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Questions How stable are psychiatric problems in children who have hemiplegia?
2 inception cohorts with 4 years follow up.
All children had a clinical diagnosis of hemiplegia. Of 88 preschool children who were assessed at 3–5 years of age, the parents of 78 children (89%) completed baseline questionnaires. Follow up was 90%. Teacher questionnaires were completed for <80% of preschool children. Of 240 schoolchildren who were assessed at 5–12 years of age, the parents of 218 children (91%) and the teachers of 224 children (93%) completed questionnaires. Follow up was 87% for parent questionnaires and 84% for teacher questionnaires.
Assessment of prognostic factors
In preschool children, the Behaviour Checklist was completed by parents. In schoolchildren, parents and teachers completed questionnaires which included a modified Rutter questionnaire and an item on mental age; hyperactivity was assessed in the teacher questionnaire using 7 items from the Conners teacher rating scale.
Main outcome measures
Number of psychiatric cases at 4 years of follow up and associations between problems at baseline and problems 4 years later.
25 of 33 preschool children and 81 of 107 schoolchildren who were identified as having a psychiatric disorder based on parent reports still had disorder 4 years later. Children with psychiatric disorder were more likely to have disorder 4 years later than those without psychiatric disorder at baseline (table). An association between parent reported problems at baseline and at 4 years existed in preschool children (r=0.57, p<0.001) and in schoolchildren (r=0.67, p<0.001); a similar association existed in schoolchildren when teacher reports were used (r=0.41, p<0.001). In preschool children, items on the parent questionnaire that predicted problems reported by parents 4 years later were bed wetting (r=0.32, p<0.05), day wetting (r=0.42, p<0.001), soiling (r=0.45, p<0.001), overactiveness (r=0.33, p<0.01), “hard to handle” (r=0.35, p<0.01), tantrums (r=0.33, p<0.01), clinginess (r=0.25, p<0.05), and problems playing with others (r=0.36, p<0.01).
In children with hemiplegia, 76% of those who had a psychiatric disorder still had a disorder 4 years later. The presence of psychiatric problems at baseline was associated with a 2.6-fold and 2.8-fold increased risk of psychiatric problems in preschool and schoolchildren, respectively, at 4 years.
This longitudinal study by Goodman is the latest to examine the association between hemiplegia or chronic brain disorders and psychiatric conditions. Few adequate studies have evaluated the persistence of psychiatric problems and their predictors in hemiplegic children. Goodman used well accepted, validated behaviour screening measures to address this issue.1
By using measures completed by parents and teachers, which were repeated at 4 years follow up, Goodman has contributed several important findings. He appropriately acknowledges the limitations of screening tools; however, he also shows positive correlations between these ratings and actual assessment findings.
The practical implications of this study for clinicians are several. Firstly, the study shows the importance of considering all aspects of a child's development and functioning, not just the obvious physical intervention needs. Secondly, this population of children is clearly at risk for psychiatric difficulties, which may be chronic. Thirdly, this research implies that behaviours such as enuresis in many children with cerebral palsy may be predictive of later psychiatric problems and should not be considered to be merely a developmental delay. Fourthly, features of attentional difficulties were identified as major risk markers and should be monitored routinely. It was interesting to note that no predictors of internalising disorders were clearly identified in this study, and predictive markers tended to be earlier externalising behaviours.
Future work should focus on identifying effective interventions, including determining if children with chronic brain disorders respond to the same interventions that are effective for typical behavioural or psychiatric difficulties. Another issue is whether early parenting support can influence the prevalence or chronicity of these psychiatric conditions—although Goodman suggests that “adverse family factors are more likely to be consequences than causes of the children's psychiatric problems.” Although this study makes an important contribution, clearly further research is warranted to address these issues.
Sources of funding: Med ical Research Council; Wellcome Trust; Scope.
For correspondence: Dr R Goodman, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Fax +44 (0)171 708 5800.
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