Implications of providing wrist-hand orthoses for children with cerebral palsy: evidence from a randomised controlled trial.

PURPOSE: To investigate the effects of providing rigid wrist-hand orthoses plus usual multidisciplinary care, on reducing hand impairments in children with cerebral palsy. METHODS: A pragmatic, multicentre, assessor-blinded randomised controlled trial aimed to enrol 194 children aged 5-15 years, with wrist flexor Modified Ashworth Scale score ≥1. Randomisation with concealed allocation was stratified by study site and passive wrist range. The treatment group received a rigid wrist-hand orthosis, to wear ≥6 h per night for 3 years. Analysis included repeated measures mixed-effects linear regression models, using intention-to-treat principles. RESULTS: The trial stopped early due to insufficient recruitment: 74 children, across all Manual Ability Classification System levels, were randomised (n = 38 orthosis group; n = 36 control). Mean age was 10.2 (SD 3.1) years (orthosis group) and 9.1 (SD 2.8) years (control). Data showed some evidence that rigid wrist-hand orthosis impacted passive wrist extension with fingers extended in the first year [mean difference between-groups at 6 months: 13.15° (95%CI: 0.81-25.48°, p = 0.04); 12 months: 20.94° (95%CI: 8.20-33.69°, p = 0.001)]. Beyond 18 months, participant numbers were insufficient for conclusive findings. CONCLUSION: The study provided detailed data about short- and long-term effects of the wrist-hand orthosis and highlighted challenges in conducting large randomised controlled trials with this population. Trial Registration: Australia and New Zealand Clinical Trials Registry: U1111-1164-0572 IMPLICATIONS FOR REHABILITATIONThere may be incremental benefit, for children with cerebral palsy, at 6 and 12 months on passive wrist range from wearing a rigid wrist-hand orthosis designed according to this protocol.The rigid-wrist-hand orthosis evaluated in this study, which allowed for some tailoring for individual children's presentations, differed in design from past recommendations for "resting hand" positioning.Longitudinal follow up of children with cerebral palsy prescribed a rigid wrist-hand orthosis is essential to monitor any benefit.Minor adverse events were commonly experienced when wearing the orthosis and should be discussed prior to prescription of a rigid wrist-hand orthosis.

The Neurological Hand Deformity Classification: Construct validity, test-retest, and inter-rater reliability.

BACKGROUND: The Neurological Hand Deformity Classification (NHDC) is an impairment-based tool that classifies hand deformity into one of two ordinal scales: flexion or extension deformities. Classification is made from live observation or from recorded video footage. Differentiation between the levels is determined by wrist position and wrist and finger movement. PURPOSE: To examine aspects of validity and reliability of the NHDC. STUDY DESIGN: A measurement study design. METHODS: Data from a convenience sample of 127 children with cerebral palsy, 66 males: 61 females, ranging in age from 8 months to 15 years, across all Manual Ability Classification System levels I to V, were analyzed. Construct validity was assessed by testing predetermined hypotheses of relationships between the NHDC and measures of body function and activity measures with observed performance using the Chi Squared Test of Independence and Spearman Correlation Coefficient. Test-retest and inter-rater reliability were assessed by calculating agreement between repeated measures and paired raters using weighted kappa and Cohen's kappa with 95% confidence intervals. RESULTS: Predicted hypotheses for the NHDC were met in nine of 10 Spearman's rho correlations with body structure measures and in 2 of 7 correlations with activity measures. Test-retest for flexion deformities: κw = 0.84; 95% CI 0.70-0.98; and extension deformities: κ = 1.0; 95% CI 1.0-1.0 was good to excellent; inter-rater reliability for flexion deformities: κw = 0.76; 95% CI 0.67-0.85; and extension deformities κ = 0.75; 95% CI 0.43-1.0 was moderate to excellent. CONCLUSION: Expected relationships between the NHDC and other measures, stability between repeated measures and acceptable between-rater agreement supports confidence classifying hand deformity in children with cerebral palsy with the NHDC.

Unpacking the application of Q methodology for use in occupational therapy research.

BACKGROUND: Occupational therapy research has not fully utilized available research methods when exploring occupational therapists' views on specific interventions and service provision nor when exploring consumer priorities and the impact of occupational therapy services. Q methodology, a quantitative method for the systematic assessment of qualitative data, is an approach that can be used to examine viewpoints related to occupational therapy. AIMS/OBJECTIVES: To add experiential knowledge to guide researchers new to navigating Q methodology and encourage researchers to consider the application of Q methodology when exploring viewpoints pertinent to occupational therapy practice and research. MATERIAL AND METHODS: The application of Q methodology in published occupational therapy and occupational science research is identified, and an experience-based review of Q methods undertaken. RESULTS: More detailed explanation and reflection on each stage of Q methodology, including the factor analysis stage, than is currently available in the literature is presented to support successful implementation of this method. CONCLUSION: Sharing experience in implementing Q methodology may inform and encourage researchers in its use as one method for bridging the gap between qualitative and quantitative data. SIGNIFICANCE: The rigor of the method's processes may add credibility to identified viewpoints and how they could inform occupational therapy practice.Key messagesQ methodology can be used in occupational therapy research to explore consumer and therapist viewpoints regarding interventions, service provision, priorities and the profession itself.Q methodology employs a specific, repeatable process within each stage of the research process to ensure rigour.Q methodology provides an approach to combining qualitative research methods with quantitative analysis techniques to understand the viewpoints of interest.

Mobile arm supports in Duchenne muscular dystrophy: a pilot study of user experience and outcomes.

PURPOSE: This pilot study examined whether two different types of non-powered mobile arm supports (MAS) enhanced upper limb function and independence with activities of daily living (ADLs) in people with Duchenne muscular dystrophy (DMD). METHOD: A mixed methods cross-sectional design was used. Participants were four males with DMD, aged 16 to 20 years (M = 18.25 years). Two participants were current MAS users, and two had previously used MAS. To explore experiences of MAS use, semi-structured interviews were undertaken, then transcribed verbatim and analysed thematically. To measure the impact of MAS on arm function and ADLs, participants using MAS completed the Performance of the Upper Limb (PUL) and the DMD Upper Limb Patient Reported Outcome Measure with and without MAS. Participants no longer using MAS only completed the PUL without MAS. RESULTS: MAS enhanced upper limb function and independence with ADLs in three of four participants. Eating and drinking was most often positively impacted by MAS. Access to informal support for MAS set-up, and ongoing input from a clinician or assistive technology (AT) supplier with MAS expertise, were important enablers to successful MAS use. Barriers to use included inadequate upper limb strength, interference of MAS with wheelchair controls, and AT funding delays. CONCLUSION: MAS should be considered by individuals with DMD and clinicians working with them as the disease progresses and strength declines. Potential barriers to MAS use need to be addressed to ensure maximum utility. AT funding delays must also be minimized to avoid impact on outcomes of people with DMD.Implications for RehabilitationIndividuals with DMD, and clinicians working with them, may consider MAS to aid achievement of functional goals as the disease progresses and upper limb function declines.Both objective and subjective outcome measures should be used when evaluating the effectiveness of MAS.Consideration should be given to the potential interference of MAS with wheelchair controls and the availability of informal or paid supports (e.g., family, support workers, teachers) to aid MAS use.Efficient and timely funding of MAS is required, as delays may negatively impact outcomes for people with progressive neurological conditions, such as DMD.

Prescribing upper limb orthoses for children with cerebral palsy: a Q methodology study of occupational therapists' decision making.

Purpose: This study identified occupational therapists' viewpoints that guide their practice of upper limb orthosis prescription for children with cerebral palsy (CP).Methods: A qualitative study utilising Q methodology explored participants' viewpoints. Thirty-nine occupational therapists (38 females) were purposively recruited to rank statements generated from interviews of experienced clinicians and peer reviewed and published literature. Statements about reasons for orthoses prescription, were ranked according to what guides decision making the most to least. Data from ranked statements were analysed using by-person factor analysis to reveal the different ways statements were grouped. The resultant factors, based on the average arrangement of statements associated with each factor, were interpreted and named as viewpoints.Results: Viewpoints identified: 1. Potential effect of the orthosis (n = 12 sorts); 2. Biomechanical presentation (n = 12 sorts); and 3. Client/therapist relationship (n = 10 sorts). The "Client's goals" statement was ranked highest across all viewpoints.Conclusions: Viewpoints identified may inform development of clinical guidelines. Further research is required to (i) identify valid and reliable classification and assessment tools to guide decision making; and (ii) establish the mechanism of the effect of orthotic intervention by considering the link between the biomechanical purpose of the orthosis (e.g., mobilise tissue) and aim of intervention (prevent contracture).Implications for rehabilitationQ methodology provided an opportunity to identify viewpoints of occupational therapists that guide their upper extremity orthosis prescription decision making.Consistent with best-practice, clients' goals were the primary focus of decision making in each viewpoint.It is recommended that clinicians consider the identified viewpoints; 1) the potential effects of the orthosis, 2) the biomechanical presentation of the child, within 3) an established client/therapist relationship when prescribing upper extremity orthoses.Practice guidelines to inform upper limb orthotic intervention may be developed using the identified viewpoints.

Diagnostic tests for autism spectrum disorder (ASD) in preschool children.

BACKGROUND: Autism spectrum disorder (ASD) is a behaviourally diagnosed condition. It is defined by impairments in social communication or the presence of restricted or repetitive behaviours, or both. Diagnosis is made according to existing classification systems. In recent years, especially following publication of the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5; APA 2013), children are given the diagnosis of ASD, rather than subclassifications of the spectrum such as autistic disorder, Asperger syndrome, or pervasive developmental disorder - not otherwise specified. Tests to diagnose ASD have been developed using parent or carer interview, child observation, or a combination of both. OBJECTIVES: Primary objectives1. To identify which diagnostic tools, including updated versions, most accurately diagnose ASD in preschool children when compared with multi-disciplinary team clinical judgement.2. To identify how the best of the interview tools compare with CARS, then how CARS compares with ADOS.a. Which ASD diagnostic tool - among ADOS, ADI-R, CARS, DISCO, GARS, and 3di - has the best diagnostic test accuracy?b. Is the diagnostic test accuracy of any one test sufficient for that test to be suitable as a sole assessment tool for preschool children?c. Is there any combination of tests that, if offered in sequence, would provide suitable diagnostic test accuracy and enhance test efficiency?d. If data are available, does the combination of an interview tool with a structured observation test have better diagnostic test accuracy (i.e. fewer false-positives and fewer false-negatives) than either test alone?As only one interview tool was identified, we modified the first three aims to a single aim (Differences between protocol and review): This Review evaluated diagnostic tests in terms of sensitivity and specificity. Specificity is the most important factor for diagnosis; however, both sensitivity and specificity are of interest in this Review because there is an inherent trade-off between these two factors.Secondary objectives1. To determine whether any diagnostic test has greater diagnostic test accuracy for age-specific subgroups within the preschool age range. SEARCH METHODS: In July 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 10 other databases, and the reference lists of all included publications. SELECTION CRITERIA: Publications had to: 1. report diagnostic test accuracy for any of the following six included diagnostic tools: Autism Diagnostic Interview - Revised (ADI-R), Gilliam Autism Rating Scale (GARS), Diagnostic Interview for Social and Communication Disorder (DISCO), Developmental, Dimensional, and Diagnostic Interview (3di), Autism Diagnostic Observation Schedule - Generic (ADOS), and Childhood Autism Rating Scale (CARS); 2. include children of preschool age (under six years of age) suspected of having an ASD; and 3. have a multi-disciplinary assessment, or similar, as the reference standard.Eligible studies included cohort, cross-sectional, randomised test accuracy, and case-control studies. The target condition was ASD. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all studies for inclusion and extracted data using standardised forms. A third review author settled disagreements. We assessed methodological quality using the QUADAS-2 instrument (Quality Assessment of Studies of Diagnostic Accuracy - Revised). We conducted separate univariate random-effects logistical regressions for sensitivity and specificity for CARS and ADI-R. We conducted meta-analyses of pairs of sensitivity and specificity using bivariate random-effects methods for ADOS. MAIN RESULTS: In this Review, we included 21 sets of analyses reporting different tools or cohorts of children from 13 publications, many with high risk of bias or potential conflicts of interest or a combination of both. Overall, the prevalence of ASD for children in the included analyses was 74%.For versions and modules of ADOS, there were 12 analyses with 1625 children. Sensitivity of ADOS ranged from 0.76 to 0.98, and specificity ranged from 0.20 to 1.00. The summary sensitivity was 0.94 (95% confidence interval (CI) 0.89 to 0.97), and the summary specificity was 0.80 (95% CI 0.68 to 0.88).For CARS, there were four analyses with 641 children. Sensitivity of CARS ranged from 0.66 to 0.89, and specificity ranged from 0.21 to 1.00. The summary sensitivity for CARS was 0.80 (95% CI 0.61 to 0.91), and the summary specificity was 0.88 (95% CI 0.64 to 0.96).For ADI-R, there were five analyses with 634 children. Sensitivity for ADI-R ranged from 0.19 to 0.75, and specificity ranged from 0.63 to 1.00. The summary sensitivity for the ADI-R was 0.52 (95% CI 0.32 to 0.71), and the summary specificity was 0.84 (95% CI 0.61 to 0.95).Studies that compared tests were few and too small to allow clear conclusions.In two studies that included analyses for both ADI-R and ADOS, tests scored similarly for sensitivity, but ADOS scored higher for specificity. In two studies that included analyses for ADI-R, ADOS, and CARS, ADOS had the highest sensitivity and CARS the highest specificity.In one study that explored individual and additive sensitivity and specificity of ADOS and ADI-R, combining the two tests did not increase the sensitivity nor the specificity of ADOS used alone.Performance for all tests was lower when we excluded studies at high risk of bias. AUTHORS' CONCLUSIONS: We observed substantial variation in sensitivity and specificity of all tests, which was likely attributable to methodological differences and variations in the clinical characteristics of populations recruited.When we compared summary statistics for ADOS, CARS, and ADI-R, we found that ADOS was most sensitive. All tools performed similarly for specificity. In lower prevalence populations, the risk of falsely identifying children who do not have ASD would be higher.Now available are new versions of tools that require diagnostic test accuracy assessment, ideally in clinically relevant situations, with methods at low risk of bias and in children of varying abilities.

Development of a Shared Decision Making Model in a Community Mental Health Center.

Shared Decision Making (SDM) is an essential component of recovery oriented treatment for clients with severe and persistent mental illnesses. SDM has been found to be effective in improving outcome of treatment of non-psychiatric ailments, and studies of SDM in community mental health settings are limited. We designed and implemented a low tech SDM program in a non-academic community mental health center and evaluated the outcome on decisional certainty and satisfaction with services. The results suggest that SDM can be effectively integrated with evidence based psychiatric rehabilitation practices utilizing already existing resources.

Rationale for prescription, and effectiveness of, upper limb orthotic intervention for children with cerebral palsy: a systematic review.

PURPOSE: To explore (i) reasons for upper limb orthosis prescription for children with cerebral palsy (CP), (ii) the link between reason and effect according to intended outcome and outcome measure utilized and (iii) to classify the prescribed orthoses using standard terminology. METHOD: A prospectively registered (center for reviews and dissemination: 42015022067) systematic review searched for experimental and observational studies investigating rigid/thermoplastic upper limb orthotic intervention for children aged 0-18 with CP. The Cochrane central register, MEDLINE, CINAHL, Embase, SCOPUS and Web of Science databases were searched. Included studies were assessed for risk of bias. RESULTS: Sixteen studies met selection criteria. Two studies described a specific reason for orthosis prescription, six prescribed orthoses to manage a clinical symptom and eight did not describe a reason. Eight studies were analyzed for effect according to intended outcome with no clear connection found between reasons for prescription, outcome measures utilized and effect reported. INTERPRETATION: The lack of evidence for upper limb orthotic intervention for children with CP leads to uncertainty when considering this treatment modality. Future research is needed to evaluate the effect of orthosis wear in relation to intended outcome utilizing robust methods and valid and reliable outcome measures. Implications for rehabilitation: Insufficient evidence exists about the reason for prescription of upper limb orthoses. The connection between reason for orthosis prescription, intended outcome, outcome measure utilized and observed effect is unclear. Recommend orthosis prescription to be accompanied by clear documentation of the aim of the orthosis and description using orthosis classification system terminology. Outcome measures consistent with the reason for orthosis prescription and intended outcome of the intervention are essential to measure effectiveness of the intervention.

Minimising impairment: Protocol for a multicentre randomised controlled trial of upper limb orthoses for children with cerebral palsy.

BACKGROUND: Upper limb orthoses are frequently prescribed for children with cerebral palsy (CP) who have muscle overactivity predominantly due to spasticity, with little evidence of long-term effectiveness. Clinical consensus is that orthoses help to preserve range of movement: nevertheless, they can be complex to construct, expensive, uncomfortable and require commitment from parents and children to wear. This protocol paper describes a randomised controlled trial to evaluate whether long-term use of rigid wrist/hand orthoses (WHO) in children with CP, combined with usual multidisciplinary care, can prevent or reduce musculoskeletal impairments, including muscle stiffness/tone and loss of movement range, compared to usual multidisciplinary care alone. METHODS/DESIGN: This pragmatic, multicentre, assessor-blinded randomised controlled trial with economic analysis will recruit 194 children with CP, aged 5-15 years, who present with flexor muscle stiffness of the wrist and/or fingers/thumb (Modified Ashworth Scale score ≥1). Children, recruited from treatment centres in Victoria, New South Wales and Western Australia, will be randomised to groups (1:1 allocation) using concealed procedures. All children will receive care typically provided by their treating organisation. The treatment group will receive a custom-made serially adjustable rigid WHO, prescribed for 6 h nightly (or daily) to wear for 3 years. An application developed for mobile devices will monitor WHO wearing time and adverse events. The control group will not receive a WHO, and will cease wearing one if previously prescribed. Outcomes will be measured 6 monthly over a period of 3 years. The primary outcome is passive range of wrist extension, measured with fingers extended using a goniometer at 3 years. Secondary outcomes include muscle stiffness, spasticity, pain, grip strength and hand deformity. Activity, participation, quality of life, cost and cost-effectiveness will also be assessed. DISCUSSION: This study will provide evidence to inform clinicians, services, funding agencies and parents/carers of children with CP whether the provision of a rigid WHO to reduce upper limb impairment, in combination with usual multidisciplinary care, is worth the effort and costs. TRIAL REGISTRATION: ANZ Clinical Trials Registry: U1111-1164-0572 .

From Industry to Generativity: The First 12 Years of the Association for Academic Psychiatry Master Educator Program.

OBJECTIVE: This study presents a mixed-methods evaluation of the first 12 years of the Association for Academic Psychiatry (AAP) Master Educator (ME) program, developed in 2003 to help academic psychiatrists hone their skills as educators. Participants attend two 3-h workshops at the annual meeting, organized in 3-year cycles, for a total of 18 h. Core topics include assessment, curriculum design, and program evaluation. METHODS: Overall session rating scores from 2003 to 2014 were analyzed using descriptive statistics. A 20-question survey was sent to 58 program graduates in October 2014, exploring participant perspectives on the impact of the ME program on their careers and on the educational programs they were affiliated with. Survey responses were analyzed quantitatively (for multiple choice questions) and qualitatively (for open-ended questions). RESULTS: The mean overall session scores ranged between 4.1 and 4.9 (on a Likert-type scale of 1-5) for each 3-year cycle. Twenty-nine graduates completed the survey (50 % response rate). Survey responses indicated a positive perception of the impact of the ME program on participants' careers. Most respondents noted improvement in their teaching methods and curriculum development skills and being able to link educational theory with their individual practices. There was a significant increase in perceived confidence, leadership, and further contributions to their educational milieu. Fifteen (52 %) participants also reported generative behaviors that directly impacted others, such as developing new programs, enhancing existing programs at their institutions, or contributing to national educational efforts. CONCLUSION: The AAP ME program has demonstrated significant benefit over its 12 years of existence. This program represents one strategy to sustain and grow an international community of like-minded educators working to develop their own and future generations' skills in providing high-quality education in psychiatry.

Diagnosing autism: Australian paediatric research network surveys.

AIM: Autism spectrum disorder (ASD) is a neurodevelopmental disorder with reported prevalence of more than 1/100. In Australia, paediatricians are often involved in diagnosing ASD and providing long-term management. However, it is not known how paediatricians diagnose ASD. This study aimed to investigate whether the way Australian paediatricians diagnose ASD is in line with current recommendations. METHODS: Members of the Australian Paediatric Research Network were invited to answer questions about their ASD diagnostic practice in a multi-topic survey and also as part of a study about parents needs around the time of a diagnosis of ASD. RESULTS: The majority of the 124 paediatricians who responded to the multi-topic survey and most who responded to the parent needs survey reported taking more than one session to make a diagnosis of ASD. Most paediatricians included information from preschool, child care or school when making a diagnosis, and over half included information from speech pathology or psychology colleagues more than 50% of the time. The main reasons for not including assessment information in the diagnostic process were service barriers such as no regular service available or long waiting lists. More than 70% reported ordering audiology and genetic tests more than half of the time. CONCLUSION: Not all paediatricians are following current recommendations for diagnosing ASD more than 50% of the time. While there are good reasons why current diagnostic approaches may fall short of expected standards, these need to be overcome to ensure diagnostic validity and optimal services for all children and their families.

Congenital Methemoglobinemia Type II-Clinical Improvement with Short-Term Methylene Blue Treatment.

We report a case of prophylactic management with methylene blue (MB) in an almost 4-year-old male with congenital methemoglobinemia type II. He has a CYB5R3 compound heterozygote mutation, causing a cytochrome-b(5) reductase deficiency. Since the MB treatment regimen has commenced, his methemoglobin level has been significantly lower. He has shown modest behavioral improvements (as assessed on the Achenbach behavior report scales). There have been no iatrogenic side effects. These findings are encouraging for symptomatic improvement with regular prophylactic MB treatment but represent a single case report, which must be interpreted with caution.

What is the experience of psychiatry residents learning to prescribe? A qualitative research inquiry.

BACKGROUND: Understanding how psychiatry residents learn to prescribe is important for the future of psychiatry. Prescribing is a complicated act that involves much more than signing a prescription. During residency, psychiatrists develop seminal attitudes and habits about prescribing. There have been no published studies focusing on psychiatry residents' experience when learning to prescribe. AIMS: Qualitative methodology lends itself to a deep exploration of the process of learning how to prescribe. We undertook a qualitative study questioning psychiatry residents about their prescribing. METHODS: Psychiatry residents were recruited from three residency programs and focus groups were conducted at each program. The focus groups were audiotaped and transcribed by a professional service. Thematic analysis was used to analyze the data and triangulation to increase the rigor of the study. RESULTS: A total of 12 residents participated. Three themes were identified concerning identity development as a psychiatrist, uncertainty and fear about prescribing, and the centrality of collaborating with the patient during the prescribing process. CONCLUSION: Psychiatry residents struggle with significant anxiety and frustration in their experience of learning to prescribe, suggesting a place for mentors and supervisors to focus.

Autism spectrum disorder: Presentation and prevalence in a nationally representative Australian sample.

OBJECTIVE: The aim of this study was to identify the prevalence of parent-reported autism spectrum disorder diagnosis in Australia, and examine the developmental profile of children with autism spectrum disorder compared to their peers. DESIGN/SETTING: Secondary analyses were undertaken on data from the Longitudinal Study of Australian Children. PARTICIPANTS: Children were recruited at kindergarten (K cohort) and birth (B cohort), and subsequently completed two-yearly 'waves' of assessments. MAIN OUTCOMES: Autism spectrum disorder diagnostic status was ascertained at Wave 4 along with age of diagnosis by parent report. Standardised tools were used to assess children's quality of life, behaviour, receptive vocabulary and non-verbal intelligence. RESULTS: Prevalence of autism spectrum disorder was 2.5% (95% confidence interval = [2.0, 3.0]) in the B cohort compared to 1.5% (95% confidence interval = [1.2, 2.0]) in the K cohort. In both cohorts, children with autism spectrum disorder had poorer mean quality of life, emotional-behavioural functioning and receptive vocabulary compared with non-autism spectrum disorder peers, and a higher proportion of children with autism spectrum disorder had problems in these areas. However, between 6% and 9% of children with moderate to severe autism spectrum disorder and 12-20% with mild autism spectrum disorder were not reported to have problems with social interaction. CONCLUSION: The prevalence of a parent-reported diagnosis of autism spectrum disorder before age 7 in Australia was higher in the B cohort. Data from future Longitudinal Study of Australian Children waves will clarify whether autism spectrum disorder has been diagnosed earlier in the B cohort or if there is a continued increase in prevalence. Future waves will also provide crucial information about the types and severity of problems experienced during the primary and secondary school years which will assist service planning.

Improving allied health professionals' research implementation behaviours for children with cerebral palsy: protocol for a before-after study.

BACKGROUND: Cerebral palsy is a permanent disorder of posture and movement caused by disturbances in the developing brain. It affects approximately 1 in every 500 children in developed countries and is the most common form of childhood physical disability. People with cerebral palsy may also have problems with speech, vision and hearing, intellectual difficulties and epilepsy. Health and therapy services are frequently required throughout life, and this care should be effective and evidence informed; however, accessing and adopting new research findings into day-to-day clinical practice is often delayed. METHODS/DESIGN: This 3-year study employs a before and after design to evaluate if a multi-strategy intervention can improve research implementation among allied health professionals (AHPs) who work with children and young people with cerebral palsy and to establish if children's health outcomes can be improved by routine clinical assessment. The intervention comprises (1) knowledge brokering with AHPs, (2) access to an online research evidence library, (3) provision of negotiated evidence-based training and education, and (4) routine use of evidence-based measures with children and young people aged 3-18 years with cerebral palsy. The study is being implemented in four organisations, with a fifth organisation acting as a comparison site, across four Australian states. Effectiveness will be assessed using questionnaires completed by AHPs at baseline, 6, 12 and 24 months, and by monitoring the extent of use of evidence-based measures. Children's health outcomes will be evaluated by longitudinal analyses. DISCUSSION: Government, policy makers and service providers all seek evidence-based information to support decision-making about how to distribute scarce resources, and families are seeking information to support intervention choices. This study will provide knowledge about what constitutes an efficient, evidence-informed service and which allied health interventions are implemented for children with cerebral palsy. TRIAL REGISTRATION: Trial is not a controlled healthcare intervention and is not registered.

Rasch analysis of The Melbourne Assessment of Unilateral Upper Limb Function.

AIM: This study investigated the internal construct validity and dimensionality of the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment), a widely-used measure of quality of upper limb movement, valid for children aged 2 years 6 months to 15 years with cerebral palsy. METHOD: Rasch analysis was used to assess of Melbourne Assessment raw scores for 163 children (94 males, 69 females; mean age 8y, SD 3y 5mo). Analysis was undertaken on the full scale comprising 37 scores and on groups of scores separated into four distinct movement subscales: range of movement, accuracy, dexterity, and fluency. Tests were conducted to evaluate overall model fit, item fit, suitability of the response options, unidimensionality, and differential item functioning (DIF) for sex, child age, and different raters. RESULTS: The results did not support the unidimensionality of the 37-score scale. The four subscales showed adequate model fit after removal of some score items, and rescaling of others. The resulting subscales showed good internal consistency and no DIF for sex or child age. INTERPRETATION: This study provides empirical support for a revised version of the Melbourne Assessment which comprises 14 tasks and 30 movement scores grouped across four separate subscales. Further testing is required to assess the responsiveness of subscales to clinically important change.

Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD).

BACKGROUND: Autism spectrum disorders (ASD) are characterised by abnormalities in social interaction and communication skills, as well as stereotypic behaviours and restricted activities and interests. Selective serotonin reuptake inhibitors (SSRIs) are prescribed for the treatment of conditions often comorbid with ASD such as depression, anxiety and obsessive-compulsive behaviours. OBJECTIVES: To determine if treatment with an SSRI:1. improves the core features of autism (social interaction, communication and behavioural problems);2. improves other non-core aspects of behaviour or function such as self-injurious behaviour;3. improves the quality of life of adults or children and their carers;4. has short- and long-term effects on outcome;5. causes harm. SEARCH METHODS: We searched the following databases up until March 2013: CENTRAL, Ovid MEDLINE, Embase, CINAHL, PsycINFO, ERIC and Sociological Abstracts. We also searched ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). This was supplemented by searching reference lists and contacting known experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) of any dose of oral SSRI compared with placebo, in people with ASD. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies for inclusion, extracted data and appraised each study's risk of bias. MAIN RESULTS: Nine RCTs with a total of 320 participants were included. Four SSRIs were evaluated: fluoxetine (three studies), fluvoxamine (two studies), fenfluramine (two studies) and citalopram (two studies). Five studies included only children and four studies included only adults. Varying inclusion criteria were used with regard to diagnostic criteria and intelligence quotient of participants. Eighteen different outcome measures were reported. Although more than one study reported data for Clinical Global Impression (CGI) and obsessive-compulsive behaviour (OCB), different tool types or components of these outcomes were used in each study. As such, data were unsuitable for meta-analysis, except for one outcome (proportion improvement). One large, high-quality study in children showed no evidence of positive effect of citalopram. Three small studies in adults showed positive outcomes for CGI and OCB; one study showed improvements in aggression, and another in anxiety. AUTHORS' CONCLUSIONS: There is no evidence of effect of SSRIs in children and emerging evidence of harm. There is limited evidence of the effectiveness of SSRIs in adults from small studies in which risk of bias is unclear.

Children with cerebral palsy and periventricular white matter injury: does gestational age affect functional outcome?

This study aimed to determine differences in functional profiles and movement disorder patterns in children aged 4-12 years with cerebral palsy (CP) and periventricular white matter injury (PWMI) born >34 weeks gestation compared with those born earlier. Eligible children born between 1999 and 2006 were recruited through the Victorian CP register. Functional profiles were determined using the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS), Communication Function Classification System (CFCS), Functional Mobility Scale (FMS) and Bimanual Fine Motor Function (BFMF). Movement disorder and topography were classified using the Surveillance of Cerebral Palsy in Europe (SCPE) classification. 49 children born >34 weeks (65% males, mean age 8 y 9 mo [standard deviation (SD) 2 y 2 mo]) and 60 children born ≤ 34 weeks (62% males, mean age 8 y 2 mo [SD 2 y 2 mo]) were recruited. There was evidence of differences between the groups for the GMFCS (p=0.003), FMS 5, 50 and 500 (p=0.003, 0.002 and 0.012), MACS (p=0.04) and CFCS (p=0.035), with a greater number of children born ≤ 34 weeks more severely impaired compared with children born later. Children with CP and PWMI born >34 weeks gestation had milder limitations in gross motor function, mobility, manual ability and communication compared with those born earlier.

Reliable classification of functional profiles and movement disorders of children with cerebral palsy.

OBJECTIVE: To examine the inter-rater reliability of the Communication Function Classification System (CFCS), Bimanual Fine Motor Function (BFMF), Surveillance of Cerebral Palsy in Europe (SCPE) classification tree, and Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) and periventricular white matter injury (PWMI) aged 4-11 years. METHOD: Twenty children were assessed by two raters using the four tools, in addition parents undertook ratings on the Manual Ability Classification System (MACS). Kappa statistics were used to calculate the level of agreement between raters' classifications. RESULTS: Participants comprised 12 males and 8 females with CP and PWMI, mean age 8 years 1 month (standard deviation 2 years 3 months). Inter-rater reliability across the four tools was 0.98 (CFCS, BFMF, and GMFCS) and 0.84 (SCPE). IMPLICATIONS: These findings suggest that these four tools are reasonably robust to inter-rater variability supporting their routine use along with the MACS in clinical and research applications.

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.