, and behavioral) challenges faced in daily life by children with unilateral cerebral palsy (UCP).

METHODS

In this cross-sectional study, parents completed the Five to Fifteen questionnaire and provided demographic information for 46 children aged 6-15 years (mean 11.01 ± 2.89 SD).

RESULTS

Most children were reported to have problems in both motor and non-motor domains, ranging from 20 to 92% depending on the domain. Perception and learning were the non-motor functions most commonly reported as challenging (63 and 65%, respectively). The total number of problems was significantly higher in age groups above 9 years. The correlation between all domains was high, but was consistently higher with the fine motor sub-domain, which could be used to predict executive function, perception, memory, and learning outcomes (R²=0.502, 0.642, 0.192, 0.192).

CONCLUSION

Most children with CP have everyday challenges beyond their primary motor deficiencies.

Measuring intellectual ability in cerebral palsy: The comparison of three tests and their neuroimaging correlates

Standard intelligence scales require both verbal and manipulative responses, making it difficult to use in cerebral palsy and leading to underestimate their actual performance. This study aims to compare three intelligence tests suitable for the heterogeneity of cerebral palsy in order to identify which one(s) could be more appropriate to use. Forty-four subjects with bilateral dyskinetic cerebral palsy (26 male, mean age 23 years) conducted the Raven's Coloured Progressive Matrices (RCPM), the Peabody Picture Vocabulary Test-3rd (PPVT-III) and the Wechsler Nonverbal Scale of Ability (WNV). Furthermore, a comprehensive neuropsychological battery and magnetic resonance imaging were assessed. The results show that PPVT-III gives limited information on cognitive performance and brain correlates, getting lower intelligence quotient scores. The WNV provides similar outcomes as RCPM, but cases with severe motor impairment were unable to perform it. Finally, the RCPM gives more comprehensive information on cognitive performance, comprising not only visual but also verbal functions. It is also sensitive to the structural state of the brain, being related to basal ganglia, thalamus and white matter areas such as superior longitudinal fasciculus. So, the RCPM may be considered a standardized easy-to-administer tool with great potential in both clinical and research fields of bilateral cerebral palsy.

The Effects of the Severity of Periventricular Leukomalacia on the Neuropsychological Outcomes of Preterm Children

This study investigates the developmental outcomes of preterm children according to severity of periventricular leukomalacia. One hundred preterm children with periventricular leukomalacia evident on brain magnetic resonance imaging and who had undergone neuropsychologic evaluation were selected. Intellectual disability was noted in 27.8% of the children with mild periventricular leukomalacia, 53.2% with moderate periventricular leukomalacia, and 77.1% with severe periventricular leukomalacia. The rates of major neurodevelopmental impairments such as cerebral palsy or intellectual disability were related to the severity of periventricular leukomalacia but not to gestational age or epilepsy. There were significant differences in the intelligence quotient (IQ) and social maturity quotient between 3 groups of periventricular leukomalacia. The performance IQ was significantly lower than the verbal IQ. Behavioral problems were noted in about one-third of the children but the rate was not related with the severity of periventricular leukomalacia. Our study revealed the significant associations between severity of periventricular leukomalacia and cognitive and social adaptive functions in the preterm children.

Profile of associated impairments at age 5 years in Australia by cerebral palsy subtype and Gross Motor Function Classification System level for birth years 1996 to 2005

AIM

To describe the distribution of impairments among persons with cerebral palsy (CP) in a large Australian cohort.

METHOD

Records of persons on the Australian Cerebral Palsy Register (ACPR) (n=3466) born from 1996 to 2005 were reviewed to extract year of birth, sex, CP subtype, Gross Motor Function Classification System (GMFCS) level, and impairments in vision, hearing, speech, intellect, and epilepsy. The distributions of GMFCS levels and CP subtype were plotted, and the proportions of each level of impairment were tabulated and presented as stacked graphs within the GMFCS and CP subtype distributions.

RESULTS

The proportions of persons with CP with each associated impairment increased with increasing GMFCS level. Compared with other spastic CP subtypes, individuals with spastic quadriplegia had higher frequencies of all associated impairments. Other than epilepsy, which was most prevalent in persons with spastic quadriplegia (53%), all impairments were most frequent in non-spastic CP subtypes. Hearing impairment was recorded for 21% of persons with dyskinesia whereas the hypotonic subtype had the highest prevalence of visual impairment (57%), intellectual impairment (90%), and speech impairment (95%).

INTERPRETATION

Distributions of associated impairments across all GMFCS levels and CP subtypes in a large cohort are presented in formats suitable for clinical use and discussion with families.

The impact of visual impairment on the ability to perform activities of daily living for persons with severe/profound intellectual disability

BACKGROUND

The ability to perform activities of daily living (ADL) as a component of participation is one of the factors that contribute to quality of life. The ability to perform ADL for persons experiencing severe/profound intellectual disability (ID) may be reduced due to their cognitive and physical capacities. However, until recently, the impact of the significantly prevalent visual impairments on the performance of activities of daily living has not yet been revealed within this group.

AIM

The purpose of this prospective cross-sectional study was to investigate the impact of visual impairment on the performance of activities of daily living for persons with a severe/profound intellectual disability.

METHOD

The Barthel Index (BI) and Comfortable Walking Speed (CWS) were used to measure the ability of performing activities of daily living (ADL) in 240 persons with severe/profound ID and having Gross Motor Functioning Classification System (GMFCS) levels I, II or III; this included 120 persons with visual impairment. The impact of visual impairment on ADL was analyzed with linear regression.

RESULTS

The results of the study demonstrated that visual impairment slightly affects the ability of performing activities of daily living (BI) for persons experiencing a severe/profound intellectual disability. GMFCS Levels II or III, profound ID level, and visual impairment each have the effect of lowering BI scores. GMFCS Levels II or III, and profound ID level each have the effect of increasing CWS scores, which indicates a lower walking speed. A main effect of visual impairment is present on CWS, but our results do show a substantive interaction effect between GMFCS level III and visual impairment on Comfortable Walking Speed in persons with a severe/profound intellectual disability.

CONCLUSIONS

Visual impairment has a slight effect on ability to perform ADL in persons experiencing severe/profound ID.