Assessing aspects of early social communication in non-speaking children with bilateral cerebral palsy.

PURPOSE: Research suggests that rates for autism may be higher in cerebral palsy than in the general population. For those with severe bilateral physical impairment (GMFCS level IV and V) and little or no speech, describing a profile of social communication skills has been difficult because there are currently no assessments for early social communication specifically tailored for these children. Our aim was to explore the assessment of aspects of joint attention and social reciprocity in this group of children with CP. METHODS: We compared the performance of children with bilateral CP on carefully designed assessments of joint attention and social responsiveness with groups of children with Down syndrome and autism. All three groups were matched for chronological age and mental age. RESULTS: Approximately 30% of the children with bilateral CP had early social communication scores similar to the autistic children. The remaining 70% of children with CP had a range of early social communication scores similar to the children with Down syndrome. CONCLUSION: It is possible to assess key early social communication skills in non-speaking children with bilateral motor disability. This could provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.

With carefully designed activities, which do not rely on motor skills or verbal exchanges, it was possible to assess joint attention and social responsiveness skills in a group of non-speaking children with bilateral motor disability.We were able to identify a subgroup of non-speaking children with severe motor disability (approximately 30% of our cohort) whose scores on our assessments were similar to a group of autistic children.The ability to describe key early social communication skills should provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.

Use of eye-pointing by children with cerebral palsy: what are we looking at?

BACKGROUND: Children with cerebral palsy often show significant communication impairment due to limited or absent speech. Further, motor impairment can restrict the use of movement, including pointing, to signal interest and intent. For some children, controlled gaze can be an effective 'point-substitute': such 'eye-pointing' can be used to request items, establish mutual interest in an event, or select vocabulary within an alternative or augmentative communication (ACC) system. However, in clinical practice there is a lack of clarity about how the term 'eye-pointing' is used, how 'eye-pointing' is recognized or how it relates to social development. AIMS: To present a clinical description of the term 'eye-pointing' with reference to children with severe cerebral palsy who cannot speak or finger-point. To consider this description within a wider discussion of the importance of gaze in communication development. METHODS & PROCEDURES: Cumulative clinical observations during assessment of children referred to a specialist multidisciplinary communication clinic have provoked discussion between the authors on what factors precipitate use of the term 'eye-pointing' in young children with severe cerebral palsy. In particular, discussion has centred on whether use of the term is appropriate in individual cases and whether guidance is available about how gaze should be observed in this developmentally vulnerable group of children. A literature search was also conducted in order to explore whether the use and meaning of the term is established. CONCLUSIONS & IMPLICATIONS: In interactions with non-speaking children, determining whether a child is using eye-gaze communicatively requires observation and interpretation of several factors. These processes will be informed by reflection on what is known about other aspects of the child's communication and interaction skills. Within the literature, the term 'eye-pointing' is sometimes used when describing the communication functions of individuals using augmentative and alternative communication (AAC) systems, and is occasionally qualified by a definition. No papers have been found that set out a clinical description universally applicable to children with severe motor impairment. Moreover, guidance is lacking on how possible episodes of 'eye-pointing' might be confidently distinguished from other episodes of directed gaze in young, developing communicators. The discussion of the term makes reference to the importance of gaze in early communication development, and explores factors that might influence gaze and its interpretation in young children with cerebral palsy. A description of eye-pointing for this group is offered. The authors suggest that this will bring practical benefits to those supporting the communication development of children with severe cerebral palsy.

An examination of relations between participation, communication and age in children with complex communication needs.

The aim of this study was to examine variation in the frequency of children's participation in out-of-school activities as a function of speech intelligibility, perceived effectiveness of the child's communication aid, and age. Sixty-nine caregivers of children with complex communication needs provided with communication aids completed a questionnaire survey. Rate of participation was higher for younger than for older children, particularly in recreational activities. Younger children with partial intelligibility participated more frequently in recreational and social activities than both younger children without speech and older children. Results and limitations are discussed within the context of participation research in childhood disability, highlighting the impact of communicative resources and maturation on everyday participation.

Development and testing of the eye-pointing classification scale for children with cerebral palsy.

PURPOSE: The aim of this study was to develop and test a new classification scale to describe looking behaviours (gaze fixations and gaze shifts) in relation to eye-pointing. METHODS: The Eye-pointing Classification Scale (EpCS) was developed and tested following established procedures for the construction and evaluation of equivalent scales, and involved 2 phases: Drawing on research literature, Phase 1 involved initial drafting of the scale through a series of multi-disciplinary group discussions; evaluation of the scale through a survey procedure, and subsequent expert group evaluation. Phase 2, was an examination of scale reliability and relationships between child characteristics and level of EpCS classification. RESULTS: In Phase 1, an initial draft of the scale was developed and then evaluated by 52 participants in 10 countries, leading to its refinement. Subsequent expert evaluation of content, style and structure indicated that no further refinement was required. In Phase 2, the scale achieved excellent levels of reliability in clinical testing. A significant relationship was identified between level of child motor ability and EpCS classification, and level of child language understanding and EpCS classification.Implications for rehabilitationNon-speaking children with severe bilateral cerebral palsy who have limited upper limb movement may communicate by using controlled looking behaviours to point to objects and people, referred to as eye-pointing.However, there is little consensus as to which looking behaviours represent eye-pointing and which do not.The Eye-pointing Classification Scale (EpCS) was developed to describe looking behaviours related to eye-pointing in this population of childrenThe EpCS provides a new robust tool for clinical management and research with children with cerebral palsy.

Worster-Drought syndrome: poorly recognized despite severe and persistent difficulties with feeding and speech.

AIM: Worster-Drought syndrome (WDS), or congenital suprabulbar paresis, is a permanent movement disorder of the bulbar muscles causing persistent difficulties with swallowing, feeding, speech, and saliva control owing to a non-progressive disturbance in early brain development. As such, it falls within the cerebral palsies. The aim of this study was to describe the physical and neuropsychological profiles of children with WDS. METHOD: Forty-two children with WDS (26 males, 16 females; mean age 7y 10mo, SD 3y 1mo; range 2y 6mo to 16y 5mo) were studied prospectively using a standard protocol. RESULTS: All of the children had severe bulbar dysfunction; 36 out of 42 had feeding difficulties and 23 of 38 had unintelligible speech, which was poorly compensated for by augmentative communication. There were accompanying disturbances in cognition (mean non-verbal IQ 59), behaviour (12/40 attention-deficit-hyperactivity disorder [ADHD]), social communication (8/42 autism), and epilepsy (12/39). The severity of bulbar dysfunction and impact of additional impairments made it difficult to use formal assessments. INTERPRETATION: WDS causes severe and persistent bulbar dysfunction that is often accompanied by additional impairments, as in other cerebral palsies. Speech prognosis is particularly poor. Early diagnosis with appreciation of the underlying neurology would encourage critical evaluation of interventions and long-term planning to improve outcome.

Impact of Positive Feedback on Antimicrobial Stewardship in a Pediatric Intensive Care Unit: A Quality Improvement Project.

We hypothesized that antimicrobial stewardship (AMS) could be enhanced through positive feedback for the behaviors of healthcare professionals. This project aimed to reduce antimicrobial consumption in a Pediatric Intensive Care Unit (PICU) by >5%, with secondary aims to reduce broad-spectrum antimicrobial consumption, and processes related to AMS. Learning from Excellence is a positive feedback initiative conceptualized at our institution. METHODS: This project took place over 12 months (April 2017-March 2018) in a 31-bedded PICU. We identified and measured processes about AMS daily. Healthcare professionals, achieving success in these processes, received positive feedback via Learning from Excellence, during a 6 months intervention period. Selected reports were followed with appreciative inquiry interviews to reinforce positive feedback. We calculated antimicrobial consumption data from existing databases (antimicrobial doses dispensed divided by PICU bed-days). Health Care-Associated Infection (HCAI) rates were included as a balancing measure. RESULTS: Antimicrobial consumption was 6.5% lower during the intervention period compared with the matching period from the previous year. We reduced broad-spectrum antimicrobial (meropenem) consumption by 17.6%. Improvements in processes were mixed: a daily review of antimicrobials and documentation of antimicrobial prescription and administration significantly improved. Other processes failed to improve. HCAI rates did not change. CONCLUSIONS: Positive feedback can be used as a QI intervention to improve processes around AMS. This intervention may contribute to a reduction in antimicrobial consumption. Not all processes are impacted equally, and there may be a "dose-response" effect. Further evaluation would benefit from a trial study design in other settings.

Hope as a predictor of academic performance.

This study was designed to assess whether the two subscales of the Hope Scale significantly predict semester grade point average (GPA), over and above American College Test (ACT) scores and Trait Anxiety (Spielberger State-Trait Anxiety Inventory.) The Hope Scale includes two subscales, goal-directed determinism (Agency) and the ability to plan ways to attain goals (Pathway). As predicated, scores on the Hope Scale correlated significantly with semester GPA. Scores on the Agency subscale correlated positively with semester GPA in this college sample, but not those on the Pathways subscale. Partial correlations retained the association of scores on the Agency subscale and GPA, even when intelligence (ACT scores) and anxiety (Trait Anxiety scores) were controlled. Implications are discussed.

Comparative water quality of lightly- and moderately-impacted streams in the southern Blue Ridge Mountains, USA.

For less-developed regions like the Blue Ridge Mountains, data are limited that link basin-scale land use with stream quality. Two pairs of lightly-impacted (90-100% forested) and moderately-impacted (70-80% forested) sub-basins of the upper Little Tennessee River basin in the southern Blue Ridge were identified for comparison. The pairs contain physically similar stream reaches, chosen for the purpose of isolating forest conversion as a potential driver of any detected differences in water quality. Streams were sampled during baseflow conditions twice monthly over a six-month period from September 2003 through February 2004. Parametric t-tests were run for each parameter measured between the lightly-and moderately-impacted streams within each pair. Statistically significantly higher mean values of suspended and dissolved solids, nitrate, specific conductivity, turbidity, and temperature were observed in the moderately impacted streams versus the lightly impacted streams in both pairs, while dissolved oxygen levels were lower in the moderately-impacted streams. No significant differences were demonstrated in orthophosphate or ammonium concentration. A near-bankfull runoff event on February 6, 2004, was sampled for stormflow values, and the results support baseflow findings. The water quality of these streams is very good when compared with lower relief areas like the Piedmont, and none of the parameters measured in this study exceeds levels of known threat to stream biota. However, the demonstration that moderate reductions in forest cover are associated with stream water quality degradation carries important implications for stream management in this rapidly developing mountainous region.