Relationship between early infant motor repertoire and neurodevelopment on the hammersmith infant neurological examination in a developmentally vulnerable First Nations cohort.

AIM: To implement a culturally-adapted screening program aimed to determine the ability of infant motor repertoire to predict early neurodevelopment on the Hammersmith Infant Neurological Examination (HINE) and improve Australian First Nations families' engagement with neonatal screening. METHODS: A prospective cohort of 156 infants (55 % male, mean (standard deviation [SD]) gestational age 33.8 (4.6) weeks) with early life risk factors for adverse neurodevelopmental outcomes (ad-NDO) participated in a culturally-adapted screening program. Infant motor repertoire was assessed using Motor Optimality Score-revised (MOS-R), captured over two videos, 11-13+6 weeks (V1; <14 weeks) and 14-18 weeks (V2; ≥14 weeks) corrected age (CA). At 4-9 months CA neurodevelopment was assessed on the HINE and classified according to age-specific cut-off and optimality scores as; developmentally 'on track' or high chance of either adverse neurodevelopmental outcome (ad-NDO) or cerebral palsy (CP). RESULTS: Families were highly engaged, 139/148 (94 %) eligible infants completing MOS-R, 136/150 (91 %), HINE and 123 (83 %) both. Lower MOS-R at V2 was associated with reduced HINE scores (ß = 1.73, 95 % confidence interval [CI] = 1.03-2.42) and high chance of CP (OR = 2.63, 95%CI = 1.21-5.69) or ad-NDO (OR = 1.38, 95%CI = 1.10-1.74). The MOS-R sub-category 'observed movement patterns' best predicted HINE, infants who score '4' had mean HINE 19.4 points higher than score '1' (95%CI = 12.0-26.9). Receiver-operator curve analyses determined a MOS-R cut-off of <23 was best for identifying mild to severely reduced HINE scores, with diagnostic accuracy 0.69 (sensitivity 0.86, 95%CI 0.76-0.94 and specificity 0.40, 95 % CI 0.25-0.57). A trajectory of improvement on MOS-R (≥2 point increase in MOS-R from 1st to 2nd video) significantly increased odds of scoring optimally on HINE (OR = 5.91, 95%CI 1.16-29.89) and may be a key biomarker of 'on track' development. INTERPRETATION: Implementation of a culturally-adapted program using evidence-based assessments demonstrates high retention. Infant motor repertoire is associated with HINE scores and the early neurodevelopmental status of developmentally vulnerable First Nations infants.

Study protocol: peer delivered early intervention (Learning through Everyday Activities with Parents for Infants at risk of Cerebral Palsy: LEAP-CP) for First Nation Australian infants at high risk of cerebral palsy - an RCT study.

INTRODUCTION: Cerebral palsy (CP) is the most common childhood physical disability with rates approximately 50% higher in First Nations Australian children. This study aims to evaluate a culturally-adapted parent-delivered early intervention programme for First Nations Australian infants at high risk of CP (Learning through Everyday Activities with Parents for infants with CP; LEAP-CP). METHODS AND ANALYSIS: This study is a randomised assessor masked controlled trial. Infants with birth/postnatal risk factors will be eligible for screening. Infants at high risk of CP ('absent fidgety' on General Movements Assessment, and/or 'suboptimal score' on the Hammersmith Infant Neurological Examination) aged 12-52 weeks corrected age will be recruited. Infants and their caregivers will be randomised to receive LEAP-CP (intervention) or health advice (comparator). LEAP-CP is a culturally-adapted programme of 30 home visits delivered by a peer trainer (First Nations Community Health Worker); and includes goal-directed active motor/cognitive strategies, CP learning games and caregiver educational modules. The control arm receives a monthly health advice visit, based on the Key Family Practices, WHO. All infants continue to receive standard (mainstream) Care as Usual. Dual child primary outcomes are Peabody Developmental Motor Scales-2 (PDMS-2) and Bayley Scales of Infant Development-III. The primary caregiver outcome is the Depression, Anxiety and Stress Scale. Secondary outcomes include function, goal attainment, vision, nutritional status and emotional availability. SAMPLE SIZE: total of 86 children (43/group) will enable an effect size of 0.65 on the PDMS-2 to be detected (80% power, α=0.05; 10% attrition). ETHICS AND DISSEMINATION: Ethics approval through Queensland ethics committees and Aboriginal Controlled Community Health Organisation Research Governance Groups, with families providing written informed consent. Findings will be disseminated with guidance from the Participatory Action Research, in collaboration with First Nations communities; peer-reviewed journal publications and national/international conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12619000969167p.

Can web-based implementation interventions improve physician early diagnosis of cerebral palsy? Protocol for a 3-arm parallel superiority randomised controlled trial and cost-consequence analysis comparing adaptive and non-adaptive virtual patient instructional designs with control to evaluate effectiveness on physician behaviour, diagnostic skills and patient outcomes.

INTRODUCTION: Cerebral palsy (CP) is the most common childhood physical disability. Accurate diagnosis before 6 months is possible using predictive tools and decision-making skills. Yet diagnosis is typically made at 12-24 months of age, hindering access to early interventions that improve functional outcomes. Change in practice is required for physicians in key diagnostic behaviours. This study aims to close the identified research-practice gap and increase accurate CP diagnosis before 6 months of age through tailored web-based implementation interventions. This trial will determine whether adaptive e-learning using virtual patients, targeting CP diagnostic behaviours and clinical decision-making skills, effectively changes physician behaviour and practice compared with non-adaptive e-learning instructional design or control. METHODS AND ANALYSIS: This study is a 3-arm parallel superiority randomised controlled trial of two tailored e-learning interventions developed to expedite physician CP diagnosis. The trial will compare adaptive (arm 1) and non-adaptive (arm 2) instructional designs with waitlist control (arm 3) to evaluate change in physician behaviour, skills and diagnostic practice. A sample size of 275 paediatric physicians enables detection of small magnitude effects (0.2) of primary outcomes between intervention comparators with 90% power (α=0.05), allowing for 30% attrition. Barrier analysis, Delphi survey, Behaviour Change Wheel and learning theory frameworks guided the intervention designs. Adaptive and non-adaptive video and navigation sequences utilising virtual patients and clinical practice guideline content were developed, integrating formative key features assessment targeting clinical decision-making skills relative to CP diagnosis.Physician outcomes will be evaluated based on postintervention key feature examination scores plus preintervention/postintervention behavioural intentions and practice measures. Associations with CP population registers will evaluate real-world diagnostic patient outcomes. Intervention costs will be reported in a cost-consequence analysis from funders' and societal perspectives. ETHICS AND DISSEMINATION: Ethics approved from The University of Sydney (Project number 2021/386). Results will be disseminated through peer-reviewed journals and scientific conferences. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry: ACTRN 12622000184774.

Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

Early detection of Australian Aboriginal and Torres Strait Islander infants at high risk of adverse neurodevelopmental outcomes at 12 months corrected age: LEAP-CP prospective cohort study protocol.

INTRODUCTION: Neurodevelopmental disorders (NDD), including cerebral palsy (CP), autism spectrum disorder (ASD) and foetal alcohol spectrum disorder (FASD), are characterised by impaired development of the early central nervous system, impacting cognitive and/or physical function. Early detection of NDD enables infants to be fast-tracked to early intervention services, optimising outcomes. Aboriginal and Torres Strait Islander infants may experience early life factors increasing their risk of neurodevelopmental vulnerability, which persist into later childhood, further compounding the health inequities experienced by First Nations peoples in Australia. The LEAP-CP prospective cohort study will investigate the efficacy of early screening programmes, implemented in Queensland, Australia to earlier identify Aboriginal and Torres Strait Islander infants who are 'at risk' of adverse neurodevelopmental outcomes (NDO) or NDD. Diagnostic accuracy and feasibility of early detection tools for identifying infants 'at risk' of a later diagnosis of adverse NDO or NDD will be determined. METHODS AND ANALYSIS: Aboriginal and/or Torres Strait Islander infants born in Queensland, Australia (birth years 2020-2022) will be invited to participate. Infants aged <9 months corrected age (CA) will undergo screening using the (1) General Movements Assessment (GMA); (2) Hammersmith Infant Neurological Examination (HINE); (3) Rapid Neurodevelopmental Assessment (RNDA) and (4) Ages and Stages Questionnaire-Aboriginal adaptation (ASQ-TRAK). Developmental outcomes at 12 months CA will be determined for: (1) neurological (HINE); (2) motor (Peabody Developmental Motor Scales 2); (3) cognitive and communication (Bayley Scales of Infant Development III); (4) functional capabilities (Paediatric Evaluation of Disability Inventory-Computer Adaptive Test) and (5) behaviour (Infant Toddler Social and Emotional Assessment). Infants will be classified as typically developing or 'at risk' of an adverse NDO and/or specific NDD based on symptomology using developmental and diagnostic outcomes for (1) CP (2) ASD and (3) FASD. The effects of perinatal, social and environmental factors, caregiver mental health and clinical neuroimaging on NDOs will be investigated. ETHICS AND DISSEMINATION: Ethics approval has been granted by appropriate Queensland ethics committees; Far North Queensland Health Research Ethics Committee (HREC/2019/QCH/50533 (Sep ver 2)-1370), the Townsville HHS Human Research Ethics Committee (HREC/QTHS/56008), the University of Queensland Medical Research Ethics Committee (2020000185/HREC/2019/QCH/50533) and the Children's Health Queensland HHS Human Research Ethics Committee (HREC/20/QCHQ/63906) with governance and support from local First Nations communities. Findings from this study will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12619000969167.

A systematic review of tests to predict cerebral palsy in young children.

AIM: This systematic review evaluates the accuracy of predictive assessments and investigations used to assist in the diagnosis of cerebral palsy (CP) in preschool-age children (<5 y). METHOD: Six databases were searched for studies that included a diagnosis of CP validated after 2 years of age. The validity of the studies meeting the criteria was evaluated using the Standards for Reporting Diagnostic Accuracy criteria. Where possible, results were pooled and a meta-analysis was undertaken. RESULTS: Nineteen out of 351 studies met the full inclusion criteria, including studies of general movements assessment (GMA), cranial ultrasound, brain magnetic resonance imaging (MRI), and neurological examination. All studies assessed high-risk populations including preterm (gestational range 23-41 wks) and low-birthweight infants (range 500-4350 g). Summary estimates of sensitivity and specificity of GMA were 98% (95% confidence interval [CI] 74-100%) and 91% (95% CI 83-93%) respectively; of cranial ultrasound 74% (95% CI 63-83%) and 92% (95% CI 81-96%) respectively; and of neurological examination 88% (95% CI 55-97%) and 87% (95% CI 57-97%) respectively. MRI performed at term corrected age (in preterm infants) appeared to be a strong predictor of CP, with sensitivity ranging in individual studies from 86 to 100% and specificity ranging from 89 to 97% There was inadequate evidence for the use of other predictive tools. SUMMARY: This review found that the assessment with the best evidence and strength for predictive accuracy is the GMA. MRI has a good predictive value when performed at term-corrected age. Cranial ultrasound is as specific as MRI and has the advantage of being readily available at the bedside. Studies to date have focused on high-risk infants. The accuracy of these tests in low-risk infants remains unclear and requires further research.