Mental Health Considerations With Cerebral Palsy

Original Editor - Ewa Jaraczewska based on the course by Pradeep Gunarathne

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

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.[1] Clinical symptoms of anxiety are a common occurrence in children with cerebral palsy. [2] 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.[3] Evidence-based treatments and rehabilitation programmes with a life-span perspective for mental health issues in individuals with cerebral palsy requires multidisciplinary approach.[1]

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[edit | edit source]

Cerebral Palsy[edit | edit source]

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"[4]

Mental Health[edit | edit source]

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.”[5]

"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".[6]

Mental Health Disorders[edit | edit source]

"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". [7]

  • 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.[8]
  • The list below include examples of the childhood and adolescents mental health disorders:

Epidemiology of Mental Disorders in CP[edit | edit source]

"The motor function does not predict the risk of other mental disorders then intellectual disability in children and adolescents with CP".[3]

  • When compared to control group, children with cerebral palsy are affected by mental disorders more frequently:[3]
    • 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 [9]
    • Significant increase in emotional disorders from seven to eleven years of age[9]
  • Girls are twice as likely to have anxiety.[2]
  • Long term disability in adolescents highly correlates with depressive and anxiety symptoms.[10]
  • Adolescents with disability have lower scores for self-worth, appearance satisfaction, scholastic competence and social acceptance when compared with adolescents without disability.[10]
  • The prevalence of the mental health problems remains high throughout childhood and even into adulthood.
  • There is a considerable overlap of mental health symptoms and psychiatric disorders in children with CP.[11]

Factors Leading to Mental Health Challenges in CP[edit | edit source]

Physical Limitations[edit | edit source]

The emotional distress, anxiety, and depression in children and adolescents with cerebral palsy can develop as a result of physical limitations.[12]Physical limitation can lead to limited physical activity which elevates the risk of depression. [13] 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.[14]

  • Neuromuscular dysfunction, muscle weakness, and elevated demand for oxygen during physical activities are factors lowering the participation in physical activity for children with CP.[15]
  • 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[edit | edit source]

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).[16]
  • 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.[16]
  • 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.[12]
  • 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.[17]
  • 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.[15]

Communication[edit | edit source]

Communication problems can be defined as "having no speech, difficulties with pronunciation, or slow speech".[9]

  • Difficulties engaging in one-on-one conversation are present in around 55% of children with cerebral palsy.[18] These difficulties include the following:
    • dysarthria which presents with limited speech intelligibility (21% to 36% of children with CP) [19]
    • inability to speak (19% to 32% of children with CP) [20]
  • Difficulty in expressing emotions and needs due to communication challenges for individuals with cerebral palsy can lead to frustration and emotional distress. [12]
  • 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.[21]
  • 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.[22]

Participation[edit | edit source]

ICF–CY defines participation as "involvement in life situations." [23] It is an important health outcome.[24] School life, family and peer group activities , and engagement in work and leisure are the main ICF components.[24]

Participation and mental health in children and adolescents with CP are linked. The examples below demonstrate this link:

  • Children with cerebral palsy (CP) aged 8–12 years participate less in everyday activities than children in the general populations. [24]
  • Children with CP have low social participation and relationships which may contribute to poor mental health.[24]
  • Adolescents with CP engaged less often in an organised sport.
  • Social factors that include difficulty with friendships and bully victimisation are associated with a higher occurrence of mental health disorders in children with CP.[25]

Sexual Development[edit | edit source]

According to the World Health Organisation, sexuality is a “central aspect of being human” [26], 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.”[26] 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.[27]

Watch this video where Natasha talks about her life with cerebral palsy and mental health challenges:

[28]

Signs and Symptoms of Mental Health Problems in CP[edit | edit source]

Common signs indicative of mental health problems in children and adolescents with CP include changes in behaviour, such as increased irritability, withdrawal from social interactions, excessive worry or fear, difficulty concentrating, changes in eating or sleeping patterns, loss of interest in activities they once enjoyed, and regression in communication skills.[12]

The followings are the signs to watch for when suspecting depression, anxiety, and fear in children with CP: [12]

Depression

  • persistent sadness
  • lack of interest in activities
  • changes in appetite and weight
  • feelings of hopelessness

Anxiety

  • excessive worry
  • restlessness
  • muscle tension
  • avoidance of situations that trigger anxiety

Fear

  • withdrawal
  • panic attacks
  • regression in developmental milestones

Mental Health Problems in Parents of Children with CP[edit | edit source]

Parents and caregivers may experience their own mental health problems as they navigate the challenges of raising a child with CP. Depression and anxiety are more frequently occurring in parents of children with CP when compared with parents of children typically developed. [29]

Risk Factors[edit | edit source]

The following risk factors for mental health problems in parents of children with CP have been identified:[30]

  • The level of independence in child's motor functioning. Severe impairments is positively linked to parental mental health.
  • Poor parental coping strategies
  • Low parental self-esteem
  • High caregiving burden
  • Low parental social support
  • Parental dissatisfaction with disclosure of diagnosis
  • Clinical, community and social factors in the early to middle childhood period

The challenges of being a parent of a child with CP are social and psychoemotional.[29] They include daily care challenges (having additional parenting tasks like helping with activities of daily living and mobility, family management, and comprehension of children’s functionality), internal challenges (grief dealing related to diagnosis and adjustment in parental expectations, mental health issues, and achievements), and social challenges (being scrutinised as a parent of a child with disability, ack of autonomy and not being able to fulfil own professional goals).[29]

Recognising these challenges and offering resources and support can improve the overall mental health of the family unit.[12]

Assessment[edit | edit source]

Mental health problems in children with CP should be identified and treated as early as possible. Routine care of a child with CP should focus equally on the assessment of motor impairment and mental health. [31] There is no one effective tool in identifying the presence of mental health problems in children or young people with cerebral palsy. The following tools were identified in various studies:

Multidisciplinary Treatment Approach[edit | edit source]

Mental health disorders in children and adolescents with CP cannot be underestimated and must be identified as they can hinder integration of the child in the community. The multidisciplinary team of experts should take a holistic approach to assess and care for these individuals:

  • The most comprehensive approach can be provided in the child's school with its natural, inclusive setting, as it is a "familiar meeting place for most children, providing a more accessible and comfortable site for students to receive mental health services than hospital or community mental health settings." [35]
  • The team of specialised addressing mental health problem in children with CP should include school counsellors, psychologists, supported by a speech-language pathologist (SLP), educational therapist (ET), occupational and physical therapists.
  • The children with CP are often the target of bullying. It is important to recognise red flags indicating the presence of harassment and address the problems very early .[36]
  • Preventative strategies addressing mental and physical health outcomes as the child transition into young adulthood will diminish the impact these factors have on health and well-being during the developmental time. [1]

The following recommendations may help to choose the best approach:[12]

  • Use simple and straightforward language tailored to the individual's comprehension level.
  • Incorporate non-verbal cues such as gestures, facial expressions, and augmentative communication devices to enhance communication and help children express their thoughts and feelings.
  • Use active listening to make the child feel heard and understood. Take time to listen attentively and respond empathetically, to help foster a sense of trust and rapport.
  • Incorporate pain management strategies into treatment plans. It can significantly improve the mental well-being of children with cerebral palsy leading to reduced anxiety, improved sleep patterns, and enhance overall quality of life.
  • Offer emotional support for individuals with cerebral palsy and their families.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Sienko SE. An exploratory study investigating the multidimensional factors impacting the health and well-being of young adults with cerebral palsy. Disabil Rehabil. 2018 Mar;40(6):660-666.
  2. ↑ 2.0 2.1 2.2 McMahon J, Harvey A, Reid SM, May T, Antolovich G. Anxiety in children and adolescents with cerebral palsy. J Paediatr Child Health. 2020 Aug;56(8):1194-1200.
  3. ↑ 3.0 3.1 3.2 Rackauskaite G, Bilenberg N, Uldall P, Bech BH, Østergaard J. Prevalence of mental disorders in children and adolescents with cerebral palsy: Danish nationwide follow-up study. Eur J Paediatr Neurol. 2020 Jul;27:98-103.
  4. ↑ The Definition and Classification of Cerebral Palsy. Dev Med Child Neurol. 2007 Feb;49(s109):1-44.
  5. ↑ World Health Organization. Promoting mental health: concepts, emerging evidence, practice (Summary Report) Geneva: World Health Organization; 2004.
  6. ↑ Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World Psychiatry. 2015 Jun;14(2):231-3.
  7. ↑ Mental disorders. World Health Organization 2022. Available from https://www.who.int/news-room/fact-sheets/detail/mental-disorders [last access 23.12.2023]
  8. ↑ Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Available from https://www.psychiatry.org/psychiatrists/practice/dsm [last access 23.12.2023]
  9. ↑ 9.0 9.1 9.2 Bjorgaas HM, Elgen IB, Hysing M. Trajectories of psychiatric disorders in a cohort of children with cerebral palsy across four years. Disabil Health J. 2021 Jan;14(1):100992.
  10. ↑ 10.0 10.1 Helseth S, Abebe DS, Andenæs R. Mental health problems among individuals with persistent health challenges from adolescence to young adulthood: a population-based longitudinal study in Norway. BMC Public Health. 2016 Sep 15;16:983.
  11. ↑ Bjorgaas HM, Elgen I, Boe T, Hysing M. Mental health in children with cerebral palsy: does screening capture the complexity? ScientificWorldJournal. 2013 Apr 3;2013:468402.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Gunarathne P. Mental Health Considerations With Cerebral Palsy. Plus Course 2023
  13. ↑ Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. Am J Prev Med 2013; 45: 649–57.
  14. ↑ Lal S, Tremblay S, Starcevic D, Mauger-Lavigne M, Anaby D. Mental health problems among adolescents and young adults with childhood-onset physical disabilities: A scoping review. Front Rehabil Sci. 2022 Sep 6;3:904586.
  15. ↑ 15.0 15.1 Whitney DG, Warschausky SA, Peterson MD. Mental health disorders and physical risk factors in children with cerebral palsy: a cross-sectional study. Dev Med Child Neurol. 2019 May;61(5):579-585.
  16. ↑ 16.0 16.1 Ramstad K, Jahnsen R, Skjeldal OH, Diseth TH. Mental health, health related quality of life and recurrent musculoskeletal pain in children with cerebral palsy 8-18 years old. Disabil Rehabil. 2012;34(19):1589-95.
  17. ↑ Riquelme I, Sabater-Gárriz Á, Montoya P. Pain and Communication in Children with Cerebral Palsy: Influence on Parents' Perception of Family Impact and Healthcare Satisfaction. Children (Basel). 2021 Jan 27;8(2):87.
  18. ↑ Pennington L, Dave M, Rudd J, Hidecker MJC, Caynes K, Pearce MS. Communication disorders in young children with cerebral palsy. Dev Med Child Neurol. 2020 Oct;62(10):1161-1169.
  19. ↑ Zhang JY, Oskoui M, Shevell M. A population-based study of communication impairment in cerebral palsy. J Child Neurol. 2015 Mar;30(3):277-84.
  20. ↑ Nordberg A, Miniscalco C, Lohmander A, Himmelmann K. Speech problems affect more than one in two children with cerebral palsy: Swedish population-based study. Acta Paediatr. 2013 Feb;102(2):161-6.
  21. ↑ Whitney DG, Peterson MD, Warschausky SA. Mental health disorders, participation, and bullying in children with cerebral palsy. Dev Med Child Neurol. 2019 Aug;61(8):937-942.
  22. ↑ Oakes L. Why is mental health being overlooked in those with cerebral palsy? HSR Psychology 2019. Available from https://hsrpsychology.co.uk/blog/why-is-mental-health-being-overlooked-in-those-with-cerebral-palsy/ [last access 26.12.2023]
  23. ↑ WHO. International classification of functioning, disability and health. Children and youth version 2007.
  24. ↑ 24.0 24.1 24.2 24.3 Michelsen SI, Flachs EM, Damsgaard MT, Parkes J, Parkinson K, Rapp M, Arnaud C, Nystrand M, Colver A, Fauconnier J, Dickinson HO, Marcelli M, Uldall P. European study of frequency of participation of adolescents with and without cerebral palsy. Eur J Paediatr Neurol. 2014 May;18(3):282-94.
  25. ↑ Whitney DG, Peterson MD, Warschausky SA. Mental health disorders, participation, and bullying in children with cerebral palsy. Dev Med Child Neurol. 2019 Aug;61(8):937-942.
  26. ↑ 26.0 26.1 Defining sexual health. World Health Organisation. Available from https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health [last access 27.12.2023]
  27. ↑ Power R, Heanoy E, Das MC, Karim T, Muhit M, Badawi N, Khandaker G. The Sexual and Reproductive Health of Adolescents with Cerebral Palsy in Rural Bangladesh: A Qualitative Analysis. Arch Sex Behav. 2023 May;52(4):1689-1700.
  28. ↑ headspaceAustralia. Mental Health & Disabilities - Natasha's Story. Available from: https://www.youtube.com/watch?v=FnTaKgQ0Mzs [last accessed 28/12/2023]
  29. ↑ 29.0 29.1 29.2 Guimarães A, Pereira A, Oliveira A, Lopes S, Nunes AR, Zanatta C, Rosário P. Parenting in Cerebral Palsy: Understanding the Perceived Challenges and Needs Faced by Parents of Elementary School Children. Int J Environ Res Public Health. 2023 Feb 21;20(5):3811.
  30. ↑ Sivaratnam C, Devenish B, Howells K, Chellew T, Reynolds K, Rinehart N. (2021) Risk factors for mental health difficulties in parents of children with cerebral palsy: a systematic review and meta-analysis. Clinical Psychologist 2021; 25 (1): 1-18.
  31. ↑ National Guideline Alliance (UK). Cerebral palsy in under 25s: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jan. (NICE Guideline, No. 62.) 24, Assessment of mental health problems.Available from https://www.ncbi.nlm.nih.gov/books/NBK533247/ [last access 27.12.2023]
  32. ↑ McCullough N, Parkes J. Use of the child health questionnaire in children with cerebral palsy: a systematic review and evaluation of the psychometric properties. Journal of pediatric psychology. 2008 Jan 1;33(1):80-90.
  33. ↑ Bjorgaas HM, Elgen IB, Hysing M. 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. Children (Basel). 2022 Jul 6;9(7):1009.
  34. ↑ Goodman R, Renfrew D, Mullick M. Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. Eur Child Adolesc Psychiatry. 2000 Jun;9(2):129-34.
  35. ↑ Atkins MS, Hoagwood KE, Kutash K, Seidman E. Toward the integration of education and mental health in schools. Adm Policy Ment Health. 2010 Mar;37(1-2):40-7.
  36. ↑ Cantero MJ, Medinilla EE, Martínez AC, Gutiérrez SG. Comprehensive approach to children with cerebral palsy. Anales de Pediatría (English Edition). 2021 Oct 1;95(4):276-e1.
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