Mental Health Considerations With Cerebral Palsy

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Introduction

Cerebral palsy (CP) is a lifelong condition that affects motor function, communication, and daily living activities. Progression of musculoskeletal deformities associated with this condition and changes in psychosocial development are factors leading to mental health challenges. Clinical symptoms of anxiety are a common occurrence in children with cerebral palsy. Other mental health issues diagnosed in individuals with cerebral palsy include depression, autism, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD). Contributing factors to mental health issues in cerebral palsy can include biological and environmental factors. When untreated, mental health issues can lead to negative consequences such as decreased participation in social activities and lower academic or work performance. Screening for both cognitive dysfunction and other mental disorders should become an integral part of the assessment of children with CP. Evidence-based treatments and rehabilitation programmes with a life-span perspective for mental health issues in individuals with cerebral palsy requires multidisciplinary approach.

This article discusses the impact of cerebral palsy on mental health issue and introduces evidence-based interventions for addressing mental health issues in individuals with cerebral palsy.

Definitions

Cerebral Palsy

There is no universally accepted definition of cerebral palsy, and there is no a single method to classify the impairment. The following definition was accepted in 2005 by the international multidisciplinary group. It is a modified definition first published by Bax in 1964:

"Cerebral palsy describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, by epilepsy and by secondary musculoskeletal problems"

Mental Health

Mental health is "a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

"Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognise, express and modulate one's own emotions, as well as empathise with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium".

Mental Health Disorders

"A mental disorder is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour.  It is usually associated with distress or impairment in important areas of functioning".

• Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) is the most updated list of manual disorders based on scientific literature and contributions from subject matter experts.
• The list below include examples of the childhood and adolescents mental health disorders:
  • inattentiveness
  • hyperactivity
  • anxiety
  • depression
  • conduct problems
  • autism spectrum disorder (ASD)
  • attention-deficit/ hyperactivity disorder (ADHD)
  • oppositional defiant disorder/conduct disorder (ODD/CD)
  • substance use disorder
  • learning disorder and other developmental disorders
  • tic disorder
  • early-onset schizophrenia
  • bipolar disorder
  • obsessive-compulsive disorder (OCD)

Epidemiology of Mental Disorders in CP

"The motor function does not predict the risk of other mental disorders then intellectual disability in children and adolescents with CP".

• When compared to control group, children with cerebral palsy are affected by mental disorders more frequently:
  • 3.5 times more frequently for mental disorders
  • 2.5 times more prevalent for autism spectrum disorders
  • 2.7 times more common for affective or anxiety disorders
  • Twice as often for ADHD
  • A five-fold increase in psychiatric disorders
  • Significant increase in emotional disorders from seven to eleven years of age
• Girls are twice as likely to have anxiety.
• Long term disability in adolescents highly correlates with depressive and anxiety symptoms.
• Adolescents with disability have lower scores for self-worth, appearance satisfaction, scholastic competence and social acceptance when compared with adolescents without disability.
• The prevalence of the mental health problems remains high throughout childhood and even into adulthood.

Factors Leading to Mental Health Challenges in CP

Physical Limitations

The emotional distress, anxiety, and depression in children and adolescents with cerebral palsy can develop as a result of physical limitations.Physical limitation can lead to limited physical activity which elevates the risk of depression. Subclinical mental health problems like depression and anxious symptoms are present more frequently in young people with disability as compared to young people without disability.

• Neuromuscular dysfunction, muscle weakness, and elevated demand for oxygen during physical activities are factors lowering the participation in physical activity for children with CP.
• Frequent hospitalisations and surgeries negatively impact participation in physical activities for children with CP.
• As they progress into the adulthood, children with CP experience significant decline in mobility.

Pain

Pain experienced by children with cerebral palsy can increase level of anxiety and depressive disorders:

• Musculoskeletal pain is associated with self-reported mental health problems and lower health-related quality of life (HRQL).
• Assessment of HRQL should become an integral part of the clinical visits as it has the potential to capture both pain and mental health problems.
• Chronic pain problem as a result of muscle spasticity, joint contracture, and other related issues can significantly impact the child's mental well-being and lead to anxiety, depression, and sleep disturbances.
• Pain negatively affect physical activity and sleep in paediatric population.
• A lower quality of life, behaviour, emotional problems, and other mental health disorders in children with CP have been associated with pain.
• Best practice recommendation include pain management as a clinical priority as it may have a substantial impact on the physical and mental health profiles in children with CP.

Communication

Communication problems can be defined as "having no speech, difficulties with pronunciation, or slow speech".

• Difficulties engaging in one-on-one conversation are present in around 55% of children with cerebral palsy. These difficulties include the following:
  • dysarthria which presents with limited speech intelligibility (21% to 36% of children with CP)
  • inability to speak (19% to 32% of children with CP)
• Difficulty in expressing emotions and needs due to communication challenges for individuals with cerebral palsy can lead to frustration and emotional distress.
• Communication problems can limit participation and enjoyment in social and recreational activities for individuals with CP which can profoundly impact on the individual’s quality of life and self-concept.
• Speech difficulties may prevent children with CP verbally express any problems they are experiencing. In addition learning disability experience by half of children with cerebral palsy may overshadow or mask their mental health problems.

Participation

ICF–CY defines participation as "involvement in life situations." It is an important health outcome. School life, family and peer group activities , and engagement in work and leisure are the main ICF components.

Participation and mental health in children and adolescents with CP are linked:

• Children with cerebral palsy (CP) aged 8–12 years participate less in everyday activities than children in the general populations
• Children with CP have low social participation and relationships which may contribute to poor mental health.
• Children with CP are at increased risk for being bullied which may contribute to poor mental health.
• Adolescents with CP spent considerably less time with their friends
• Adolescents with CP engaged less often in "organised sport"

Sexual Development

According to the World Health Organisation, sexuality is a “central aspect of being human” , and sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.”Dating and sex are part of the peer and social relationships. Any delay in dating behaviours and physical and emotional difficulties with sex negatively affect peer and social relationships for adolescents with CP.

• Parental anxiety regarding adolescent with CP sexual development has been reported

Signs and Symptoms of Mental Health Problems CP

Children with cerebral palsy may exhibit specific signs indicative of depression, anxiety, and fear. Depression in a child with cerebral palsy might manifest as persistent sadness, a lack of interest in activities, changes in appetite and weight, and feelings of hopelessness.

Anxiety, on the other hand, may lead to excessive worry, restlessness, muscle tension, and avoidance of situations that trigger anxiety.

Fear can be particularly pronounced in children with cerebral palsy, often stemming from the challenges they face. They may fear physical pain, the reaction of peers and adults, or the uncertainty of their condition. These emotions can manifest as withdrawal, panic attacks, or regression in developmental milestones. Some common signs to watch for include changes in behaviour, such as increased irritability; withdrawal from social interactions; excessive worry or fear; difficulty concentrating; changes in eating or sleeping patterns; and a loss of interest in activities they once enjoyed. Additionally, pay attention to any regression in developmental milestones or communication skills.

Parenting

Parents and caregivers may experience stress, anxiety, and depression as they navigate the challenges of raising a child with CP. Recognising these challenges and offering resources and support can improve the overall mental health of the family unit.

Assessment

• Screening tools, such as the Strengths and Difficulties Questionnaire (SDQ) . SDQ is a brief screening questionnaire for mental health problems, including versions for self-report, parent-report and teacher-report.consisting of 25 items. Four of the items record problem domains, each including five items, and one pro-social domain, including five items. Some researchers questioned this tool lack of sensitivity in delineating between psychiatric disorders. Goodman et al. found that the questionnaire identi- fied less than 50% of individuals with specific phobias, separation anxiety and eating disorders.
• Screen for Child Anxiety Related Disorders (SCARED) The 41-item SCARED questionnaire8 – parent version was used to screen for anxiety disorders. The SCARED is a questionnaire constructed to measure symptoms of DSM IV-linked anxiety disorders in children.8

Multidisciplinary Approach

holistic approach to care that includes preventative strategies to address both mental and physical health outcomes should begin well in advance to their transition into young adulthood in order to mitigate the impact these factors have on health and well-being during this critical developmental time.

look for signs of mental health challenges and communicate with other healthcare professionals like psychologists or counsellors whenever necessary.

One essential approach is to use simple and straightforward language tailored to the individual's comprehension level incorporating non-verbal cues such as gestures, facial expressions, and augmentative communication devices can greatly enhance communication and help children express their thoughts and feelings. Moreover, active listening plays a pivotal role in making them feel heard and understood. By taking time to listen attentively and respond empathetically, you can foster a sense of trust and rapport, which is crucial for addressing both physical and mental health needs.

incorporate pain management strategies into treatment plans. This not only helps physical discomfort but can also significantly improve the mental well-being of children with cerebral palsy. Pain relief can lead to reduced anxiety, improved sleep patterns, and enhance overall quality of life.

Emotional support is an essential part of holistic care for individuals with cerebral palsy and their families.

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