Early detection and intervention in cerebral palsy: from knowledge to action.

Abstract

One of the greatest challenges facing clinicians and investigators is identifying risk factors in early infancy that can reliably predict disability which manifests later in life. Many experienced clinicians are reluctant to make a diagnosis of cerebral palsy (CP) before 18 to 24 months of age, and major CP registries would not consider the diagnosis as valid before 4 or 5 years. This may result in a delay in accessing specialized services, which might lead to negative outcomes. Based on the available evidence, the collaborative efforts of investigators from around the world1 has produced clinical recommendations that can now help clinicians to make an early (and sometimes tentative) diagnosis of CP or, in some cases, predict a high risk of CP between 3 months and 12 months of age. Once there is overwhelming evidence, the next most important step in assessment will be to turn that knowledge into practice. This can be achieved by using such tools as Prechtl’s qualitative General Movements Assessment (GMA) or the Hammersmith Infant Neurological Examination (HINE) for infants under 5 months’ corrected age,1 together with detailed medical history-taking and comprehensive clinical examination. Furthermore, training about and uptake of reliable measures must be promoted. It is important to identify the barriers to implementation. These may include existing notions about early manifestation and detection of neurodevelopmental disorders, and possible difficulties in accessing standardized assessments for children in middle- or low-income countries (LMICs). Some clinicians have already implemented early detection programmes. Recently published experiences in Australia2 and various clinics in the USA3 suggest that when assessments are carried out using the recommended tools and followed-up with referral to specialized clinics early, the age at which CP is diagnosed can be lowered to under 12 months. In LMICs where providing expensive medical equipment for diagnosis is challenging, the GMA can considerably facilitate infant screening for early detection of developmental disorders.4 However, we believe that what would really change the current situation would be universal implementation of the GMA. Carrying out early detection only makes sense if there are evidence-based interventions during the first few months of life. In recent years, the evidence base for therapeutic approaches in CP has continued to expand, offering clinicians and families the possibility of newer, hopefully safer, and more effective interventions. Currently, early intervention in children with developmental disorders could be described as a learning process for both the child and their family to find their own shared meaningful goals, in terms of functional capabilities, activities, and the child’s participation in daily life. This is also true for the children with the most severe impairments, for whom provision of appropriate adaptive equipment is used to optimize positioning, mobility, and communication, to enable opportunities to learn about their own body and the people and objects surrounding them. This, in turn, guides action, perception, and interaction, which become fully meaningful when envisaged in the framework of the International Classification of Functioning, Disability and Health, and the F-words for child development: functioning, family, fitness, fun, friends, and future.5 One of the key pillars of the European Academy of Childhood Disability (EACD) and other likeminded organizations is the discussion of research results and dissemination of knowledge. To this end, the upcoming annual meeting in Barcelona will dedicate part of its programme to detection and early intervention for childhood motor disorders, with several presentations in two pre-congress symposia focusing on infants born preterm and children with autism spectrum disorder, alongside several keynote lectures. Interest is already evident from the large number of mini-symposia and oral communications on this topic submitted to the congress.