White Matter Injury and General Movements in High-Risk Preterm Infants

BACKGROUND AND PURPOSE

Very preterm infants (birth weight, <1500 g) are at increased risk of cognitive and motor impairment, including cerebral palsy. These adverse neurodevelopmental outcomes are associated with white matter abnormalities on MR imaging at term-equivalent age. Cerebral palsy has been predicted by analysis of spontaneous movements in the infant termed "General Movement Assessment." The goal of this study was to determine the utility of General Movement Assessment in predicting adverse cognitive, language, and motor outcomes in very preterm infants and to identify brain imaging markers associated with both adverse outcomes and aberrant general movements.

MATERIALS AND METHODS

In this prospective study of 47 preterm infants of 24-30 weeks' gestation, brain MR imaging was performed at term-equivalent age. Infants underwent T1- and T2-weighted imaging for volumetric analysis and DTI. General movements were assessed at 10-15 weeks' postterm age, and neurodevelopmental outcomes were evaluated at 2 years by using the Bayley Scales of Infant and Toddler Development III.

RESULTS

Nine infants had aberrant general movements and were more likely to have adverse neurodevelopmental outcomes, compared with infants with normal movements. In infants with aberrant movements, Tract-Based Spatial Statistics analysis identified significantly lower fractional anisotropy in widespread white matter tracts, including the corpus callosum, inferior longitudinal and fronto-occipital fasciculi, internal capsule, and optic radiation. The subset of infants having both aberrant movements and abnormal neurodevelopmental outcomes in cognitive, language, and motor skills had significantly lower fractional anisotropy in specific brain regions.

CONCLUSIONS

Aberrant general movements at 10-15 weeks' postterm are associated with adverse neurodevelopmental outcomes and specific white matter microstructure abnormalities for cognitive, language, and motor delays.

Patients with KCNJ11-related diabetes frequently have neuropsychological impairments compared with sibling controls

AIMS

KCNJ11-related diabetes is the most common form of permanent neonatal diabetes and has been associated with a spectrum of neurodevelopmental problems. We compared neurodevelopmental outcomes in patients with KCNJ11 mutations and their sibling controls.

METHODS

Through our Monogenic Diabetes Registry (http://monogenicdiabetes.uchicago.edu/), we evaluated 23 patients with KCNJ11 mutations with (n = 9) and without (n = 14) global developmental delay successfully treated with sulfonylurea and 20 healthy sibling controls, using a battery of targeted neuropsychological and behavioural assessments with scaled scores that are comparable across a wide range of ages.

RESULTS

Patients with KCNJ11-related diabetes without global developmental delay had significant differences compared with sibling controls on a range of assessments including IQ, measures of academic achievement and executive function. KCNJ11 patients with global delay exhibited significant differences in behavioural symptoms with a tendency to avoid social contact and displayed a reduced ability to adapt to new circumstances. Parents reported more immature behaviour, gross mood swings, bizarre thoughts, other unusual and severe behaviours, and there were also significant deficits in all subdomains of daily living skills.

CONCLUSIONS

This series represents the largest and most comprehensive study of neuropsychological and behavioural dysfunction of individuals with KCNJ11 diabetes and is the first to compare outcome with sibling controls. Our data demonstrate the variety of neurodevelopmental problems seen in those with KCNJ11 mutations, even in those without recognized global developmental delays. These data can be used to counsel families and guide structured neurodevelopmental assessments and treatments based on the initial genetic diagnosis in patients with neonatal diabetes.

Victimization and depression among youth with disabilities in the US child welfare system

AIM

This study aimed to examine the prevalence of victimization among a United States-wide cohort of youth with disabilities (YWD) investigated for maltreatment in the child welfare system (CWS) and their correlation with mental health.

METHODS

Data were drawn from baseline interviews in the second National Survey of Child and Adolescent Well-Being, a national representative survey of youth involved in the CWS. Interviews took place between 2008 and 2009 and included 675 youth, 11-17 years old and residing with biological families across 83 counties nationwide. The sample consisted of 405 females (60.1%) and 270 males (39.9%), mean age = 13.5 years. We identified YWD if they reported one or more physical or neurodevelopmental health condition (n = 247). Reported victimization experiences and Children's Depression Inventory (CDI) scores were analysed using weighted regression analyses.

RESULTS

One-quarter of YWD in the CWS reported three or more victimizations during the prior year compared with 19% of youth without disabilities. The odds of YWD reporting a one-unit increase in level of victimization was 75% higher (P < 0.05) than youth without disabilities. Prevalence of clinical depression was significantly higher among YWD (14 vs. 5.5%; P < 0.05). Unlike youth without disabilities, the odds of clinical depression were 92% higher for every one-unit increase in victimization among YWD, controlling for covariates (P < 0.05). Of CWS-involved youth who reported three or more victimizations, 24.4% of YWD and 2.2% of non-disabled youth had CDI scores in the clinical range.

CONCLUSION

YWDs in the US CWS are at high risk of experiencing victimization and clinical depression. Our findings suggest that health professionals need to screen CWS-involved YWD for multiple forms of victimization, and develop and implement trauma-informed services that target the mental health sequelae that may jeopardize their independence in adulthood.

Optimizing neurodevelopmental outcomes after prematurity: lessons in neuroprotection and early intervention

In recent decades, advances in maternal-fetal, obstetrics, and neonatal medicine have led to the increased survival of preterm infants. Very preterm infants (<32 weeks gestation), who comprise a small fraction (1.4%) of all neonates, have had dramatic increases in their survival. In addition, late preterm infants (33-36 weeks gestation) are a growing population of all preterm births and may include over 10% of all births. Both populations experience ongoing and significant challenges once they are discharged from the neonatal intensive care unit (NICU), including medical, nutritional, and developmental issues. Similarly, preterm infants may experience ongoing challenges once they enter school. As a result, clinicians should be aware of the unique neurodevelopmental issues that affect this population of children, including what they experience at different developmental stages. This review will describe how selected neonatal interventions impact on very preterm and late preterm infants. In addition, we will discuss the developmental and functional components of school readiness in very preterm and late preterm infants, using the International Classification of Functioning, Disability, and Health (ICF) as a framework for health, enablement, disability, and participation. This framework allows us to describe children's strengths and challenges across body structure and body function, activities, and social roles in the context of child and family supports. We will explicitly describe the role of physicians and health professional teams in providing ongoing support and coordination of care throughout childhood for preterm infants who have experienced neonatal intensive care.

Concurrent validity of the parent-completed Ages and Stages Questionnaires, 2nd Ed. with the Bayley Scales of Infant Development II in a low-risk sample

Abstract Background This study assessed the concurrent validity of the Ages and Stages Questionnaire (ASQ) compared with Bayley Scales of Infant Development II (BSID II) amongst children aged 24 months. Methods Data were collected from 53 infants and mothers who participated in the New York State Angler Cohort Child Development Study. Parents completed the 24-month ASQ to assess communication, personal-social, problem-solving ability, and fine and gross motor control. The BSID II was administered by a clinical psychologist at the 24-month home visit for cognitive and psychomotor assessment. The ASQ was scored using age-specific norms of <2 SDs below any domain mean to define failure. A BSID II score of <85 indicated mild or severe delay, while a score of <70 suggested a severe delay. Results Scores on the ASQ communication and personal-social domains were moderately correlated with the BSID II Mental Scale (R= 0.52, P < 0.001; R= 0.45, P < 0.01) and ASQ gross motor with the BSID II Motor Scale (R= 0.46, P < 0.01), whereas ASQ problem-solving and fine motor domains were not significantly correlated with BSID II scores. The ASQ had a sensitivity of 100% and specificity of 87% at 24 months (n= 40) for severely delayed status. Conclusions Results suggest the ASQs provide a simple, valid, and cost-effective method for clinicians and field-based researchers to reduce the number of standardized assessments required to identify developmentally delayed infants at age 24 months. Future studies should further assess the validity of the ASQs in larger, more diverse populations of infants.

Neuroimaging and cerebral palsy in children

Cerebral palsy (CP) is a description of a spectrum of central nervous system (CNS) impairments that affect mobility, communication, intellectual ability, and neurobehavior as a result of developmental brain dysfunction. CP is the most common contributor to motor disability in children with prevalence of about 2-3/1000 live births globally. Presently, no curative therapies or successful methods of prevention on a population level are available for children with one of the cerebral palsy syndromes. Despite these challenges, orthopedic, rehabilitation, neuropharmacological, and other management interventions can help maintain mobility, prevent deformity, and promote quality of life for children with CP. Typically, the diagnosis of CP is based on clinical observations and parent concerns regarding delays in attaining motor milestones (e.g., rolling, sitting, crawling, walking), not on laboratory testing or neuroimaging. However, since 2004 the American Academy of Neurology (AAN) has recommended that neuroimaging of the CNS be part of diagnostic process for cerebral palsy. Although the guideline was initially met with controversy and criticism, neuroimaging has allowed a broader appreciation of timing of lesions, extent of white matter involvement, and the complexity of the motor spectrum of disability. In this article we shall describe the major types of neuroimaging techniques and review their roles in identification and evaluation of children with one of the cerebral palsy syndromes. The authors will focus on the emerging knowledge of how brain structure can inform us about children's functioning, especially among children with prematurity, recognizing that we are only beginning to understand brain plasticity and developmental resiliency.

Severity of neonatal retinopathy of prematurity is predictive of neurodevelopmental functional outcome at age 5.5 years. Behalf of the Cryotherapy for Retinopathy of Prematurity Cooperative Group

OBJECTIVE

The purpose of this study was to assess the relation between neonatal retinopathy of prematurity (ROP) in very low birth weight infants and neurodevelopmental function at age 5.5 years.

METHODS

Longitudinal follow-up of children occurred in 2 cohorts of the Multicenter Cryotherapy for Retinopathy of Prematurity Study. The extended natural history cohort followed 1199 survivors of <1251 g birth weight from 5 centers. The threshold randomized cohort (ThRz) followed 255 infants <1251 g from 23 centers who developed threshold ROP and who consented to cryotherapy to not more than 1 eye. At 5.5 years both cohorts had ophthalmic and acuity testing and neurodevelopmental functional status determined with the Functional Independence Measure for Children (WeeFIM).

RESULTS

Evaluations were completed on 88.7% of the extended natural history cohort; 87% had globally normal functional skills (WeeFIM: >95). As ROP severity increased, rates of severe disability increased from 3.7% among those with no ROP, to 19.7% of those with threshold ROP. Multiple logistic regression analysis demonstrated that better functional status was associated with favorable visual acuity, favorable 2-year neurological score, absence of threshold ROP, having private health insurance, and black race. Evaluations were completed on 87.4% of the ThRz children. In each functional domain, the 134 children with favorable acuity in their better eye had fewer disabilities than did the 82 children with unfavorable acuity: self-care disability 25.4% versus 76.8%, continency disability 4.5% versus 50.0%, motor disability 5.2% versus 42.7%, and communicative-social cognitive disability 22.4% versus 65.9%, respectively.

CONCLUSION

Severity of neonatal ROP seems to be a marker for functional disability at age 5. 5 years among very low birth weight survivors. High rates of functional limitations in multiple domains occur in children who had threshold ROP, particularly if they have unfavorable visual acuity.

The WeeFIM instrument: its utility in detecting change in children with developmental disabilities

OBJECTIVE

To examine the utility of the WeeFIM instrument ("WeeFIM") in detecting changes in the functional status of children with disability.

DESIGN

Prospective longitudinal design with correlation and responsiveness analysis.

SETTING

Three facilities providing services to children with developmental disabilities in western New York State.

PARTICIPANTS

Two hundred five children (72 girls, 133 boys) with identified medical disabilities receiving special services were administered the WeeFIM. Subjects ranged in age from 11 to 87 months and came from diverse socioeconomic and ethnic backgrounds. Scores for 174 children were available for 3 administrations performed over a 1-year period.

MAIN OUTCOME MEASURES

The responsiveness of the WeeFIM instrument was examined using 5 statistical procedures: Reliability Change Index, Proportional Change Index, effect size, standardized response means, and paired t tests.

RESULTS

All 5 indexes of responsiveness indicated statistically significant (p < .05) or reliable changes over time. The transfer subscale of the WeeFIM showed a skewed distribution that affected the results for some responsiveness indexes. The advantage, limitations, and assumptions of the responsiveness indexes are described and graphic examples of change over time are presented to validate the responsiveness of the WeeFIM instrument.

CONCLUSION

The WeeFIM instrument showed the ability to document change in functional abilities over a 1-year period in children with chronic disabilities.

Extreme prematurity and school outcomes

The purpose of this study was to assess the impact of extreme prematurity on three global measures of school outcomes. Using a matched cohort design, exposed infants comprised all surviving singleton infants < or = 28 weeks gestation born at one regional neonatal intensive care hospital between 1983 and 1986 (n = 132). Unexposed infants comprised randomly selected full-term infants (> or = 37 weeks gestation) frequency matched on date of birth, zip code and health insurance. All children were selected from a regional tertiary children's centre serving western New York population. Standardised telephone interviews elicited information on grade repetition, special education placement and use of school-based services. Unconditional logistic regression was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI) adjusted for potential confounders for children without major handicaps. Extreme prematurity was associated with a significant increase in risk of grade repetition (OR = 3.22; 95% CI = 1.63, 6.34), special education placement (OR = 3.16; 95% CI = 1.14, 8.76) and use of school-based services (OR = 4.56; 95% CI = 1.82, 11.42) in comparison with children born at term, even after controlling for age, race, maternal education, foster care placement and the matching factors. These findings suggest that survivors of extreme prematurity remain at risk of educational underachievement.

Functional limitations and key indicators of well-being in children with disability

OBJECTIVES

To compare measures of well-being in children with and without different types and severity of limitations.

DESIGN

Nationally representative data for American children aged 5 to 17 years were drawn from the 1994 and 1995 National Health Interview Surveys on Disability (NHIS-D) (N = 41,300) and the Year 2000 Health Supplement to the 1994 NHIS-D (N = 9530). Family resources, safety, health status, and health access were measures of environment. The presence and severity of limitations were measured in the domains of mobility, self-care, communication, and learning.

RESULTS

Children with functional limitations were more likely to live in families with limited resources and have greater exposure to secondhand smoke, less access to health care, and lower health status. Children with a limitation were not less likely to have a regular source of medical care, but they more often were delayed or prevented from getting necessary health care due to cost or insurance.

CONCLUSIONS

Standard measures of child well-being were appropriate for children with functional limitations and showed their unfavorable situations. Children with functional limitations more often have unfavorable family resources, less healthy home environments, poorer health status, and less health service access than other children, making them more susceptible to developmental difficulties beyond those difficulties associated with the challenges of their specific functional limitations.

Functional outcomes in self-care, mobility, communication, and learning in extremely low-birth weight infants

Gaps have existed in specifying degrees of severity of cerebral palsy assessment of self-care and communicative competencies, and specifying age-appropriate preschool educational and behavioral competencies. Imbedded in the concept of measuring functional status is the interaction between health and neurologic impairments, developmental challenges and competencies, family resources and disadvantages, and the child's current status. In reviewing historic outcomes of severe ROP over the past 40 years, it was noted that severe ROP caused blindness in 2% to 11% of survivors. There was a constant observation that approximately 50% of severe ROP survivors with blindness had multiple functional and developmental challenges beyond blindness alone. Similarly, in reviewing outcomes of cerebral palsy, it is imperative to describe the severity of cerebral palsy and functional consequences in motor, selfcare, communication, and learning. The reason to measure the functional status of children with neurodevelopmental impairments before first grade is that the degrees of severity of these disorders can be specified before attending school with peers. Subtler aspects of neurodevelopmental impairments need to assess impact on literacy, information learning, written language, social competencies with peers, and recreational and community participation. In this way, we can understand the vulnerabilities and resiliences of children and families of VLBW and ELBW status. This is a critical step in understanding long-term quality of life and independent living issues. In addition, our efforts can address those factors and pathways whereby multiple disabilities and multiple functional limitations cluster. Our biomedical intervention can prioritize strategies that lessen severe multiple disabilities and simultaneously support families, when despite our best efforts functional challenges are life long.

Functional assessment and care of children with neurodevelopmental disabilities

OBJECTIVES

To determine the relationship between pediatric assessment scores and ratings by parents and teachers regarding the amount of assistance required to complete basic activities of daily living; and to examine the relationship among scores for three commonly used pediatric assessments.

DESIGN

Prospective correlational study. 205 children with developmental disabilities. The children ranged in age from 11 to 87 mo and included 72 females and 133 males of diverse socioeconomic and ethnic backgrounds. The children were evaluated by using the Battelle Developmental Inventory Screening Test, Vineland Adaptive Behavior Scales, Functional Independence Measure for Children (WeeFIM instrument), and the Amount of Assistance Questionnaire.

RESULTS

The test-retest reliability coefficients for items on the Amount of Assistance Questionnaire were found to range from 0.82 to 0.97. Correlations among subscale scores and amount of assistance ratings were highest for the WeeFIM instrument and Battelle Developmental Inventory Screening Test. The highest correlation was between WeeFIM total rating and total amount of assistance rating (r = 0.91).

CONCLUSION

Total WeeFIM instrument ratings and severity of disability were the best predictors of amount of assistance ratings provided by parents and teachers.

Measuring functional status and family support in older school-aged children with cerebral palsy: comparison of three instruments

OBJECTIVE

To compare a pediatric and an adult version of a functional status measure and a family support measure for assessing school-age children with spastic cerebral palsy.

DESIGN

A prospective study involved functional status measurements using the Pediatric Functional Independence Measure (WeeFIM), the Adult Functional Independence Measure (FIM), and a family support measure, the Amount of Assistance Questionnaire (AAQ).

PARTICIPANTS

The feasibility sample consisted of 47 children aged 2 to 12 yrs with cerebral palsy. The study sample consisted of 20 children aged 7 to 16 yrs with spastic cerebral palsy (50% diplegia, 50% quadriplegia).

INTERVENTIONS

Initial assessment interview included the WeeFIM, developmental milestones, educational achievement information, and the AAQ. Within 1 month, a follow-up phone interview using the FIM was completed.

MAIN OUTCOME MEASURE

The WeeFIM and FIM measure independence in self-care, sphincter control, mobility, locomotion, communication, and social cognition. The AAQ measures the time and assistance required by a child in essential daily tasks.

RESULTS

Pearson's correlation coefficient exceeded .97 for WeeFIM and FIM total score in the total sample as well as in two subgroups of children: those with diplegia and quadriplegia. Total scores in WeeFIM and FIM as well as domain scores were significantly different between children with diplegia and quadriplegia. Parental amount of assistance on the AAQ was significantly correlated with WeeFIM and FIM scores.

CONCLUSION

Either the WeeFIM or FIM can be used for monitoring functional status through adolescence in children with spastic cerebral palsy. Functional limitations are highly related to requirements for parental assistance.

Measuring functional status in children with genetic impairments

One of the consequences of genetic impairments in early childhood is their long-term effect on children's developmental skills in communication, learning, and adaptive behaviors. Functional assessment provides families and clinicians with a common language for describing a child's strengths and limitations in self-care (feeding, dressing, grooming, bathing, continence), mobility, and communication/social cognition. The National Center for Medical Rehabilitation Research described a model of disablement that includes five dimensions: pathophysiology, impairment, functional limitations, disability, and societal limitations. Using this framework, along with the Functional Independence Measure for children, the WeeFIM(R), we describe functional strengths and challenges in children with Down syndrome, spina bifida, congenital limb anomalies, congenital heart disease, urea cycle disorders, severe multiple developmental disabilities, and DiGeorge malformation sequence. We also briefly describe several pediatric functional/adaptive assessment instruments used by developmental professionals (Battelle Developmental Inventory, Vineland Adaptive Behavior Scales, Amount of Assistance Questionnaire). By tracking functional status, health professionals can prioritize secondary and tertiary prevention strategies that optimize self-care, mobility, communication, and learning. When functional limitations interfere with the acquisition of these essential skills, family and community support programs can be maximized.

Measuring developmental and functional status in children with disabilities

This study compared performance on the Functional Independence Measure for Children (WeeFIM), the Battelle Developmental Inventory Screening Test (BDIST), and the Vineland Adaptive Behavior Scales (VABS) in children with developmental disabilities. The three instruments were administered to 205 children with identified disabilities. All 205 children were tested using the WeeFIM instrument. The BDIST was administered to 101 children and the VABS to the remaining 104 children. Administration was counterbalanced and randomized across all three instruments. A proportional sampling plan was used to select the 205 children, who ranged in age from 11 to 87 months. A variety of medical diagnoses and levels of severity of motor, cognitive, and communication impairments were systematically included in the sample. Correlations (r) among subscales for all three instruments ranged from 0.42 to 0.92. Correlations for total scores ranged from 0.72 to 0.94. Analyses of potential moderator variables found no significant relation between age and severity of disability (r=0.05) or between socioeconomic status (SES) and severity of disability (r=0.21). Correlations with age were strongest for those subscale scores involving gross and fine motor skills. Correlations with SES and subscale scores ranged from 0.03 to 0.18. The three instruments provide important information regarding childhood performance in motor, self-care, communicative, cognitive, and social skills. The WeeFIM instrument requires less administration time and provides information directly relevant to evaluating functional outcomes for children with disabilities and their families.

Growth of preterm infants with cystic periventricular leukomalacia

Etiology of the high rates of growth failure in children with cerebral palsy (CP) remains unclear. The purpose of this study was to evaluate the relation between growth failure in preterm infants with cystic periventricular leukomalacia (CPVL) and neonatal health complications. The population consisted of all preterm infants (51) with a gestational age of <33 weeks who were admitted to the Children's Hospital of Buffalo from 1988 to 1993 and who had CPVL. Out of the 41 survivors with CPVL who were followed, 39 developed CP and 18 developed growth failure during infancy. At the time of greatest growth failure, the majority (72%) of infants had signs of undernutrition as defined by the Waterlow (1972) classification. Oral feeding impairment was the sole risk factor for the occurrence of growth failure. Undernutrition appears to be important in the occurrence of growth failure in preterm infants with CPVL and CP.

The vulnerable preschool child: the impact of biomedical and social risks on neurodevelopmental function

The scope of preschool children with biological risk and social disadvantage is large and includes over 1 million (28%) newborns per year. Currently in 1996, 7% of children are born with low birth weight, 1% are born with very low birth weight, 20% have alcohol exposure, and 10% have other drug exposure. Poverty is dynamic and impacts on 25% of children less than 6 years old with increased frequency in children who are minority, have mothers with less than a high school education, or are unmarried. There has been a markedly increased survival in very low birth weight and extremely low birth weight infants in the past 10 years. Outcomes of these neonatal populations reveals that parenchymal brain injury is the major predictor of cerebral palsy which occurs in 7% to 10% of very low birth weight survivors. However, poverty is the major predictor of low IQ. Fetal alcohol syndrome occurs in 1.9 per 1,000 births and is most often associated with mild mental retardation and educational underachievement. Studies investigating cocaine revealed that it is a multifactorial problem overlapping with polysubstance abuse and other risk factors for social disadvantage. The overwhelming number of children do not have cerebral palsy or severe mental retardation. The long-term impact is more subtle and needs more systematic analysis as well as critical evaluation of cognitive impairments and educational under-achievement. Hypoxic ischemic encephalopathy (HIE) cannot be determined by one biological measure. Though multiple disability occurs in 70% of children with Sarnat stage 3 HIE, 30% of survivors are not disabled. Children with mild to moderate HIE have long-term outcomes that are influenced by 9- to 12-month neurodevelopmental status and social disadvantage. By combining strategies to lessen biological risks and enhance developmentally appropriate environments, long-term outcomes of preschool children can be optimized.

Improved disability population estimates of functional limitation among American children aged 5-17

OBJECTIVES

This paper (a) creates and validates measures for population survey data to assess functional limitation in mobility, self-care, communication, and learning ability for school-age American children; (b) calculates rates of functional limitation using these measures, and provides population estimates of the number of children with limitations; and (c) examines these limitations as a function of socioeconomic factors.

METHOD

The study is based on data for children aged 5-17 collected in the 1994 National Health Interview Survey on Disability. Ordinal values are assigned to survey items in the four functional areas and analyzed to produce scales of high reliability. These measures are used to identify within a 95% confidence interval the number of children with these limitations. Ordered logistic regression models measure the effects of functional limitations on disability and societal limitation. Socioeconomic differences are measured with an ordered logistic regression model that predicts severity and comorbidity.

RESULTS

Limitations in learning ability (10.6%) and communication (5.5%) are the most common, with mobility (1.3%) and self-care (0.9%) occurring less often. Six percent of children have one serious functional limitation and 2.0% have two or more serious functional limitations. This corresponds to 4.0 million school-age American children with serious functional limitations. Functional limitation is strongly linked to socioeconomic disadvantage and to residence in single-mother households.

CONCLUSIONS

Future population research should use multiple-item scales for four distinct areas of functional limitation, and a summary that takes into account both severity and comorbidity. The improved estimates of the number of school-age children with functional limitation in this paper may help contribute to a more informed scientific and policy discussion of functional limitation and disability among American school-age children. Future research on the disability process among children must consider the role of socioeconomic disadvantage and family structure.

Interrater agreement and stability of the Functional Independence Measure for Children (WeeFIM): use in children with developmental disabilities

OBJECTIVE

Examination of the interrater agreement and stability of ratings obtained using the Functional Independence Measure for Children (WeeFIM) in a sample of children with developmental disabilities.

DESIGN

A relational design was used in which two sets of WeeFIM scores were collected under four conditions: same rater-short interval; same rater-long interval; different rater-short interval; and different rater-long interval.

SETTING

WeeFIM scores were collected in outpatient developmental rehabilitation centers, school programs, and the children's homes.

PARTICIPANTS

Data were collected for 205 children ranging in age from 11 to 87 months. All children had a medical diagnosis of disability and were receiving habilitative-educational intervention or follow-along services including neurodevelopmental surveillance.

INSTRUMENT

The WeeFIM instrument examines basic daily living and functional skills in children from birth to 7 years of age. The WeeFIM is modeled after the Functional Independence Measure (FIM) for adults and includes 18 items in the following subscales: self-care, sphincter control, transfers, locomotion, communication, and social cognition.

RESULTS

Kappa values for items ranged from .44 to .82. Intraclass correlation coefficients (ICC) for the six subscales ranged from .73 to .98. Total WeeFIM ICC values were greater than .95 for all analyses.

CONCLUSIONS

The WeeFIM ratings for the 205 children with developmental disabilities participating in this investigation were consistent across raters and time.

Neuropsychological and functional outcomes of very low birth weight infants

Advances in perinatal and neonatal management have resulted in a significant increase in the survival of fragile extremely low birth weight (ELBW) infants > 1,000 g at birth. The evaluation and reporting of the outcome of these infants aids in assessing the efficacy of interventions, provides data to aid in policy decisions, and provides critical information for parents and primary care providers. Comprehensive assessment of multiple domains including neurologic/neurosensory, developmental-cognitive, visual perceptual, speech/language, motor, functional skills for daily living, and Kindergarten readiness permit a total view of the child within the context of the family. Survival of VLBW infants < 800 g has steadily improved from 0% (1943 to 1945) to 49% to 70% (1994 to 1995). Rates of cerebral palsy, mental retardation, blindness, and deafness have remained stable in the 1980s and 1990s. There is evidence, however, that the percent of functional limitations may be increasing. A requirement for Special Education Resources among VLBW infants remains high at 44% to 56%. As increasing numbers of infants at the limits of viability survive, the medical community must remain vigilant in its surveillance and advocate both humanistically and scientifically for comprehensive strategies that optimize long-term functional, academic, and family outcomes.

The stability and equivalence reliability of the functional independence measure for children (WeeFIM)

The reliability of the Functional Independence Measure for Children (WeeFIM) was examined in 37 non-disabled children and 30 children with disabilities, from 12 to 76 months of age. The WeeFIM is derived from the Functional Independence Measure (FIM) and includes 18 items involving six functional subscales. Stability was assessed by administering the WeeFIM instrument to each child's caregiver on two occasions separated by 7 to 14 days. Intraclass correlation co-efficients (ICCs) for individual items ranged from 0.90 to 0.99. The ICC for the six WeeFIM subscales ranged from 0.94 for social cognition to 0.99 for transfers and locomotion. The ICC value for total WeeFIM test-retest reliability was 0.98 for children with disabilities and 0.99 for children without disabilities. Equivalence reliability was examined by comparing ratings obtained when using personal assessment with ratings collected during a telephone interview. No statistically significant differences were found for individual items, subscale scores or total WeeFIM values.

Neurodevelopmental outcome of infants with hypoplastic left heart syndrome

The neurodevelopmental outcome of hypoplastic left heart syndrome in infants remains unclear. All 11 survivors of staged surgical repair of hypoplastic left heart syndrome received standardized neurodevelopmental assessments at one regional children's hospital. Seven children (64%) had major developmental disabilities. Quality-of-life outcomes must be considered when management options for children with hypoplastic left heart syndrome are evaluated.

Diabetic embryopathy: possible pathogenesis

Despite recent emphasis upon improved metabolic control during early diabetic pregnancy, the offspring of insulin-dependent diabetic women continue to have a 2- to 4-fold increased risk of congenital malformations. We recently evaluated the affected offspring of 4 insulin-dependent diabetic women. All had abnormal ears in association with vertebral defects. Our analysis of the structural defects of these infants and a review of the literature suggest that the pathogenesis of some cases of the diabetic embryopathy may involve a primary insult to developing somite mesoderm and associated cephalic neural crest cells.

The Functional Independence Measure for Children (WeeFIM). Conceptual basis and pilot use in children with developmental disabilities

Few tools are available to pediatricians for tracking and monitoring disability status in children. We describe the conceptual basis and pilot use of the Functional Independence Measure for Children (WeeFIM). Our pilot use of this instrument in children with limb deficiency, Down's syndrome, spina bifida, cerebral palsy, and extreme prematurity demonstrates that the WeeFIM is a valid measure for tracking disability in preschool age and middle childhood. The WeeFIM measures the impact of developmental strengths and difficulties on independence at home, in school, and in the community. This allows the pediatrician to prioritize interventions for enhancing comprehensive functional outcomes and supporting families.

WeeFIM. Normative sample of an instrument for tracking functional independence in children

A cross-sectional community sample of 417 children, ages 6 months to 8 years without developmental delays or in developmental programs, was seen. The Functional Independence Measure for Children (WeeFIM) was used to assess independence in self-care, sphincter control, transfers, locomotion, communication, and social cognition. Mean total WeeFIM was similar for males and females. There was a significant correlation between the age of the child in months and total WeeFIM scores for children ages 2 to 5 years (n = 222, r = .80, P < .01). There was a progressive increase of functional independence with increasing chronological age across all WeeFIM domains. We conclude that the WeeFIM is a useful instrument for measuring disability in children.

Multivariate risks among extremely premature infants

This study was designed to identify risk factors for mortality and morbidity of extremely premature infants born in the surfactant era. The study cohort included 194 infants born at < 29 weeks' gestation at one regional tertiary center between 1983 and 1986. Forty-one infants died. Blinded neurodevelopmental assessments were performed on 149 of 153 (97%) survivors at a mean age of 52 months. Thirty-one (21%) survivors had major impairments: 15 had mental retardation, 8 had multiple impairments, 7 had cerebral palsy, and 1 was blind. Logistic regression analysis identifies five significant risk factors for mortality: grade III or IV intraventricular hemorrhage, birth weight < 800 gm, 5-minute Apgar score < or = 3, male sex, and absence of surfactant therapy. Significant risk factors for any major impairment included sepsis (relative risks [RR] = 6.4), male sex (RR = 3.1), and nonwhite race (RR = 2.8). Hydrocephalus requiring shunting was a significant risk factor for cerebral palsy (RR = 16.4) and neonatal retardation (RR = 16.0). Nonwhite race (RR = 7.3), sepsis (RR = 6.8), and male sex (RR = 3.7) also were significant risk factors for mental retardation. Confirmation of these risk factors should facilitate development of targeted interventions for optimizing long-term outcome.

Predictors of mortality, morbidity, and disability in a cohort of infants < or = 28 weeks' gestation

This study attempted to identify predictors for mortality, morbidity, disability, and educational handicap at age 4 years in a cohort of 194 infants born at 23 to 28 weeks' gestation at one regionalized tertiary center from 1983 to 1986. Forty-one infants died (21%); standardized neurodevelopmental and functional assessments were conducted on 149 of 153 (97%) survivors at a mean age of 52 months. Five significant predictors of death were identified with logistic regression analysis: gestational age 23 to 26 weeks, intraventricular hemorrhage grades 3 or 4, male gender, five-minute Apgar < or = 3, and absence of prophylactic calf lung surfactant extract. Significant predictors of neurodevelopmental morbidity included sepsis, male gender, and nonwhite race. Significant predictors of disability at age four included neurodevelopmental impairment and severe retinopathy of prematurity. Low socioeconomic status, nonwhite race and male gender were predictive of educational handicap. These findings suggest that outcomes may have distinct pathophysiologies. The role of biomedical events appears strongest for death.

Functional status of extremely preterm infants at kindergarten entry

Functional status was formally assessed in 149 of 153 surviving members of an extremely preterm (< or = 28 weeks) birth cohort born at one tertiary center between 1983 and 1986. The children were observed in the completion of motor, speech and self-care tasks, and administered either the Vineland Daily Living Skills Scale (VDLS) or the Functional Independence Measure for children (WeeFIM). 31 children had major neurodevelopmental impairment. Only 5 per cent were considered to have severe functional limitation. The prevalence of functional limitation varied by definition: 11 children were limited using the WeeFIM instrument and 35 using the VDLS instrument. These findings suggest that the majority of extremely preterm children are functional at kindergarten entry, but will require continuous monitoring of academic skills.

Kindergarten readiness after extreme prematurity

OBJECTIVE

To assess kindergarten readiness among survivors of extreme prematurity and to identify predictors of special education requirements.

DESIGN

Historic cohort design.

SETTING

Regionalized tertiary pediatric center.

PARTICIPANTS

One hundred forty-nine (97%) of 153 children who were alive at follow-up (mean +/- SD age, 52.7 +/- 9.9 months).

SELECTION PROCEDURES

Study cohort included infants (gestation, 23 to 28 weeks), born between 1983 and 1986 (N = 194), who were alive at follow-up (N = 153, 79% survival).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Standardized neurodevelopmental and psychometric evaluations were administered by a multidisciplinary team that was blinded to the neonatal course. Thirty-one children (21%) had major neurodevelopmental impairments. By using the McCarthy Scales of Children's Abilities for children free of major impairments, 61 (63%) had one or more minor neurodevelopmental impairments noted. Half of the surviving children were thought to require special education resources at kindergarten entry. Multivariate logistic regression identified three significant predictors of special education: low socio-economic status, nonwhite race, and male gender.

CONCLUSIONS

Social and demographic variables were associated with minor neurodevelopmental impairments and special education requirements among extremely premature children. Continued developmental follow-up and targeted interventions to reduce the risk of educational underachievement appear to be warranted.

Risk factors for major neurodevelopmental impairments and need for special education resources in extremely premature infants

The purpose of this cohort study was to determine the incidence of and risk factors for major neurodevelopmental impairments among survivors of extreme prematurity. The study cohort comprised 100 infants born between 24 and 28 weeks of gestational age at one tertiary center from 1983 to 1984. Twenty-five infants (25%) died; 75 (75%) survived until follow-up (mean, 60 months). Standardized neurodevelopmental and psychometric assessments were performed in blind fashion on 68 of the 75 surviving children (91% follow-up). Informal assessments (parent, teacher, and physician reports) were obtained instead for seven (9%) children who had relocated outside of the area. Overall, 19 children (25%) had one or more major impairments: mental retardation, 9; cerebral palsy, 4; multiple impairments, 5; and blindness, 1. Despite a high prevalence of impairments, 95% of children (n = 71) were functionally independent [corrected]. Special educational resources were definitely necessary for seven (9%) and possibly needed for 36 (48%) additional children. Univariate analyses revealed four significant risk factors for cerebral palsy: hydrocephalus (relative risk = 12.2), grades III and IV intraventricular hemorrhage (relative risk = 5.8), 5-minute Apgar score lower than 7 (relative risk = 5.7), and bronchopulmonary dysplasia (relative risk = 5.5). Hydrocephalus was the only significant risk factor observed for mental retardation (relative risk = 5.4). Risk factors predicting a need for special education resources included sepsis (relative risk = 24.9), low socioeconomic status (relative risk = 16.3), and nonwhite race (relative risk = 3.0). Thus our data suggest that biomedical factors appear to confer the greatest risk of major impairments; sociodemographic factors appear to have a significant impact on educational risk in extremely premature infants who do not die. Continued follow-up with biomedical and developmental-social interventions appears warranted to decrease the risk of educational underachievement in this population.

Multiple minor malformations as a marker for prenatal etiology of cerebral palsy

A consecutive series of 137 patients with cerebral palsy living in institutions and aged between 18 and 30 years was examined for minor malformations, using a modified Weighted Anomaly Score. After examination, the patients were divided into two groups, based on whether their cerebral palsy was prenatal or postnatal in onset. A further subset of prenatal-onset patients with unidentified etiology was also analysed. Both the prenatal group with known etiology and the subgroup with unknown etiology had significantly more minor malformations than the postnatal group. These results suggest that multiple minor malformations may indicate prenatal etiology of cerebral palsy.

Acquired cervical spine impairment in young adults with cerebral palsy

Three patients with spastic cerebral palsy and no associated movement disorder--each of whom presented with loss of functional skills and delay in the definitive diagnosis of cervical myelopathy--are reported, in order to increase awareness of the possibility of cervical spine pathology in these adults. The possibility of myelopathy should be investigated when considering the etiology of functional deterioration. A functional neurological examination for all multiply disabled individuals is proposed as a reference for future comparison.

Noninvasive determination of acetaminophen disposition in Down's syndrome

In this study we evaluated subjects with Down's syndrome for the possibility that direct or indirect gene dosage effects of trisomy 21 alter the fate of acetaminophen. We also investigated the usefulness of noninvasive sampling techniques to obtain parameter estimates for drug disposition in these developmentally disabled individuals. After administration of 5 mg/kg and 20 mg/kg oral doses of acetaminophen, subjects with Down's syndrome resembled control subjects in most pharmacokinetic and metabolic parameters, including apparent half-life, volume of distribution per kilogram body mass, total body clearance per kilogram of body mass, extrapolated saliva concentration at time zero, and the urinary excretion of acetaminophen glucuronide and sulfate conjugates. Glutathione conjugation tended to increase and sulfate conjugation tended to decrease in all subjects as the acetaminophen dose increased from 5 mg/kg to 20 mg/kg. Results based on these samples of very limited size also suggest that acetaminophen metabolism to glutathione-derived conjugates may have been increased in subjects with Down's syndrome. The similarity of estimates of acetaminophen pharmacokinetics and data on metabolic fate between subjects with Down's syndrome and normal volunteers indicates that large effects of trisomy 21 on these processes are unlikely. Also, these results were in agreement with extensive data obtained with invasive techniques, indicating that simple noninvasive methodologies appear to be well suited for studying acetaminophen disposition in populations of developmentally disabled individuals.

Prenatal cocaine exposure and fetal vascular disruption

The question of the potential teratogenicity of cocaine has been raised by the increasing frequency of its abuse in the United States. In previous studies, an increased incidence has been documented of spontaneous abortion, placental abruption, prematurity, intrauterine growth retardation, and neurologic deficits in the infants of women who abused cocaine. More recently, it has been suggested in studies that fetal vascular disruption accompanying maternal cocaine abuse may lead to cavitary central nervous system lesions and genitourinary anomalies. In this article, 10 children born of women who abused cocaine are described, 9 of whom have congenital limb reduction defects and/or intestinal atresia or infarction. The spectrum of anomalies associated with embryonic and fetal vascular disruption accompanying maternal cocaine abuse is thus enlarged. The specific risk for congenital anomalies accompanying maternal cocaine abuse during an individual pregnancy is unknown. However, data from these patients and the available literature suggest that counseling pregnant women concerning cocaine use should incorporate warnings about the possibility of associated embryonic or fetal vascular disruption.

Symptomatic atlantoaxial instability associated with medical and rehabilitative procedures in children with Down syndrome

The Canadian College of Medical Genetics recently questioned the rationale for radiographic screening for atlantoaxial instability in Down syndrome. We report a case series of four children with Down syndrome with symptomatic atlantoaxial instability and followed for more than 5 years. In all cases a medical or rehabilitational procedure was associated with significant apnea, cardiopulmonary compromise, or severe neurological impairments. None of these patients were screened radiographically. The need for protocols to detect atlantoaxial instability in children with Down syndrome undergoing medical and rehabilitational procedures is highlighted by these cases.

N-acetylator variability in Down's syndrome: characterization with caffeine

Little is known regarding the biotransformation of drugs in Down's syndrome. In particular, there are no published studies that examine metabolic pathways such as N-acetylation, which can exhibit genetically-determined variability. The objective of the present investigation was to compare the acetylator phenotypes of white subjects with Down's syndrome with age-matched control subjects, with use of caffeine as the pharmacologic probe. After the ingestion of caffeine-containing beverages, spot urine collections were obtained at 2 and 4 hours in 22 subjects with Down's syndrome and in 22 control subjects (age range of 4 to 49 years). The urinary excretion ratios of 5-acetylamino-6-amino-3-methyluracil (AAMU) to 1-methylxanthine (1X) determined in these 2-hour and 4-hour samples were highly correlated (r = 0.82; p less than 0.001). In addition, more extensive urinary excretion studies performed for an 8-hour period in three subjects with Down's syndrome demonstrated that the coefficient of variability for the ratio of AAMU/1X ranged from 10.1% to 14.2%, which is similar to the reproducibility previously reported for control subjects. A trimodal distribution of acetylator phenotypes was observed, with no differences in average or frequency distribution of ratio values between the subjects with Down's syndrome and the control subjects. This study demonstrates that polymorphic N-acetylator status, as assessed by caffeine metabolism, is similar in subjects with Down's syndrome and in control subjects.

Relationships between laterality of congenital upper limb reduction defects and school performance

Eighty children (34 males, 46 females) with congenital upper limb reduction defects who attended a regional amputee clinic between 1956 and 1986 were classified as to whether they exhibited learning difficulties in school, as indicated by grade failure or by placement in learning disability classrooms. Children with right-sided defects were more likely to encounter learning difficulties than were children with left-sided defects (Chi-square = 6.8; df = 1; p less than 0.01). Children with right-limb defects also were more likely than children with left-limb defects to experience reading problems (Chi-square = 5.9; df = 1; p less than 0.05). These results suggest the need for neuropsychological and neurophysiological study of children with limb reduction defects.