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There have been few studies of emotional and behavioural difficulties in preschool children with cerebral palsy (CP). The paper by Sigurdardottir et al.1 has strong design features with a control group and reports from parents and teachers. Although the sample of 36 is small, this is really only a problem for the subgroup analyses which have such large confidence intervals that interpretation is speculative. Also eight of the potential sample were excluded because of severe disability, again rendering suspect the subgroup analyses by IQ and motor function.

The findings are generally similar to those in older children with CP. There is an increased prevalence of emotional and behavioural difficulties compared with the general population and the determinants of such difficulties are similar.

I wondered whether the article would help me answer two questions. The first is: why are emotional and behavioural difficulties more common in children with CP than in the general population? A common view is that the brain damage may have disrupted pathways or networks which regulate emotions and the learning of behaviour and render the brain less adaptive. The present finding that the difficulties are more common in the children with an IQ of less than 70 would support this.1 But it would also support the view that there may be unrecognized subtle learning difficulties2 which render many situations more difficult to cope with, leading to the reactive behaviour problems displayed by most children in such circumstances.

Another possible cause is that the child may feel self-conscious and embarrassed in aspiring to be like other children and as a result experience emotional symptoms and feelings of isolation. This might explain why children with hemiplegia are more likely to have emotional and behavioural difficulties than children with more severe motor problems. Because the difference between them and the general population is smaller, their peers, parents and teachers, and they themselves may have unrealistic expectations that ‘normality’ can be achieved; peers in particular may be more likely to tease and discriminate. However the current finding of these difficulties being already present in preschool children argues against such an explanation as self-consciousness and discriminatory attitudes from peers are unlikely to be present so soon.1

Parent-child interactional styles may also contribute to the higher prevalence. Parents of children with CP experience more stress than parents of children in the general population;3 and parental stress is known to be associated with emotional and behavioural difficulties in all children.4 But maybe even more important is whether parents of a disabled child manage and set boundaries differently for a disabled child. I highly recommend the article by Woolfson5 which reviews the literature on how societal views and parent preconceptions may mix with feelings of guilt and sadness to alter fundamentally how parents deal with a child with CP. Certainly the finding that emotional and behavioural difficulties are already present in the preschool years when parent-child interactional styles are set is consistent with the hypothesis that a disabled child may be managed differently.

The second question is: do the results help guide interventions? My practice has changed in relation to pain in children with CP, now that we know it is so prevalent and such a strong determinant of quality of life and participation. I now always ask about pain and the child often talks about pain that had not been mentioned before, even to their parents.

My practice has also changed in relation to behavioural development. In the preschool years especially, I ask about sleep, tantrums, and concentration, etc. and invite parental reflection on how they manage their child’s behaviour. Do they do it differently to their management of their other children? Do they understand or explain difficulties as being due to the CP, rather than the normal interactions between parents and all children? Parents are often surprised when I suggest they manage their child with CP in the same way they do other children.

Where emotional and behavioural difficulties persist, the results of the work done by Sigurdardottir et al. make a strong case for seeking specialist psychological help to try to modify relationships whilst the child is still young.

References

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  2. References
  • 1
    Sigurdardottir S, Indredavik MS, Eiriksdottir A, Einarsdottir K, Gudmundsson HS, Vik T. Behavioural and emotional symptoms of preschool children with cerebral palsy. A population-based study. Dev Med Child Neurol DOI: 10.1111/j.1469-8749.2010.03698.x (Published online 24th May 2010)
  • 2
    Bottcher L, Flachs EM, Uldall P. Attentional and executive impairments in children with spastic cerebral palsy. Dev Med Child Neurol 2010; 52: e427.
  • 3
    Glenn S, Cunningham C, Poole H, Reeves D, Weindling M. Maternal parenting stress and its correlates in families with a young child with cerebral palsy. Child Care Health Dev 2009; 35: 718.
  • 4
    Sipal RF, Schuengel C, Voorman JM, Van EckM, Becher JG. Course of behaviour problems of children with cerebral palsy: the role of parental stress and support. Child Care Health Dev 2010; 36: 7484.
  • 5
    Woolfson L. Family well-being and disabled children: a psychosocial model of disability-related child behaviour problems. Br J Health Psychol 2004; 9: 113.