EMOTIONAL AND BEHAVIORAL IMPAIRMENTS

The prevalence of emotional and behavioral problems in different populations of children with CP is reportedly 30% to 80% (61) but in general, it has not been well defined in the literature. A wide variety of behavioral and emotional disorders are possible, including attention deficit disorder, passivity, immaturity, anger, sadness, impulsivity, emotional lability, low self-esteem, and anxiety. A population-based analysis of behavior problems in children with CP identified problem behaviors in 25% of the children as assessed by parent reports (61). Specific behaviors that were most common in this population included dependency, being headstrong, and hyperactivity. An additional population-based study in Europe found a similar prevalence of significant emotional and behavioral symptoms in 26% of children with CP (62). The most common problems identified were in peer relationships (32%), hyperactivity (31%), and emotion (29%). Difficulty with peer relationships has been found even in children with milder CP (GMFCS I). Compared to their classmates, children with mild CP were found to have fewer reciprocated friendships, fewer sociable and leadership behaviors, and were more isolated and victimized by their classmates (63). A potentially important contributing factor to impaired behavioral and social functioning is decreased cognitive EF (64).

Although, there is widespread agreement that emotional and behavioral dysfunction is common in children with CP, there is very limited research on effective interventions to address the issue. There is emerging evidence that parenting interventions and cognitive behavioral therapy, such as the Stepping Stones Triple P and Acceptance and Commitment Therapy, may be beneficial (65). An early awareness of the risk for emotional and behavioral disorders by professionals and parents is important, so that they can be recognized early. Referral to a mental health specialist should be considered, as well as a neuropsychological evaluation, including EF.

EPILEPSY

The overall occurrence of epilepsy is reported to be between 15% and 55% in a mixed population of children and adults with CP (66). A wide variety of types of seizures are possible, and a clear correlation between various risk factors and seizure frequency or type has yet to be established. Seizures are more common in children with more severe CP and in children with quadriparesis and hemiparesis versus diparesis (67).

OROMOTOR IMPAIRMENTS

Oromotor impairments are associated with more severe CP. A weak suck, poor coordination of the swallowing mechanism, tongue thrusting, and a tonic bite reflex may all lead to feeding difficulties and increased risk for aspiration. Speech disorders range from mild articulation disorders to anarthria, and are most commonly seen in children with spastic quadriparesis or athetosis. Oromotor dysfunction may also lead to difficulty controlling oral secretions and drooling, which may negatively affect social interactions. A wide range of interventions exist to address drooling, but a recent Cochrane review concluded that there is insufficient evidence to inform clinical practice (68). Oromotor impairments are also associated with dental malocclusion and difficulty with oral hygiene, leading to an increased risk of periodontal disease.

NUTRITIONAL DISORDERS

The assessment of growth and nutrition in children with CP can be difficult due to the lack of a reliable means of measuring stature in children with contractures and scoliosis and the lack of appropriate reference data or growth curves specific to CP (69). Population-based growth patterns of CP have been published (70), but they probably include many children with conditions affecting growth and feeding, and therefore should not be considered prescriptive of how children with CP should grow (69).

Poor oromotor skills, gastroesophageal reflux, and the inability to self-feed or communicate hunger can all increase the risk for malnutrition in children with CP. The North American Growth in Cerebral Palsy Project (NAGCPP) is a population-based study that identified the presence of feeding problems in 58% of children with moderate to severe CP (71). In addition, children with a pattern of severe feeding dysfunction were described as having the greatest risk for poor nutritional status and health, but even those with only mild feeding dysfunction were identified as being at risk for poor nutritional status. Subjects who were enterally fed were taller and had greater body fat stores when compared to subjects with similar motor impairments who were exclusively fed by mouth (72). Data from the NAGCPP also revealed that children with the best growth had better health and social participation (71).

For children who are unable to obtain adequate nutrition by mouth, gastrostomy or jejunostomy tubes are often utilized. There is evidence that this results in improved weight gain, but there is the potential for adverse events including overfeeding, site infection, stomach ulcer and reflux (73). A recent Cochrane review of gastrostomy feeding versus oral feeding alone in children with CP did not reveal a single randomized controlled trial (RCT) on this topic (74). Given the lack of evidence to guide clinical practice, the decision on the most appropriate means of nutritional support should be made in the context of each individual patient and family.

Although malnutrition is a primary concern, children with CP are also at risk for overfeeding and obesity. Children with more severe CP have lower total energy expenditure and higher body fat content than age- and sex-matched children without disabilities, placing them at risk for overfeeding with energy-dense enteral feeds (75). A study of ambulatory children with CP showed an increase in the prevalence of obesity from 7.7% to 16.5% over a 10-year period, an increase similar to that seen in the general pediatric population in the United States (76).

 
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