Mental health in children with cerebral palsy: does screening capture the complexity?

The effects of neurofeedback training for children with cerebral palsy and co-occurring attention deficits: A pilot study

BACKGROUND

Limited research exists regarding the effectiveness of electroencephalogram (EEG) neurofeedback training for children with cerebral palsy (CP) and co-occurring attention deficits (ADs), despite the increasing prevalence of these dual conditions. This study aimed to fill this gap by examining the impact of neurofeedback training on the attention levels of children with CP and AD.

METHODS

Nineteen children with both CP and co-occurring ADs were randomly assigned to either a neurofeedback or control group. The neurofeedback group received 20 sessions of training, lasting approximately 1 h per day, twice a week. Theta/beta ratios of the quantitative electroencephalography (QEEG) recordings were measured pre-training and post-training in the resting state. The Continuous Performance Test (CPT), the Test of Visual Perceptual Skills-3rd Version (TVPS-3) and the Conners' Parent Rating Scale (CPRS) were measured at pre- and post-training.

RESULTS

The neurofeedback group showed both decreased theta/beta ratios compared with control group (p = 0.04) at post-training and a within-group improvement during training (p = 0.02). Additionally, the neurofeedback group had a trend of decreased omission rates of the CPT (p = 0.08) and the visual sequential memory and the visual closure subscores in the TVPS-3, compared with the control group (p = 0.02 and p = 0.01, respectively).

CONCLUSIONS

The results suggested that children with CP and co-occurring AD may benefit from neurofeedback training in their attention level. Further research is needed to explore long-term effects and expand its application in this population.

Use of complementary and alternative medicine in children affected by oncologic, neurologic and liver diseases: a narrative review

Complementary and alternative medicine (CAM) consist of a broad group of restorative resources often linked to existing local cultures and established health care systems and are also increasingly used in children with some serious illnesses. In this narrative review, we examine the epidemiology of the use, efficacy, and safety of complementary and alternative medicine in pediatric oncology, neurology, and hepatology. We searched for relevant articles published in Pubmed evaluating CAM use and its efficacy in safety in children affected by oncologic, neurologic and liver diseases. CAM is used to improve the success of conventional therapies, but also to alleviate the pain, discomfort, and suffering resulting from the diseases and their treatment, which are often associated with a significant burden of adverse effects. CAM use must be evaluated in children with neurological, oncological and liver diseases.

PredictMed-epilepsy: A multi-agent based system for epilepsy detection and prediction in neuropediatrics

BACKGROUND AND OBJECTIVE

Epileptic seizures are associated with a higher incidence of Developmental Disabilities and Cerebral Palsy. Early evaluation and management of epilepsy is strongly recommended. We propose and discuss an application to predict epilespy (PredictMed-Epilepsy) and seizures via a deep-learning module (PredictMed-Seizures) encompassed within a multi-agent based healthcare system (PredictMed-MHS); this system is meant, in perspective, to be integrated into a clinical decision support system (PredictMed-CDSS). PredictMed-Epilespy, in particular, aims to identify factors associated with epilepsy in children with Developmental Disabilities and Cerebral Palsy by using a prediction-learning model named PredictMed. PredictMed-epilespy methods: We performed a longitudinal, multicenter, double-blinded, descriptive study of one hundred and two children with Developmental Disabilities and Cerebral Palsy (58 males, 44 females; 65 inpatients, 37 outpatients; 72 had epilepsy - 22 of intractable epilepsy, age: 16.6±1.2y, range: 12-18y). Data from 2005 to 2021 on Cerebral Palsy etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor skills, and eating and drinking abilities were collected. The machine-learning model PredictMed was exploited to identify factors associated with epilepsy. The guidelines of the "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis" Statement (TRIPOD) were followed. PredictMed-epilepsy results: Cerebral Palsy etiology [(prenatal > perinatal > postnatal causes) p=0.036], scoliosis (p=0.048), communication (p=0.018) and feeding disorders (p=0.002), poor motor function (p<0.001), intellectual disabilities (p=0.007), and type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p=0.002)] were associated with having epilepsy. The prediction model scored an average of 82% of accuracy, sensitivity, and specificity. Thus, PredictMed defined the computational phenotype of children with Developmental Disabilities/Cerebral Palsy at risk of epilepsy. Novel contribution of the work: We have been developing and we have prototypically implemented a Multi-Agent Systems (MAS) that encapsulates the PredictMed-Epilepsy module. More specifically, we have implemented the Patient Observing MAS (PoMAS), which, as a novelty w.r.t. the existing literature, includes a complex event processing module that provides real-time detention of short- and long-term events related to the patient's condition.

Prediction Model for Identifying Factors Associated with Epilepsy in Children with Cerebral Palsy

(1) Background: Cerebral palsy (CP) is associated with a higher incidence of epileptic seizures. This study uses a prediction model to identify the factors associated with epilepsy in children with CP. (2) Methods: This is a retrospective longitudinal study of the clinical characteristics of 102 children with CP. In the study, there were 58 males and 44 females, 65 inpatients and 37 outpatients, 72 had epilepsy, and 22 had intractable epilepsy. The mean age was 16.6 ± 1.2 years, and the age range for this study was 12−18 years. Data were collected on the CP etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor function, and feeding abilities from 2005 to 2020. A prediction model, Epi-PredictMed, was implemented to forecast the factors associated with epilepsy. We used the guidelines of “Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis” (TRIPOD). (3) Results: CP etiology [(prenatal > perinatal > postnatal causes) p = 0.036], scoliosis (p = 0.048), communication (p = 0.018), feeding disorders (p = 0.002), poor motor function (p < 0.001), intellectual disabilities (p = 0.007), and the type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p = 0.002)] were associated with having epilepsy. The model scored an average of 82% for accuracy, sensitivity, and specificity. (4) Conclusion: Prenatal CP etiology, spasticity, scoliosis, severe intellectual disabilities, poor motor skills, and communication and feeding disorders were associated with epilepsy in children with CP. To implement preventive and/or management measures, caregivers and families of children with CP and epilepsy should be aware of the likelihood that these children will develop these conditions.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

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.

Emotional Well-Being of Children and Youth with Severe Motor and Communication Impairment: A Conceptual Understanding

BACKGROUND

Children and youth with severe motor and communication impairment (SMCI) have difficulty providing self-expression through typical speech, writing with a paper and pencil, or using a standard keyboard. Their emotional expressions can be missed by peers and novel caregivers.

PURPOSE

To describe the indicators and components of emotional experiences for children/youth with SMCI.

METHODS

Primary guardians of nine children/youth with SMCI were involved in photo/video data collection and follow-up qualitative interviews. Twenty-one familiar people (e.g., friends, family members, and/or care team) participated in semi-structured qualitative interviews.

RESULTS

A conceptual understanding of emotional well-being specific to the population has been developed consisting of nine themes, encompassed by four domains i) Core Attributes, ii) Personal Experiences, iii) Surroundings, iv) Expression and Reception.

CONCLUSIONS

Emotional experiences of children/youth with SMCI are diversely expressed. Primary guardian and familiar person insight can be amplified to positively impact care and participation.

Mental Health in Pre-Adolescents with Cerebral Palsy: Exploring the Strengths and Difficulties Questionnaire as a Screening Tool in a Follow-Up Study including Multi-Informants

There is a high prevalence of mental health problems in children with Cerebral Palsy (CP). Still, knowledge regarding the trajectory of mental health problems throughout childhood and differences according to informants is lacking. There is also a need for more knowledge regarding the validity of mental health screening tools. In the present study, we assessed changes in parent-rated mental health problems in a cohort of 36 children with CP from school-starting age to pre-adolescence and differences in mental health problems according to informants. Further, we assessed the validity of the Strengths and Difficulties Questionnaire (SDQ) for psychiatric disorders. The study cohort was assessed using the SDQ and a child psychiatric diagnostic instrument at school-starting age and at pre-adolescence. Mean parental SDQ scores increased significantly for emotional, hyperactivity and total problems. Self-reported impact of mental health problems was significantly lower than parent-reported impact, and parents and pre-adolescents reported significantly higher mean scores than teachers for emotional problems, conduct problems and total problem scores. Validated against psychiatric disorders, the SDQ was satisfactory for screening children with CP for risk of psychiatric disorders at pre-adolescence. We recommend that mental health screening be integrated into the regular follow-up for children with CP.

Correlates of Mental Health in Adolescents and Young Adults with Cerebral Palsy: A Cross-Sectional Analysis of the MyStory Project

Background: It is important to gain a better understanding of mental health issues in adolescents and young adults (AYA) with cerebral palsy (CP). In this cross-sectional study, we explore if demographics, social and clinical questionnaire scores, and cortisol levels in hair samples from AYA with CP are associated with higher scores on anxiety and/or depression questionnaires. Methods: Data from a community-based sample of 63 AYA with CP (30 females; ages 16 to 30 (median age of 25)) were analyzed. Forty-one (65%) participants (20 females) provided a hair sample. Outcomes were assessed using bivariate linear regression analyses and hierarchical regression analyses. Results: Clinical depressive and anxiety symptoms were present in 33% and 31% of participants, respectively. Family functioning, B = 9.62 (95%CI: 5.49–13.74), fatigue, B = 0.15 (95%CI: 0.05–0.25), and pain, B = 1.53 (95%CI: 0.48–2.58) were statistically significant predictors of depressive symptoms. Fatigue, B = 0.24 (95%CI: 0.12–0.35) and pain, B = 1.63 (95%CI: 0.33–2.94) were statistically significant predictors of anxiety. Cortisol levels from hair samples were not found to be associated with depressive symptoms or anxiety. Conclusions: A high prevalence of mental health problems and co-occurring physical problems was found in AYA with CP. Integrating mental support into regular care for AYA with CP is recommended.

Psychological Interventions for Individuals With Acquired Brain Injury, Cerebral Palsy, and Spina Bifida: A Scoping Review

BACKGROUND

With current medical advancements, more adolescents with neurodevelopmental disorders are transitioning from child- to adult-centred health care services. Therefore, there is an increasing demand for transitional services to help navigate this transition. Health care transitions can be further complicated by mental health challenges prevalent among individuals with cerebral palsy (CP), spina bifida (SB), and childhood onset acquired brain injury (ABI). Offering evidence-based psychological interventions for these populations may improve overall outcomes during transition period(s) and beyond. The objective of this scoping review is to identify key characteristics of psychological interventions being used to treat the mental health challenges of adolescents and adults with CP, SB, and childhood onset ABI.

METHODS

Methodological frameworks by Arksey and O'Malley, and Levac and colleagues were used to explore studies published between 2009 and 2019. Included studies were required to be written in English and report on a psychological intervention(s) administered to individuals at least 12 years of age with a diagnosis of CP, SB, or childhood onset ABI. All study designs were included.

RESULTS

A total of 11 studies were identified. Of these, eight reported psychological interventions for childhood onset ABI, while three reported on CP. No studies reporting on SB were identified. Commonly used interventions included acceptance and commitment therapy (ACT), psychotherapy, and cognitive behavioral therapy (CBT).

CONCLUSIONS

There are a limited number of studies investigating psychological interventions for individuals with childhood onset ABI and CP, and none for individuals with SB. Further research into effective psychological interventions for these populations will improve mental health outcomes and transitional services.

Telephone-guided self-help for mental health difficulties in neurological conditions: a randomised pilot trial

OBJECTIVE

This study aimed to conduct a randomised pilot trial to assess the feasibility of a randomised controlled trial (RCT) to investigate the effect of telephone-guided self-help for the treatment of mental health difficulties in children with neurological conditions.

DESIGN

Preliminary RCT. The primary outcome measure was the Strengths and Difficulties Questionnaire.

SETTING

Neurology clinics in a national tertiary paediatric hospital.

PATIENTS

Young people attending neurology clinics who met criteria for mental health difficulties according to the Development and Wellbeing Assessment.

INTERVENTIONS

12 weeks of telephone-guided self-help based on a modular approach to psychological therapy for children delivered to children and/or their parents (n=17; eight males; mean age 12.04 years, SD=3.34) or a waiting list for telephone-guided self-help with no additional intervention over 12 weeks (n=17; nine males; mean age 10.53 years, SD=3.14).

RESULTS

124 participants completed the DAWBA, and 34 children and young people were entered into the trial. 65% of those randomised to the intervention arm completed the full intervention, and the intervention was acceptable to those completing it. However, there were significant problems related to lack of data completion (38% data loss for primary outcome measure), choice of control comparator and outcome measures. Due to significant loss of data at follow-up, the effect size findings are considered unreliable.

CONCLUSIONS

Further feasibility work should be conducted to improve data completeness before progression to a definitive trial of guided self-help for mental health problems in children with neurological conditions can be recommended.

TRIAL REGISTRATION NUMBER

ISRCTN21184717.

Effects of equine-assisted activities on attention and quality of life in children with cerebral palsy in a randomized trial: examining the comorbidity with attention-deficit/hyperactivity disorder

Background

Attention problems and decreased quality of life are frequently accompanied in Cerebral Palsy (CP), which can negatively affect rehabilitation of physical disability. However, the majority of affected children remain untreated in the aspects of attention or psychosocial factors. Equine-Assisted Activities and Therapies (EAAT) use horse as a therapeutic modality including grooming as well as mounted riding activities in which patients exercise and experience mounted stimulation. It is known to help improve attention in children with ADHD, so that it can be an exercise therapy that is expected to improvement of attention as well as rehabilitating effects in CP patients. EAA may be a promising strategy to address the unmet need for CP patients. This study aims to investigate the efficacy of EAA for children with CP, those with both CP and ADHD and confirm the comorbidity between CP and ADHD.

Methods

Forty-six children with cerebral palsy participated in this study. For the exercise group, they participated in a 40-min session twice a week for a 16-week period, while the control group engaged in daily life without any special treatments. Each children individually were assessed on attention and psychological wellbeing at baseline and post-treatment. Comorbidity were identified based on the Diagnostic and Statistical Manual of Mental Disorder 5th edition (DSM-5) and confirmed by Korean Kiddie-Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL).

Results

Perseveration rated using the Conner’s Performance Test (CPT) showed a significant decrease only in the exercise group (p < .024). However, no significant improvement in children’s quality of life was observed after EAA program compared with control group. Among the total participants, fifteen children (31.91%) were diagnosed with ADHD. When conducting an additional analysis with the subsample of CP patients diagnosed with ADHD, the d’, commission error and perseveration showed a significant decrease only in the exercise group. Children with CP and ADHD reported an improvement in quality of life both in exercise and control group, but only in the exercise group social functioning exhibited a significant difference.

Conclusion

The positive effects of the EAA on attention and quality of life were confirmed. Children with CP in the exercise group were more capable to sustain their attention longer. Those with CP and ADHD showed an increase in attention and perceived to have better social skills after receiving 16 weeks of EAA compared to those in the control group. Considering high comorbidity of CP and ADHD, it seems that the EAA program could be the better alternative treatment for CP with attentional problem. The results of this study will contribute to growing evidence for the efficacy of EAA in children especially with CP and ADHD.

Trial registration

This trial was registered on ClinicalTrials.gov (NCT03870893). Registered 26 July 2017.

Impact of the Guided Self-Determination Intervention among Adolescents with Co-Existing ADHD and Medical Disorder: A Mixed Methods Study

Adolescents with ADHD are at increased risk of having a co-existing medical disorder. Research shows that having co-existing ADHD and a medical disorder interferes with the adolescents' daily life, creating a dual task that cannot be managed as two independent disorders. Interventions to support adolescents in managing the dual task of living with co-existing ADHD and medical disorder are needed. The Guided-Self-Determination intervention might be suitable for this population, as it is an empowerment-based intervention facilitating patient involvement and self-management of a disease. The purpose of this study was to evaluate how the Guided Self-Determination intervention impacted 10 adolescents with ADHD and a co-existing medical disorder. The study used a convergent mixed methods design. Quantitative data measuring support from nurses, support from parents, and self-management were collected though self-reported questionnaires at baseline, 3 months, and 6 months and were analyzed with descriptive statistics. Qualitative data capturing the adolescents' experiences of the intervention and the intervention's impact on support from nurses, parents, and self-management were collected through semi-structured interviews and analyzed thematically. Results of the quantitative and qualitative analyses were integrated in a mixed methods analysis. The integrated results suggest that this intervention may improve adolescents' management of the difficulties of living with co-existing ADHD and a medical disorder, and that self-insight and nurse support are prerequisites for developing self-management strategies. However, the results showed that the intervention did not impact parental support. Further research is needed to evaluate the impact of the intervention on a larger scale.

Complex Comorbid Presentations are Associated with Harmful Behavior Problems among Children and Adolescents with Cerebral Palsy

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.

Trajectories of psychiatric disorders in a cohort of children with cerebral palsy across four years

BACKGROUND

Risk of psychiatric disorders has been reported for children and adolescents with cerebral palsy (CP) at different ages, however little is known regarding the long-term trajectories of these disorders.

OBJECTIVE

The aim of this study was to assess the trajectories of psychiatric disorders in children with CP, and to explore their association to risk factors.

METHODS

We assessed a cohort of children with CP at age seven and again at age eleven with a child psychiatric diagnostic instrument, and parents were informants. We assessed type of CP, Gross Motor Function Classification System (GMFCS) levels, and co-occurring medical conditions in a medical examination, through the medical records, and in an interview with the parents at the onset of the study.

RESULTS

We found a significant increase in the prevalence of emotional disorders from seven to eleven years of age (p 0.01), whereas the prevalence of behavioral disorders was stable. Half of the cohort met criteria for a psychiatric disorder at both assessment points. Type of CP, spastic bilateral or unilateral, dyskinetic or ataxic, and co-occurring medical conditions were non-significant predictors of psychiatric disorders. Subthreshold psychiatric disorders at age seven were predictive of psychiatric disorders at age eleven.

CONCLUSIONS

We found a persistently elevated prevalence of psychiatric disorders in children with CP. Prevalence of behavioral disorders was stable, whereas we found a significant four-fold increase in emotional disorders. Sub-threshold psychiatric disorders predicted later psychiatric disorders. Increased focus on early mental health symptoms as well as more knowledge regarding emotional disorders in children with CP seems warranted.

Anxiety in children and adolescents with cerebral palsy

AIMS

To describe the prevalence of, and factors associated with, anxiety in 6-18-year-old children with cerebral palsy (CP) and determine how often clinicians screen for and manage anxiety in this group.

METHODS

Using a population CP register as the sampling pool, 569 families were approached by email, and 172 (mean age of children 12 years 7 months [SD 3 years 5 months]; 96 males) participated. Parents and, where able, children completed the Screen for Child Anxiety Related Emotional Disorders (SCARED). Parents also completed the Strengths and Difficulties Questionnaire. Children's medical records were searched for previous anxiety diagnoses and treatments.

RESULTS

Clinically significant anxiety was identified in 38% of children on parent reports and 46% on child reports. Girls were twice as likely to have anxiety (p = 0.02). Parent- and child-reported scores were strongly correlated (r = 0.853). Fewer parents of children with intellectual and communication impairments completed the survey. Based on the SCARED parent reports, anxiety was not identified by a clinician in 16 children (43%) with clinically significant anxiety.

CONCLUSION

Anxiety symptoms are prominent among children with CP, indicating a need for routine screening. Available screening tools are unsuitable for children with more severe limitations in cognition and communication; further research is needed to address this gap.

Adolescents' Perceptions of Living With Co-Existing ADHD and Medical Disorder in Denmark

AIM

The study aim was to explore adolescents' with co-existing ADHD and medical disorder (MD) perceptions of everyday life and support from parents and healthcare professionals.

DESIGN AND METHODS

In this qualitative study, 10 adolescents aged 13-17 years diagnosed with ADHD and a MD were included from a general pediatric hospital clinic and a child and adolescent psychiatric hospital clinic. Data obtained through semi-structured interviews were analyzed using thematic analysis.

RESULTS

The adolescents' perceptions were categorized into four themes: 1) ADHD perceived as part of the adolescent's self-understanding - yet with daily frustrations, 2) MD perceived as an interruption in everyday life, 3) ADHD and MD - an overlooked dual task, and 4) the need for supportive relationships in navigating ADHD and MD.

CONCLUSION

Living with co-existing ADHD and MD is a complex dual task, as ADHD and MD interfere with each other in everyday life. However, the adolescents overlook the dual task as they believe their difficulties would be resolved if the MD was eliminated. Moreover, supportive relationships are essential in navigating the complexities in living with co-existing ADHD and MD. Nevertheless, the adolescents take a passive role in the encounters with the healthcare professionals, whereas they are more active in encounters with peers, parents and teachers.

PRACTICE IMPLICATIONS

Healthcare professionals treating and caring for adolescents with co-existing ADHD and MD need interventions facilitating patient involvement in a patient-centered approach to support both adolescents and healthcare professionals in recognizing the dual task of having co-existing ADHD and MD.

Norepinephrine, neurodevelopment and behavior

Neurotransmitters play critical roles in the developing nervous system. Among the neurotransmitters, norepinephrine (NE) is in particular postulated to be an important regulator of brain development. NE is expressed during early stages of development and is known to regulate both the development of noradrenergic neurons and the development of target areas. NE participates in the shaping and the wiring of the nervous system during the critical periods of development, and perturbations in this process can alter the brain's developmental trajectory, which in turn can cause long-lasting and even permanent changes in the brain function and behavior later in life. Here we will briefly review evidence for the role of noradrenergic system in neurodevelopmental processes and will discuss about the potential disruptors of noradrenergic system during development and their behavioral consequences.

Total Joint Arthroplasty in Patients With Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA?

METHODS

The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting.

RESULTS

A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05).

CONCLUSION

Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Development and predictors of childhood mental health problems in former extremely preterm infants

OBJECTIVE

To investigate development and predictors of mental health problems from five to eleven years of age in children born extremely preterm (EP).

METHOD

In a national Norwegian cohort of children born before a gestational age of 28 weeks or with a birthweight <1000 g mental health was assessed by parents at five and eleven years of age using The Strengths and Difficulties Questionnaire. A Total Difficulties Score ≥ 90th percentile (TDS90) for a reference group was used as a measure of a mental health problem. Of 338 eligible EP children, 162 (48%) attended at both ages.

RESULTS

The rate of TDS90 was 52 (32%) at five and 37 (23%) at eleven years of age (p = 0.025). Of the 52 children with TDS90 at five years, 25 had TDS90 at eleven years of age, and of 37 children with TDS90 at eleven, 25 had TDS90 at five years of age. Mental health problems and an IQ of 70-84 at five years were independent predictors of TDS90 at eleven years of age.

CONCLUSION

The rate of mental health problems decreased from five to eleven years, but individual stability was moderate. Mental health problems and intellectual function in the lower normal range at preschool age were independent predictors of later mental health problems.

Identifying Factors Associated With Severe Intellectual Disabilities in Teenagers With Cerebral Palsy Using a Predictive Learning Model

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.

Prevalence and factors associated with emotional and behavioural difficulties among children living with HIV in Malawi: a cross-sectional study

BACKGROUND

Approximately 84,000 children under the age of 15 years are living with HIV in Malawi. Although the survival rate of children living with HIV in Malawi has improved due to the increased availability of antiretroviral medications, these children continue to experience numerous challenges negatively impacting on their mental health. The aim of this study was to investigate the prevalence of, and factors associated with, emotional and behavioural difficulties in children aged between 6 and 12 years living with HIV in Malawi.

METHODS

A random sample of 429 primary caregivers of children living with HIV drawn from the three main administrative regions of Malawi was recruited in a cross-sectional study. They completed a questionnaire about family socio-demographic characteristics, HIV disclosure, and child demographic and clinical characteristics, as well as the Strengths and Difficulties Questionnaire, Life Stress Scale, Support Function Scale, and Impact on Family Scale which were pre-tested and translated into the local Chichewa language. Data were analysed using descriptive statistics and logistic regression.

FINDINGS

Using the newer band categorisations of the Strengths and Difficulties Questionnaire, parent version, 31% of primary caregivers reported that their child had a slightly raised to very high level of total difficulties. Factors that were associated with difficulties were: primary caregivers' young age (adjusted odds ratio [aOR] 3.6; 95% confidence interval [CI]: 1.4-9.5); low level of education (aOR 2.6; 95% CI: 1.2-5.7); lack of employment (aOR 2.7; 95% CI: 1.2-5.9); the report of a substantial impact of the child's illness on the family (3.1; 95% CI: 1.5-6.5); and a low level of family functional support (aOR 2.0; 95% CI: 1.1-4.1). Neither non-disclosure of HIV status nor any of the child demographic or clinical factors were significant in multivariate analysis (p > .0.05).

CONCLUSION

Close to one-third of children living with HIV in this study had high scores indicative of emotional and behavioural difficulties. Emotional and behavioural difficulties in children living with HIV were associated with family demographic and psychosocial factors, but not HIV disclosure. Effective policies and programs that promote the mental wellbeing of children living with HIV in Malawi are indicated.

The prevalence of mental health disorders and symptoms in children and adolescents with cerebral palsy: a systematic review and meta-analysis

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.

Interrelationships of Functional Status and Health Conditions in Children With Cerebral Palsy: A Descriptive Study

PURPOSE

To examine the relationship among the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS) in children with cerebral palsy (CP) and to determine the average number and effect of health conditions.

METHODS

Participants were 671 children with CP aged 2 to 12 years from Canada and the United States. Cross-tabulation of functional classifications and averages were computed for the number and impact of health conditions and comparisons among groups.

RESULTS

A total of 78 of the 125 possible classification combinations were recorded. Most frequent were GMFCS I, MACS I, CFCS I; GMFCS I, MACS II, CFCS I; and GMFCS II, MACS II, CFCS I. With lower levels of function, the average number and average impact of associated health conditions increased.

CONCLUSIONS

The use of functional profiles across classification systems, with data on the associated health conditions, provides a more comprehensive picture of CP than any single classification or measure.

Mental health assessed by the Strengths and Difficulties Questionnaire for children born extremely preterm without severe disabilities at 11 years of age: a Norwegian, national population-based study

The aims were to investigate mental health problems with the Strength and Difficulties Questionnaire (SDQ) in children born extremely preterm/extremely low birth weight (EP/ELBW) without severe disabilities compared to controls, and to identify peri-, or neonatal factors possibly predicting later mental health problems. A national Norwegian cohort of 11-year-old EP/ELBW children, excluding those with intellectual disabilities, non-ambulatory cerebral palsy, blindness and/or deafness, was assessed. Parents and teachers completed the SDQ. Mean scores and scores ≥90th percentile for the control group, combined (parent and/or teacher reporting the child ≥90th percentile), and pervasive ratings (both parent and teacher reporting the child ≥90th percentile) were presented. The controls consisted of an unselected population of all 11-year-old children born in 1995 who attended public or private schools in Bergen. Of the eligible children, 216 (64%) EP/ELBW and 1882 (61%) control children participated. The EP/ELBW children had significantly higher scores and/or increased risk of parent, teacher, combined, and pervasive rated hyperactivity/inattention, emotional-, and peer problems (OR 2.1-6.3). Only parents reported the EP/ELBW children to be at an increased risk of conduct problems (OR 1.6, 95% CI 1.1-2.6). Only low maternal education at birth was significantly associated with mental health problems at 11 years of age (OR 2.5, 95% CI 1.2-5.4). EP/ELBW children without severe disabilities had increased risk of symptoms of hyperactivity/inattention, emotional-, and peer problems. None of the peri- or neonatal factors were significantly associated with later mental health problems, except for low maternal education.

Systematic Review of Screening Instruments for Psychosocial Problems in Children and Adolescents With Long-Term Physical Conditions

Children and adolescents with long-term physical conditions (LTPCs) are at greater risk of developing psychosocial problems. Screening for such problems may be undertaken using validated psychometric instruments to facilitate early intervention. A systematic review was undertaken to identify clinically utilized and psychometrically validated instruments for identifying depression, anxiety, behavior problems, substance use problems, family problems, and multiple problems in children and adolescents with LTPCs. Comprehensive searches of articles published in English between 1994 and 2014 were completed via Medline, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL databases, and by examining reference lists of identified articles and previous related reviews. Forty-four potential screening instruments were identified, described, and evaluated against predetermined clinical and psychometric criteria. Despite limitations in the evidence regarding their clinical and psychometric validity in this population, a handful of instruments, available at varying cost, in multiple languages and formats, were identified to support targeted, but not universal, screening for psychosocial problems in children and adolescents with LTPCs.

Neurological outcomes of animal models of uterine artery ligation and relevance to human intrauterine growth restriction: a systematic review

AIM

This review explores the molecular, neurological, and behavioural outcomes in animal models of uterine artery ligation. We analyse the relevance of this type of model to the pathological and functional phenotypes that are consistent with cerebral palsy and its developmental comorbidities in humans.

METHOD

A literature search of the PubMed database was conducted for research using the uterine artery ligation model published between 1990 and 2013. From the studies included, any relevant neuroanatomical and behavioural deficits were then summarized from each document and used for further analysis.

RESULTS

There were 25 papers that met the criteria included for review, and several outcomes were summarized from the results of these papers. Fetuses with growth restriction demonstrated a gradient of reduced body weight with a relative sparing of brain mass. There was a significant reduction in the size of the somatosensory cortex, hippocampus, and corpus callosum. The motor cortex appeared to be spared of identifiable deficits. Apoptotic proteins were upregulated, while those important to neuronal survival, growth, and differentiation were downregulated. Neuronal apoptosis and astrogliosis occurred diffusely throughout the brain regions. White matter injury involved oligodendrocyte precursor maturation arrest, hypomyelination, and an aberrant organization of existing myelin. Animals with growth restriction demonstrated deficits in gait, memory, object recognition, and spatial processing.

INTERPRETATION

This review concludes that neuronal death, white matter injury, motor abnormalities, and cognitive deficits are important outcomes of uterine artery ligation in animal models. Therefore, this is a clinically relevant type of model, as these findings resemble deficits in human cerebral palsy.

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

BACKGROUND AND OBJECTIVE

Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia.

METHODS

Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages.

RESULTS

The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed.

CONCLUSION

Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

Therapeutic potential of human embryonic stem cell transplantation in patients with cerebral palsy

Background

The present study evaluated the efficacy and safety of human embryonic stem cell (hESC) therapy in patients with CP.

Materials and methods

This analysis included patients (30 days-18 yr) with documented diagnosis of CP. The study consisted of four treatment phases (T1, T2, T3, T4) separated by gap phases. Efficacy of hESC therapy was evaluated based on Gross Motor Function Classification Scores Expanded and Revised (GMFCS-E & R; 1-good to 5-bad).

Results

Ninety one patients were included and all received hESC therapy in T1, 66 patients returned for T2, 38 patients for T3, and 15 patients for T4. Overall, 30.2% patients achieved GMFCS-E & R score 1 during the study with different number of patients achieving GMFCS score 1 by the end of each treatment phase (T1: 6 [6.6%]; T2: 7 [10.6%]; T3: 11 [28.9%]; and T4: 5 [33.3%]). All patients in up to 2 yr (n = 10), 2-4 yr (n = 10), 4-6 yr (n = 9), and 6-12 yr (n = 8) age groups except one of the 5 patients in the age group of 12-18 yr transitioned from GMFCS-E & R score 5 to lower scores by end of T1. Most patients transitioned to GMFCS-E & R score 2 (n = 34) from higher scores by end of T2. Eleven patients achieved GMFCS-E & R score 1 by end of T3. No serious adverse events were observed.

Conclusion

Use of hESC therapy in patients with CP is effective and safe. hESC therapy has demonstrated significant improvement in GMFCS-E & R scale.