Treatment Center For Children Research Articles

Co-designing solutions to enhance access and engagement in pediatric telerehabilitation.

Prior to the COVID-19 pandemic, children's therapy appointments provided by Ontario's publicly-funded Children's Treatment Centre (CTCs) primarily occurred in-person. With COVID-19 restrictions, CTCs offered services via telerehabilitation (e.g., video, phone), which remains a part of service delivery. CTC data shows that families experience barriers in attending telerehabilitation appointments and may need supports in place to ensure service accessibility. Our study aimed to co-design innovative solutions to enhance access and engagement in ambulatory pediatric telerehabilitation services. This manuscript reports the co-design process and findings related to solution development. This research project used an experience based co-design (EBCD) approach, where caregivers, clinicians and CTC management worked together to improve experience with telerehabilitation services. Interview data were collected from 27 caregivers and 27 clinicians to gain an in-depth understanding of their barriers and successes with telerehabilitation. Next, 4 interactive co-design meetings were held with caregivers, clinicians and CTC management to address priorities identified during the interviews. Using qualitative content analysis, data from the interviews and co-design meetings were analyzed and findings related to the solutions developed are presented. Four topics were identified from the interview data that were selected as focii for the co-design meetings. Findings from the co-design meetings emphasized the importance of communication, consistency and connection (the 3C's) in experiences with telerehabilitation. The 3C's are represented in the co-designed solutions aimed at changing organizational processes and generating tools and resources for telerehabilitation services. The 3C's influence experiences with telerehabilitation services. By enhancing the experience with telerehabilitation, families will encounter fewer barriers to accessing and engaging in this service delivery model.

Metaverse-based social skills training programme for children with autism spectrum disorder to improve social interaction ability: an open-label, single-centre, randomised controlled pilot trial.

Autism spectrum disorder (ASD) is characterised by abnormalities in social interactions and restricted and repetitive behaviors. Children with high-functioning ASD (HFASD), lack social communication skills, do not interact with others, and lack peer relationships. We aimed to develop, and evaluate the feasibility of, a metaverse-based programme to enhance the social skills of children with HFASD. This open-label, single-centre, pilot parallel randomised controlled trial (RCT) was conducted on boys aged 7-12 years with HFASD. Children were recruited from a treatment centre for children with HFASD in Korea or by self-referral through online community webpages for the parents of children with HFASD. Participants were randomly assigned (1:1) by a blinded researcher to receive either four weeks of a metaverse-based social skills training programme or a control group. Randomisation was stratified by age (children aged 7-9 and 10-12 years) using permuted blocks (block size 4). The metaverse-based social skills training programme was delivered via the metaverse platforms (Roblox) and Zoom. Children in the intervention group completed the metaverse-based social skills training programme at home for four weeks. The intervention consisted of four sessions, one session per week, for 60min each. The control group did not receive any interventions. The primary outcome measure was the median change in the Social Responsiveness Scale-2 (SRS-2) scores from pre-to post-intervention. SRS-2 is an assessment tool used to confirm the effectiveness of social interactions. Higher scores indicate lower social functioning. The trial is registered with CRIS Registration Number; KCT0006859. Between February 14, 2022, and March 31, 2022, 20 participants were enrolled. Overall, 15 children (median [Interquartile range (IQR)] age, intervention group: 9.0 [8.0-10.0]; control group: 8.5 [8.0-10.0]) participated in the programme. The intervention group included nine participants (60%), and the control group included six participants (40%). The SRS-2 total scores for the intervention group decreased from baseline 96.0 (IQR: 74.0-112.0) to post-intervention 85.0 (IQR: 84.0-103.0). The group median difference in SRS-2 scores between the intervention and control groups was 11.5 (95% CI: 8.5-14.0), with a further reduction in the intervention group. Similar trends were seen for social cognition (group median difference, 95% CI: 2.0, 1.0-4.0), social communication (group median difference, 95% CI: 2.0, 1.0-4.0), and autistic mannerism (group median difference, 95% CI: 4.0, 1.0-5.0). There were no adverse events related to study participation. The findings of this feasibility study suggest that children with HFASD can potentially be familiarised, through metaverse-based programmes, with real-life social situations to improve sociality and reduce emotional and behavioural problems. Such interventions could be delivered at home and possibly be extended to target groups that have difficulty in interacting with peers offline. The Institute of Information & Communications Technology Planning & Evaluation grant, via the Ministry of Science and ICT of the South Korean Government.

The frequency and outcome of Influenza in children admitted to Tabriz children's training and treatment center in Northwest Iran During 2014-2019

Background. Influenza causes various seasonal respiratory diseases, resulting in significant morbidity and mortality in children. Influenza is a highly contagious disease causing global pandemics. This study aimed to investigate the frequency and outcome of influenza in children admitted to the Tabriz Children's Hospital. Methods. This cross-sectional study included suspected influenza patients admitted to the Tabriz Children's Medical Center between 2014 and 2019 diagnosed with positive influenza through RT-PCR of pharyngeal secretions samples. Results. We evaluated 114 cases of influenza with a median age of 48 months (range: 2-156 months) and 53.5% were boys. A total of 87 cases (77%) were infected with subtype A/H3N2, which was the most frequent, followed by 2 cases (1.8%) of subtype A/H1N1, 23 cases (20.4%) of subtype B 23, and one case (0.8%) of uncategorized A subtype. The disease was common in winter with 63 cases (56.3%). Conclusion. The frequency of influenza in children during five years was 8.95%, which is higher in males. Also, the highest frequency of influenza in the present study was observed in the age group of 1 to 5 years. The mortality rate of influenza in children during the last five years was equal to 7.9%. Practical Implications. Children under 5 years of age are more susceptible to influenza (especially type A subtype H3N2) and higher hospitalization rate and mortality, which can be prevented with a vaccine.

The correlation between loneliness and substance use proclivity in child and adolescent substance users

ABSTRACT Purpose The study was designed to determine the relationship between loneliness and substance use proclivity in child and adolescent substance users. Method The study was conducted at the Substance Abuse Treatment Center for children and adolescents (CEMATEM) of a psychiatric hospital. A descriptive characteristics form, the UCLA Loneliness Scale, and the Substance Use Proclivity Scale were used to collect the data. The percentage distribution, arithmetic mean, and Pearson’s Correlation tests were used to analyze the data. Results The results of this study revealed that both the loneliness total mean and substance use proclivity total mean scores of the participants were 22.16 ± 2.49 (high) and 28.91 ± 1.76 (high), respectively. A statistically significant and positive correlation was also found to exist between the participant’s total mean scores of the loneliness and substance use proclivity scales (p < .01). Practice implications The lonelier the pediatric and adolescent patients participating in the study felt, the higher their substance use proclivity became.

Can Children Be Safe if Their Caregivers are Not?: Reflections on the “Promise” Study of Workforce Issues in a Residential Treatment Center for Children

ABSTRACT This article reviews findings from a recent ethnographic study of the workforce in a residential treatment center for children. Major threats to workers’ physical safety and psychosocial well-being were documented, including client violence and intensive and threatening regulatory oversight of practice. I show how, in this setting, the effects of client violence against workers and attempts to comply with the regulatory policy appear to have had unintended negative consequences for the safety of youth in care, as well as their caregivers. I argue that attempts to improve safety and the perception of safety for youth in care require a systemic understanding of how violence and its regulation affect the milieu as a whole, with attention to the well-being of both children and workers. I conclude with suggestions for how organizations can maximize safety for all.

Personal, environmental, and family factors of participation among young children.

The purpose of this study is to assess the influences of environment, population characteristics, and service utilization on participation frequency and involvement in the home setting among children 0 to 5years. Data were collected from parents of 236 children (mean age 3years and 5months, SD=1.30, girls=152 and boys=84) using a children's treatment centre in Ontario through an online survey. Two path models measuring home frequency and home involvement were assessed using structural equation modelling. The exogenous factors in the models included child's age, child's sex, child's complexity, number of environmental barriers, income, mother's participation, and service utilization. In addition to participation as the primary outcome, each model explored predictors of service utilization and mother's participation. The involvement model (R2 =0.46) explained more variance than the frequency model (R2 =0.33). Age (0.35, P<0.001) and barriers (0.07, P=0.001) predicted participation frequency in the home, χ2 (9)=8.51, P<0.4, root mean square error of approximation (RMSEA)=0.00, comparative fit index (CFI)=1.00. The home involvement model, χ2 (6)=9.79, P<0.13, RMSEA=0.06, CFI=0.97, showed that increasing age (0.09, P<0.001), lower complexity (0.13, P=0.001), and higher mother's participation (0.057, P=0.001) were significantly related to higher participation. An increase in child's age or complexity significantly influenced service utilization across both models. Complexity reduced mother's participation in both the frequency and involvement models. This study is one of the first in Canada to examine participation of young children. The aggregation of each unit factor, particularly barriers and complexity, can accrue a large impact on the child's and mother's participation. The potential to mediate this impact by removing environmental barriers and promoting mother's participation merits further study.

Play Therapy in Residential Treatment Centers for Children

ABSTRACTResidential Treatment Centers (RTCs) serve youth who have suffered extreme abuse and trauma and must reside in 24-hour facilities to receive mental health, medication, and social services. Currently, specific therapeutic interventions utilize talk therapy or cognitive therapies, which may have limited use with children due to developmental considerations, specifically children who have been through trauma that has affected their development. Child-Centered Play Therapy (CCPT) is introduced as an evidence-based expressive therapy modality that emphasizes the child’s natural language of play as a way to support emotional and psychological healing. This article discusses limitations to residential treatment center research as well as ways to implement play therapy into residential treatment settings for children who are in need of such services through the use of brief play therapy, group play therapy, and Child Parent Relationship Therapy (CPRT).

Journalist and Activist

The study explores how one community newspaper publisher in the mid-twentieth century attempted to serve the seemingly competing roles of journalist and community activist. This narrative recounts how Minnesota newspaper publisher Veda Ponikvar formed a unique alliance with a congressman, John A. Blatnik, to bring a center for the developmentally disabled to their hometown of Chisholm, Minnesota. Ponikvar and Blatnik rallied support at the local, state, and national levels for the construction of what was touted as one of the first day treatment centers for children with developmental disabilities in the state. The study offers insight into the challenges Ponikvar faced as she tried to balance her obligations as a journalist with her goals as an activist for the developmentally disabled.

Three-year trajectories of global perceived quality of life for youth with chronic health conditions.

PurposeObjectives of this longitudinal study were to examine 3-year trajectories of global perceived quality of life (QOL) for youth with chronic health conditions, as obtained from youth and parent reports, and to identify personal and environmental factors associated with the trajectory groups for each perspective.MethodsYouth with various chronic conditions aged 11–17 years and one of their parents were recruited from eight children’s treatment centers. Latent class growth analysis was used to investigate perceived QOL trajectories (separately for youth and parent perspectives) over a 3-year period (four data collection time points spaced 12 months apart). Multinomial logistic regression was employed to identify factors associated with these trajectories.ResultsA total of 439 youth and one of their parents participated at baseline, and 302 (69 %) of those youth/parent dyads completed all four data collection time points. Two QOL trajectories were identified for the youth analysis: ‘high and stable’ (85.7 %) and ‘moderate/low and stable’ (14.3 %), while three trajectories were found for the parent analysis: ‘high and stable’ (35.7 %), ‘moderate and stable’ (46.6 %), and ‘moderate/low and stable’ (17.7 %). Relative to the ‘high and stable’ groups, youth with more reported pain/other physical symptoms, emotional symptoms, and home/community barriers were more likely to be in the ‘moderate and stable’ or ‘moderate/low and stable’ groups. Also, youth with higher reported self-determination, spirituality, family social support, family functioning, school productivity/engagement, and school belongingness/safety were less likely to be in the ‘moderate and stable’ or ‘moderate/low and stable’ groups, compared to the ‘high and stable’ groups.ConclusionFindings suggest that youth with chronic conditions experience stable global perceived QOL across time, but that some individuals maintain stability at moderate to moderate/low levels which is related to ongoing personal and environmental influences. Potential benefits of universal strategies and programs to safeguard resilience for all youth and targeted interventions to optimize certain youths’ global perceived QOL are indicated.Electronic supplementary materialThe online version of this article (doi:10.1007/s11136-016-1353-z) contains supplementary material, which is available to authorized users.

Preventing work-related stress among staff working in children's cancer Principal Treatment Centres in the UK: a brief survey of staff support systems and practices.

Growing evidence of the association between health professionals' well‐being and patient and organisational outcomes points to the need for effective staff support. This paper reports a brief survey of the UK's children's cancer Principal Treatment Centres (PTCs) regarding staff support systems and practices. A short on‐line questionnaire, administered in 2012–2013, collected information about the availability of staff support interventions which seek to prevent work‐related stress among different members of the multi‐disciplinary team (MDT). It was completed by a member of staff with, where required, assistance from colleagues. All PTCs (n = 19) participated. Debriefs following a patient death was the most frequently reported staff support practice. Support groups were infrequently mentioned. There was wide variability between PTCs, and between professional groups, regarding the number and type of interventions available. Doctors appear to be least likely to have access to support. A few Centres routinely addressed work‐related stress in wider staff management strategies. Two Centres had developed a bespoke intervention. Very few Centres were reported to actively raise awareness of support available from their hospital's Occupational Health department. A minority of PTCs had expert input regarding staff support from clinical psychology/liaison psychiatry.

Impact of the Bowel Management Program on the quality of life in children with fecal incontinence.

Evaluate the impact of implementing Bowel Management Program (BMP) on quality of life (QoL) in children with fecal incontinence (FI). Children 3-12 years referred to the Children's Treatment Center of FI were included and categorized accordingto the tendency to constipation (dilated colon; group 1) or diarrhea (non-dilated colon; group 2). Evaluations were performed before and after 3 months of BMP implementation. Perceptions from parents and children about QoL were assessed by the instrument PedsQL4.0 and the severity of FI by the fecal incontinence index (FII) of Wexner scale. 43 children (mean age of 7.7 ± 3.1) were studied. 32 (74.4 %) belonged to group 1 and 11 (25.6 %) to group 2. After 3 months of BMP, it was noticed a significant improvement of the FII (14.5 ± 3.7 versus 2.8 ± 2.5; p < 0.001) in both groups. QoL perception by the parents and children increased on PedsQL4.0 evaluation (p < 0.001). There was a medium inverse statistically significant correlation of the FII and the total PedsQL4.0 score among children and parents (r = -0.47, p = 0.009 and r = -0, 39, p = 0.03, respectively). The BMP applied by a multidisciplinary dedicated team significantly improves the QoL of children with FI in the short-term period.

The effectiveness of weight-reduction stays at the children´s treatment centre of Křetín

The Children's Treatment Centre of Křetin not only treats obesity, but also respiratory diseases and locomotors system impairments. This study focuses on 25 children who were sent to the Centre by a paediatrician in order to reduce their body weight. These children were prescribed a slimming program which included physical activity and an appropriate diet. The curative stay lasted 4 weeks. After the treatment was over, it may be concluded that all children had reduced their weight. The weight reduction in boys was 4.91 kg and in girls 3.56 kg on average.

An evaluation of the Performance Diagnostic Checklist-Human Services to assess an employee performance problem in a center-based autism treatment facility.

The Performance Diagnostic Checklist-Human Services (PDC-HS) is an informant-based tool designed to assess the environmental variables that contribute to poor employee performance in human services settings. We administered the PDC-HS to 3 supervisors to assess the variables that contributed to poor performance by 4 staff members when securing clients in therapy rooms at a treatment center for children with autism. The PDC-HS identified a lack of appropriate consequences as contributing to poor staff performance. We then evaluated a PDC-HS-indicated intervention as well as an intervention not suggested by PDC-HS results. The PDC-HS-indicated intervention (graphed feedback) was effective to increase performance; the non-PDC-HS-based intervention was ineffective.

Measure of Processes of Care: a review of 20 years of research

This article reviews literature on findings from the Measure of Processes of Care (MPOC) to assess family-centred services. Systematic searches for papers citing MPOC in both PubMed and Web of Science identified 107 articles. Fifty-five met the criterion for inclusion in this review in that they reported MPOC data. Over the past 20years MPOC has been used in settings additional to the children's treatment centres for which it was designed; used in 11 countries and translated into 14 languages; and used to measure change in respondents' perceptions over time. MPOC findings have also informed our understanding of the provision of family-centred services. Overall, parents report that service providers do a good job of providing respectful, comprehensive services in partnership with families, but that there remain limitations in the provision of general information, an area for improvement. Finally, MPOC has been shown to correlate with various other measures related to the provision of family-centred services. The MPOC 'family' of measures can be used to assess both families' and service providers' experiences and perceptions of the family-centredness of services received/provided. Opportunities abound for further research enquiries.

Youth and Young Adults With Spina Bifida: Their Utilization of Physician and Hospital Services

ObjectiveTo describe current patterns of health care utilization of youth and young adults who have spina bifida (SB) and provide evidence to guide the development of health care for this growing population. DesignWe conducted a secondary analysis of health services utilization data from the Canadian Institute for Health Information to determine the rates and patterns of health care utilization, because comprehensive health care has been recognized as critical to positive health outcomes. SettingParticipants were identified from 6 publicly funded children's treatment centers. ParticipantsHealth records from youth (n=164; age range, 13.0–17.9y) and adults (n=120; age range, 23.0–32.9y) with SB contributed to this study. InterventionsNot applicable. Main Outcome MeasuresThe rates of outpatient physician visits and hospital admissions for the youth and adult groups were calculated. The proportion with a “medical home” was also calculated. ResultsThe annual rates of outpatient physician visits per 1000 persons were 8031 for youth and 8524 for adults with SB. These rates were approximately 2.9 and 2.2 times higher, repectively, than for their age-matched peers. On average, 12% of youth and 24% of adults with SB had a medical home. The annual rates of hospital admissions per 1000 persons were 329 for youth and 285 for adults with SB. Rates of admissions were 19.4 and 12.4 times higher, respectively, for these groups than for the general population. ConclusionsIt appears that persons with SB are accessing health services more often than their age-matched peers, and few have a medical home. We recommend that seamless medical care be provided to all adults with SB, coordinated by a primary care provider, to facilitate comprehensive care.

An Evaluation of the Observer Effect on Treatment Integrity in a Day Treatment Center for Children

Treatment integrity is an important concern in treatment centers but is often overlooked. Performance feedback is a well-established approach to improving treatment integrity, but is underused and undervalued. One way to increase its value to treatment centers may be to expose unrealized benefits on the observer who collects the performance feedback data. This "observer effect" could increase the value of performance feedback and promote more consistent evaluation of treatment integrity. The purpose of this investigation was to evaluate the observer effect on treatment integrity. Five supervisors who worked in a day treatment center were asked to collect performance feedback data on staff members' integrity in following a standard treatment protocol that supervisors were also expected to follow. Results showed an immediate and marked improvement in treatment integrity in three supervisors who collected but never received performance feedback. For two supervisors, this effect was reversed and replicated. Implications are discussed.

Consensus statement of the Indian academy of pediatrics on integrated management of severe acute malnutrition

Severe acute malnutrition (SAM) is a major public health issue. It afflicts an estimated 8.1 million under-five children in India causing nearly 0.6 million deaths. The improved understanding of pathophysiology of SAM as well as new internationally accepted growth charts and newer modalities of integrated intervention have necessitated a relook at IAP recommendations. A National Consultative Meeting on Integrated Management of Severe Acute Malnutrition was held in Mumbai on 16th and 17th October, 2010. It was attended by the invited experts in the field. Extensive discussions were held as per the program. The participants were then divided into six groups for detailed discussions. The groups deliberated on various issues pertaining to the task assigned and presented recommendations of the groups in a plenary session. The participants made a list of recommendations after extensive discussions. A Writing Committee was formed and was entrusted with the task of drawing a Consensus Statement on the basis of these Recommendations. After multiple deliberations, the following Consensus Statement was adopted. To critically evaluate the current global evidence to formulate a consensus among stakeholders regarding diagnosis and management of SAM. An integrated management of malnutrition is likely to yield more dividends. Thus, management of SAM should constitute an important component of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program. Determination of SAM on the basis of Z-scores using WHO Growth charts is considered statistically more appropriate than cut-offs based on percentage weight deficit of the median. Considering the fact that many children with SAM can be successfully managed on outpatient basis and even in the community, it is no more considered necessary to advise admission of all children with SAM to a healthcare facility. Management of SAM should not be a stand-alone program. It should integrate with community management therapeutic programs and linkages with child treatment center, district hospitals and tertiary level centers offering inpatient management for SAM and include judicious use of ready-to-use-therapeutic Food (RUTF). All sections of healthcare providers need to be trained in the integrated management of SAM.

Communication regarding breathing support options for youth with Duchenne muscular dystrophy

Ventilators for home use, manual and mechanically assisted coughing techniques, and the services of in-home respiratory therapists are options for youth with Duchenne muscular dystrophy (DMD). Evidence supports the use of these modalities, but there seems to be few youth who are receiving these therapies. Is there a knowledge transfer issue? Is there a lack of resources? What is the best way to discuss the issues? What do youth and parents want? To determine practices, attitudes and beliefs regarding the timing and content of client/family communication related to ventilatory support decisions for individuals with DMD. A questionnaire was sent to all 19 children's treatment centres in Ontario. The lead clinician responded on behalf of his or her centre. Another questionnaire was given to 11 families who attended a parent support meeting. Respondents from the treatment centres who provide services for youth with DMD indicated that there are resources in terms of personnel and an obligation to provide information about ventilatory support, but provision of information is often late and/or inconsistent. The family respondents wanted more information and they wanted it earlier than they are currently receiving it. Parents and youth dealing with DMD have many resources at their disposal in Ontario. The evidence is clear that there are long-term health benefits to providing ventilatory support as well as instruction in coughing assistance. Due to the classical nature of disease progression in DMD, information should be provided within reasonable timelines.

Becoming and staying physically active in adolescents with cerebral palsy: protocol of a qualitative study of facilitators and barriers to physical activity

BackgroundAdolescents with cerebral palsy (CP) show a reduced physical activity (PA). Currently there are no interventions for adolescents with CP in this critical life phase that optimise and maintain the individuals' physical activity in the long term. To develop such a program it is important to fully understand the factors that influence physical activity behaviours in adolescents with CP. The aim of this study is to explore what makes it easy or hard for adolescents with CP to be and to become physically active.Methods/DesignA qualitative research method is chosen to allow adolescents to voice their own opinion. Because we will investigate the lived experiences this study has a phenomenological approach. Thirty ambulatory and non-ambulatory adolescents (aged 10-18 years) with CP, classified as level I to IV on the Gross Motor Function Classification System and 30 parents of adolescents with CP will be invited to participate in one of the 6 focus groups or an individual interview. Therapists from all Children's Treatment Centres in Ontario, Canada, will be asked to fill in a survey. Focus groups will be audio- and videotaped and will approximately take 1.5 hours. The focus groups will be conducted by a facilitator and an assistant. In preparation of the focus groups, participants will fill in a demographic form with additional questions on physical activity. The information gathered from these questions and recent research on barriers and facilitators to physical activity will be used as a starting point for the content of the focus groups. Recordings of the focus groups will be transcribed and a content analysis approach will be used to code the transcripts. A preliminary summary of the coded data will be shared with the participants before themes will be refined.DiscussionThis study will help us gain insight and understanding of the participants' experiences and perspectives in PA, which can be of great importance when planning programs aimed at helping them to stay or to become physically active.

Reasons for Hospital Admissions Among Youth and Young Adults With Cerebral Palsy

Young NL, McCormick AM, Gilbert T, Ayling-Campos A, Burke T, Fehlings D, Wedge J. Reasons for hospital admissions among youth and young adults with cerebral palsy. Objective To identify the most common reasons for acute care hospital admissions among youth (age range, 13–17.9y) and young adults (age range, 23–32.9y) with cerebral palsy (CP). Design We completed a secondary analysis of data from the Canadian Institute for Health Information (CIHI) to determine the most frequently observed reasons for admissions and the associated lengths of stay (LOS). Setting Participants were identified from 6 children's treatment centers in Ontario, Canada. Participants Health records data from youth with CP (n=587) and young adults with CP (n=477) contributed to this study. Interventions Not applicable. Main Outcome Measures The most common reasons for hospital admission, relative frequencies of admissions for each reason, and mean LOS were reported. Results The analysis of CIHI records identified epilepsy and pneumonia as the top 2 reasons for admissions in both age groups. Both age groups were commonly admitted because of infections other than pneumonia and urinary tract infections (UTIs), gastrointestinal (GI) problems such as malabsorption, and mental illness. The reasons that were unique to youth included orthopedic and joint-related issues, other respiratory problems, and scoliosis. In young adults, mental illness was the third most common reason for admission, followed by lower GI or constipation problems, malnutrition or dehydration, upper GI problems, fractures, and UTIs. Conclusions This article provides important clinical information that can be used in the training of physicians and health care providers, and to guide future planning of ambulatory care services to support the clinical management of persons with CP over their lifespan.