DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
ORIGINAL ARTICLE
School readiness of children with cerebral palsy FRANCES E GEHRMANN 1,2
| ANDREA COLEMAN 1 | KELLY A WEIR1,4 | ROBERT S WARE 3,4 | ROSLYN N BOYD 1,2,4
1 Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, Brisbane, Qld; 2 School of Medicine, The University of Queensland, Brisbane, Qld; 3 School of Population Health, The University of Queensland, Brisbane, Qld; 4 Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane, Qld, Australia. Correspondence to Roslyn Boyd at Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women’s Hospital, Herston, Qld 4029, Australia. E-mail: [email protected]
PUBLICATION DATA
Accepted for publication 22nd November 2013. Published online 16th January 2014. ABBREVIATIONS
CSBS-DP
CTD PEDI SES
Communication and Symbolic Behaviour Scales Developmental Profile Children with typical development Pediatric Evaluation of Disability Inventory Socio-economic status
AIM To examine school readiness in preschool-age children with cerebral palsy (CP) on three of five domains compared with reported norms of children with typical development (CTD). METHOD A representative population of 151 preschool-age children with CP (87 males, 64 females; 131 [87%] with spasticity, 17 [11%] dyskinesia, 3 [4%] hypotonia) were assessed at 48 or 60 months corrected age. Children were functioning in the following Gross Motor Function Classification System (GMFCS) levels: I, 74 (49%); II, 17 (11%); III, 14 (9%); IV, 26 (17%); V, 20 (13%). Children’s motor performance, self-care, and social function were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) and communication using the Communication and Symbolic Behaviour Scales Developmental Profile (CSBS-DP). Results were compared with a reference sample of CTD (PEDI CTD n=412; CSBS-DP CTD n=790). Linear regression was used to compare these data by functional severity. RESULTS Children with CP had significantly lower PEDI scores in all domains than CTD. Selfcare scores ranged from 0.5 to more than 4SD below CTD, motor performance was 2 to >4SD below CTD, and social function between 0.5 and >4SD below CTD. Fifty-five per cent of children demonstrated significantly delayed communication skills. Non-ambulant children displayed significantly lower scores than ambulant children. INTERPRETATION Preschool-age children with CP perform significantly below their peers in three of five key readiness-to-learn skill areas including mobility, self-care, social function, and communication abilities. Broader emphasis needs to be placed on multimodal screening and intervention to prepare children with CP for school entry.
Cerebral palsy (CP) is the most common physical disability in childhood (two out of 1000 live births)1,2 and has a significant cost impact on the Australian health sector of 1.47 billion Australian dollars (AUD) per year, with an average annual cost of AUD43 431 per individual.3 Mobility and ambulation are factors of importance in individuals with CP, influencing levels of independence, performance in activities of daily living, communication skills, participation in education, vocational involvement, and quality of life. School readiness is a framework for assessing profiles of strengths and vulnerabilities of the preschool child in the context of transition to school.4 It considers a child’s readiness to learn within five major skill areas: health and physical development; emotional well-being and social competence; approaches to learning; communication skills; and cognitive skills and general knowledge.4,5 School readiness is an important paediatric concept as preschool-age developmental deficits are linked with later academic performance.6 Links exist between child development, school readiness, educational attainment, and future health behaviours.7 Identifying the breadth and severity of difficulties in 786 DOI: 10.1111/dmcn.12377
school-readiness domains can maximize a child’s schoolreadiness and increase the likelihood of academic success, which may improve future social, economic, and health outcomes.8 Assessment and prediction of school readiness using the five skill areas mentioned above has been reported in the preterm infant population with evidence that neurodevelopmental assessment can both identify school readiness5 and predict future school readiness from measures performed at 2 years of age.9 A prospective, longitudinal study of preschool-age children with typical development demonstrated that language competence is a strong predictor of school readiness.10 There are mixed reports about the impact of socioeconomic status (SES) on school readiness in preterm populations:5 one study found no significant association5 whereas another showed low SES was a powerful risk factor for not being school ready.11 Although some of the children in the preterm studies were diagnosed with CP,9,11 those with marked CP were often excluded.5 No known studies have assessed broad domains of school readiness specifically in children with CP. © 2014 Mac Keith Press
Individual areas of the five domains of school readiness have been addressed in some cohort studies. Physical disability is often the most prioritized activity limitation in children with CP, with much focus placed on the ability to walk.12 Other aspects of educational performance, such as social interaction and communication, are often overlooked despite links between reduced educational attainment and poor long-term social and health-related outcomes.7,8 When considering each school-readiness domain individually, the literature has demonstrated that in 5-year-old children with CP half present with one or more activity limitations in oromotor function and/or communication13 and 16% are non-verbal.13,14 Cohort studies of preschoolage children with CP have also addressed the domains of physical performance across the spectrum of severity in self-care16 and social functioning.15 There is a paucity of cross-sectional data in this age group about cognitive skills and general knowledge. Evaluating difficulties in domains of school readiness in a child with CP may assist therapists to optimize that child’s transition to formal education before school entry. By identifying the school readiness of children with CP compared with their peers with typical development before school entry, we can identify and implement appropriate additional assistance to maximize achievement at school. The primary aim of this study was to identify if a representative population-based cohort of preschool-age children with CP has different patterns of school readiness than children with typical development. Assessment was based on three of the five readiness-to-learn domains: (1) health and physical development, (2) emotional well-being and social competence, and (3) communication skills.5
METHOD Participants Participants were recruited from a prospective, populationbased cohort of children with physician-diagnosed CP born in Victoria, Australia, between 1 January 2004 and 31 December 2005 and in Queensland between 1 January 2006 and 31 December 2009. These children had been referred to tertiary referral centres with statewide catchment areas and expertise in CP surveillance and care as part of a nationally funded study (NHMRC 465128). The full study protocol, including ascertainment and recruitment methods for the entire prospective cohort study, has been published.16 Children were eligible for inclusion in this study if they were 48 months or older. All motor types and functional abilities were included.16 Children who had not attended an assessment at 48 or 60 months were excluded. Ethical review and approval were obtained from the relevant ethics committees at participating hospitals and universities in Victoria and Queensland, Australia. Procedures All children enrolled in the study received a clinical assessment at 48 or 60 months corrected age. Demographic data, motor type (e.g. spasticity, hypotonia, athetosis, or
• • • •
What this paper adds Preschool-age children with CP show vulnerability in most school-readiness domains. Children with CP function significantly below CTD in the domain of health and physical development. Their performance in social competence, emotional well-being, and communication skills is also below the norm. Multifaceted early developmental screening supported by multimodal interventions, may improve school readiness in children with CP.
dystonia),13 and levels in the Gross Motor Function Classification System (GMFCS)14 and Manual Ability Classification System were recorded.18 Children were assessed for motor type and GMFCS by two physiotherapists.16,19,20 SES was calculated using the Socio-Economic Indexes for Areas Index of Relative Disadvantage, which uses postcode of residence to categorize into scores, with lower scores indicating areas of lower SES.21 The school-readiness markers of physical development, social competence and emotional well-being, and communication skills were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) domains of self-care, mobility, and social function.17,18 The PEDI is a parent/carerreported standardized and reliable assessment of functional ability in a typical (home) environment used in children with disability.22,23 The PEDI is a Rasch-analysed measure and has been standardized against a sample of 412 children with typical development (CTD) between the ages of 6 months and 7 years 6 months (49.3% males). Means and SDs of subdomain scores for different CTD age groups are standardized to 50 and 10 respectively.22 The commonly accepted cut-off point of greater than 1SD below the mean as a definition of vulnerability was adopted for this study.5,11,24 Health and physical development was represented by the PEDI subdomains of self-care and mobility along with GMFCS levels, as strong relationships have been shown between gross motor capacity, mobility performance and self-care abilities, and general health. Social competence and emotional well-being was represented by the PEDI social function subdomain using areas such as problem-resolution, social interactions, play, and community function. The PEDI social function domain also represented elements of communication ability with assessment of comprehension, functional use, and expressive communication.22 The Competency domain is addressed in the Communication and Symbolic Behaviour Scales (CSBS) and PEDI social functioning, which have components that describe a child’s regulatory responses to adult- and peer-interaction requests. Previously, knowledge of colours, letters, and numbers based on the ability to communicate concepts and the use of fine motor skills in block construction and copying of shapes has been used for assessing the verbal and non-verbal cognitive components of school readiness. Both of these cognitive skill areas have high correlations with the PEDI domains of self-care and social communication. Communication skills were assessed using the CSBS Development Profile (CSBS-DP) Infant-Toddler Checklist.25 School Readiness of Children with CP Frances E Gehrmann et al.
787
This was selected as the Communication Function Classification System had not been developed at the start of data collection.26 The CSBS-DP is a parent-reported screening questionnaire, which includes three composites (social, speech, and symbolic communication) and a total standard score. The CSBS-DP has been standardized against younger children (aged 6–24mo, n=790, 50.2% male) with normative total standard scores developed for each age group (mean 100, SD 15); it can be used in older children who are functioning below a 24-month age level.25 The CSBS-DP has strong reliability and strong predictive validity at 2 years.27 When used in older children, the CSBS-DP screens for communication delay and identifies children requiring further comprehensive assessment by a speech pathologist. A total score at or below the mean for the 24-month-old age range indicates a potential communication delay and was considered a significant deficit in our cohort of preschool-age children with CP.
Statistical analysis Demographic and classification characteristics are summarized as mean (SD) for continuous variables and n (%) for categorical variables. The performance of children with CP was compared with CTD by calculating mean and SD for all PEDI subdomain standardized scores and the CSBSDP total score. The number of SDs below CTD mean was calculated for each child. As previous studies of school readiness in preterm children5,9,11,24 have all suggested 1SD as a cut-off for vulnerability across several outcome measures, we adopted the cut-off greater than 1SD below the mean, accepting that 16% of all children would be considered vulnerable. As the PEDI is typically used as a screening tool to identify children who would benefit from more intensive assessment, the use of less than 1SD is not unusual (e.g. Bayley III scales). Variation in performance depending on GMFCS level and ambulatory status was investigated by stratifying by GMFCS level; data were also stratified for term and preterm children and for 48- and 60-month assessments. Linear regression was used to compare the association between motor function (ambulant; GMFCS I–III vs non-ambulant; GMFCS IV–V) and PEDI and CSBS-DP scores. Association between performance and SES was calculated by stratifying into Socio-Economic Indexes for Areas tertiles and calculating mean and SD for all PEDI and CSBS-DP scores. Univariate linear regression was used to identify significant differences between Socio-Economic Indexes for Areas tertiles. All analyses used STATA 11.2 software (StataCorp, College Station, TX, USA). RESULTS Of the 292 children in the broader Australian CP child cohort, which included children from four birth years (NHMRC 465128), a total of 171 (109 males, 62 females) had reached the 48- to 60-month age range and were, therefore, eligible for this study. Of these, 151 children (87 males [57%]) satisfied the specific inclusion criteria for this 788 Developmental Medicine & Child Neurology 2014, 56: 786–793
study, 83 (55%) were included at their 48-month assessment, and 11 had not attended their 48- or 60-month appointment. Demographic and classification characteristics of patients are summarized in Table I. All functional levels were included (GMFCS: I, 74 [49%]; II, 17 [11%]; III, 14 [9%]; IV, 26 [17%]; V, 20 [13%]; Manual Ability Classification System: I, 60 [40%]; II, 42 [28%]; III, 14 [9%]; IV, 11 [7%]; V, 24 [16%]). There were relatively more children classified in GMFCS level I than existing national population reports of an older age group (Australian CP Register: I, 36%; II, 32%; III, 12%; IV, 14%; V, 5%).28 The predominant motor type and distribution were unilateral spasticity (44%) then bilateral spasticity (43%), dystonia/ataxia (6%), athetosis (5%), and hypotonia (2%; Table I). This distribution of motor types is similar to the Australian CP Register.27 SES was evenly distributed across three tertiles: most disadvantaged 39 (26%), middle tertile 61 (40%), and least disadvantaged 51 (34%). Children with CP at 48 to 60 months recorded lower PEDI scores in all domains compared with CTD standards (n=51; mean 50, SD 10; Table II). Eighty-five per cent of self-care assessments were more than 1SD below CTD and
Table I: Characteristics of participants Characteristics Sex, n (%) Male Female Preterm birth (
ORIGINAL ARTICLE
School readiness of children with cerebral palsy FRANCES E GEHRMANN 1,2
| ANDREA COLEMAN 1 | KELLY A WEIR1,4 | ROBERT S WARE 3,4 | ROSLYN N BOYD 1,2,4
1 Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, Brisbane, Qld; 2 School of Medicine, The University of Queensland, Brisbane, Qld; 3 School of Population Health, The University of Queensland, Brisbane, Qld; 4 Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane, Qld, Australia. Correspondence to Roslyn Boyd at Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women’s Hospital, Herston, Qld 4029, Australia. E-mail: [email protected]
PUBLICATION DATA
Accepted for publication 22nd November 2013. Published online 16th January 2014. ABBREVIATIONS
CSBS-DP
CTD PEDI SES
Communication and Symbolic Behaviour Scales Developmental Profile Children with typical development Pediatric Evaluation of Disability Inventory Socio-economic status
AIM To examine school readiness in preschool-age children with cerebral palsy (CP) on three of five domains compared with reported norms of children with typical development (CTD). METHOD A representative population of 151 preschool-age children with CP (87 males, 64 females; 131 [87%] with spasticity, 17 [11%] dyskinesia, 3 [4%] hypotonia) were assessed at 48 or 60 months corrected age. Children were functioning in the following Gross Motor Function Classification System (GMFCS) levels: I, 74 (49%); II, 17 (11%); III, 14 (9%); IV, 26 (17%); V, 20 (13%). Children’s motor performance, self-care, and social function were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) and communication using the Communication and Symbolic Behaviour Scales Developmental Profile (CSBS-DP). Results were compared with a reference sample of CTD (PEDI CTD n=412; CSBS-DP CTD n=790). Linear regression was used to compare these data by functional severity. RESULTS Children with CP had significantly lower PEDI scores in all domains than CTD. Selfcare scores ranged from 0.5 to more than 4SD below CTD, motor performance was 2 to >4SD below CTD, and social function between 0.5 and >4SD below CTD. Fifty-five per cent of children demonstrated significantly delayed communication skills. Non-ambulant children displayed significantly lower scores than ambulant children. INTERPRETATION Preschool-age children with CP perform significantly below their peers in three of five key readiness-to-learn skill areas including mobility, self-care, social function, and communication abilities. Broader emphasis needs to be placed on multimodal screening and intervention to prepare children with CP for school entry.
Cerebral palsy (CP) is the most common physical disability in childhood (two out of 1000 live births)1,2 and has a significant cost impact on the Australian health sector of 1.47 billion Australian dollars (AUD) per year, with an average annual cost of AUD43 431 per individual.3 Mobility and ambulation are factors of importance in individuals with CP, influencing levels of independence, performance in activities of daily living, communication skills, participation in education, vocational involvement, and quality of life. School readiness is a framework for assessing profiles of strengths and vulnerabilities of the preschool child in the context of transition to school.4 It considers a child’s readiness to learn within five major skill areas: health and physical development; emotional well-being and social competence; approaches to learning; communication skills; and cognitive skills and general knowledge.4,5 School readiness is an important paediatric concept as preschool-age developmental deficits are linked with later academic performance.6 Links exist between child development, school readiness, educational attainment, and future health behaviours.7 Identifying the breadth and severity of difficulties in 786 DOI: 10.1111/dmcn.12377
school-readiness domains can maximize a child’s schoolreadiness and increase the likelihood of academic success, which may improve future social, economic, and health outcomes.8 Assessment and prediction of school readiness using the five skill areas mentioned above has been reported in the preterm infant population with evidence that neurodevelopmental assessment can both identify school readiness5 and predict future school readiness from measures performed at 2 years of age.9 A prospective, longitudinal study of preschool-age children with typical development demonstrated that language competence is a strong predictor of school readiness.10 There are mixed reports about the impact of socioeconomic status (SES) on school readiness in preterm populations:5 one study found no significant association5 whereas another showed low SES was a powerful risk factor for not being school ready.11 Although some of the children in the preterm studies were diagnosed with CP,9,11 those with marked CP were often excluded.5 No known studies have assessed broad domains of school readiness specifically in children with CP. © 2014 Mac Keith Press
Individual areas of the five domains of school readiness have been addressed in some cohort studies. Physical disability is often the most prioritized activity limitation in children with CP, with much focus placed on the ability to walk.12 Other aspects of educational performance, such as social interaction and communication, are often overlooked despite links between reduced educational attainment and poor long-term social and health-related outcomes.7,8 When considering each school-readiness domain individually, the literature has demonstrated that in 5-year-old children with CP half present with one or more activity limitations in oromotor function and/or communication13 and 16% are non-verbal.13,14 Cohort studies of preschoolage children with CP have also addressed the domains of physical performance across the spectrum of severity in self-care16 and social functioning.15 There is a paucity of cross-sectional data in this age group about cognitive skills and general knowledge. Evaluating difficulties in domains of school readiness in a child with CP may assist therapists to optimize that child’s transition to formal education before school entry. By identifying the school readiness of children with CP compared with their peers with typical development before school entry, we can identify and implement appropriate additional assistance to maximize achievement at school. The primary aim of this study was to identify if a representative population-based cohort of preschool-age children with CP has different patterns of school readiness than children with typical development. Assessment was based on three of the five readiness-to-learn domains: (1) health and physical development, (2) emotional well-being and social competence, and (3) communication skills.5
METHOD Participants Participants were recruited from a prospective, populationbased cohort of children with physician-diagnosed CP born in Victoria, Australia, between 1 January 2004 and 31 December 2005 and in Queensland between 1 January 2006 and 31 December 2009. These children had been referred to tertiary referral centres with statewide catchment areas and expertise in CP surveillance and care as part of a nationally funded study (NHMRC 465128). The full study protocol, including ascertainment and recruitment methods for the entire prospective cohort study, has been published.16 Children were eligible for inclusion in this study if they were 48 months or older. All motor types and functional abilities were included.16 Children who had not attended an assessment at 48 or 60 months were excluded. Ethical review and approval were obtained from the relevant ethics committees at participating hospitals and universities in Victoria and Queensland, Australia. Procedures All children enrolled in the study received a clinical assessment at 48 or 60 months corrected age. Demographic data, motor type (e.g. spasticity, hypotonia, athetosis, or
• • • •
What this paper adds Preschool-age children with CP show vulnerability in most school-readiness domains. Children with CP function significantly below CTD in the domain of health and physical development. Their performance in social competence, emotional well-being, and communication skills is also below the norm. Multifaceted early developmental screening supported by multimodal interventions, may improve school readiness in children with CP.
dystonia),13 and levels in the Gross Motor Function Classification System (GMFCS)14 and Manual Ability Classification System were recorded.18 Children were assessed for motor type and GMFCS by two physiotherapists.16,19,20 SES was calculated using the Socio-Economic Indexes for Areas Index of Relative Disadvantage, which uses postcode of residence to categorize into scores, with lower scores indicating areas of lower SES.21 The school-readiness markers of physical development, social competence and emotional well-being, and communication skills were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) domains of self-care, mobility, and social function.17,18 The PEDI is a parent/carerreported standardized and reliable assessment of functional ability in a typical (home) environment used in children with disability.22,23 The PEDI is a Rasch-analysed measure and has been standardized against a sample of 412 children with typical development (CTD) between the ages of 6 months and 7 years 6 months (49.3% males). Means and SDs of subdomain scores for different CTD age groups are standardized to 50 and 10 respectively.22 The commonly accepted cut-off point of greater than 1SD below the mean as a definition of vulnerability was adopted for this study.5,11,24 Health and physical development was represented by the PEDI subdomains of self-care and mobility along with GMFCS levels, as strong relationships have been shown between gross motor capacity, mobility performance and self-care abilities, and general health. Social competence and emotional well-being was represented by the PEDI social function subdomain using areas such as problem-resolution, social interactions, play, and community function. The PEDI social function domain also represented elements of communication ability with assessment of comprehension, functional use, and expressive communication.22 The Competency domain is addressed in the Communication and Symbolic Behaviour Scales (CSBS) and PEDI social functioning, which have components that describe a child’s regulatory responses to adult- and peer-interaction requests. Previously, knowledge of colours, letters, and numbers based on the ability to communicate concepts and the use of fine motor skills in block construction and copying of shapes has been used for assessing the verbal and non-verbal cognitive components of school readiness. Both of these cognitive skill areas have high correlations with the PEDI domains of self-care and social communication. Communication skills were assessed using the CSBS Development Profile (CSBS-DP) Infant-Toddler Checklist.25 School Readiness of Children with CP Frances E Gehrmann et al.
787
This was selected as the Communication Function Classification System had not been developed at the start of data collection.26 The CSBS-DP is a parent-reported screening questionnaire, which includes three composites (social, speech, and symbolic communication) and a total standard score. The CSBS-DP has been standardized against younger children (aged 6–24mo, n=790, 50.2% male) with normative total standard scores developed for each age group (mean 100, SD 15); it can be used in older children who are functioning below a 24-month age level.25 The CSBS-DP has strong reliability and strong predictive validity at 2 years.27 When used in older children, the CSBS-DP screens for communication delay and identifies children requiring further comprehensive assessment by a speech pathologist. A total score at or below the mean for the 24-month-old age range indicates a potential communication delay and was considered a significant deficit in our cohort of preschool-age children with CP.
Statistical analysis Demographic and classification characteristics are summarized as mean (SD) for continuous variables and n (%) for categorical variables. The performance of children with CP was compared with CTD by calculating mean and SD for all PEDI subdomain standardized scores and the CSBSDP total score. The number of SDs below CTD mean was calculated for each child. As previous studies of school readiness in preterm children5,9,11,24 have all suggested 1SD as a cut-off for vulnerability across several outcome measures, we adopted the cut-off greater than 1SD below the mean, accepting that 16% of all children would be considered vulnerable. As the PEDI is typically used as a screening tool to identify children who would benefit from more intensive assessment, the use of less than 1SD is not unusual (e.g. Bayley III scales). Variation in performance depending on GMFCS level and ambulatory status was investigated by stratifying by GMFCS level; data were also stratified for term and preterm children and for 48- and 60-month assessments. Linear regression was used to compare the association between motor function (ambulant; GMFCS I–III vs non-ambulant; GMFCS IV–V) and PEDI and CSBS-DP scores. Association between performance and SES was calculated by stratifying into Socio-Economic Indexes for Areas tertiles and calculating mean and SD for all PEDI and CSBS-DP scores. Univariate linear regression was used to identify significant differences between Socio-Economic Indexes for Areas tertiles. All analyses used STATA 11.2 software (StataCorp, College Station, TX, USA). RESULTS Of the 292 children in the broader Australian CP child cohort, which included children from four birth years (NHMRC 465128), a total of 171 (109 males, 62 females) had reached the 48- to 60-month age range and were, therefore, eligible for this study. Of these, 151 children (87 males [57%]) satisfied the specific inclusion criteria for this 788 Developmental Medicine & Child Neurology 2014, 56: 786–793
study, 83 (55%) were included at their 48-month assessment, and 11 had not attended their 48- or 60-month appointment. Demographic and classification characteristics of patients are summarized in Table I. All functional levels were included (GMFCS: I, 74 [49%]; II, 17 [11%]; III, 14 [9%]; IV, 26 [17%]; V, 20 [13%]; Manual Ability Classification System: I, 60 [40%]; II, 42 [28%]; III, 14 [9%]; IV, 11 [7%]; V, 24 [16%]). There were relatively more children classified in GMFCS level I than existing national population reports of an older age group (Australian CP Register: I, 36%; II, 32%; III, 12%; IV, 14%; V, 5%).28 The predominant motor type and distribution were unilateral spasticity (44%) then bilateral spasticity (43%), dystonia/ataxia (6%), athetosis (5%), and hypotonia (2%; Table I). This distribution of motor types is similar to the Australian CP Register.27 SES was evenly distributed across three tertiles: most disadvantaged 39 (26%), middle tertile 61 (40%), and least disadvantaged 51 (34%). Children with CP at 48 to 60 months recorded lower PEDI scores in all domains compared with CTD standards (n=51; mean 50, SD 10; Table II). Eighty-five per cent of self-care assessments were more than 1SD below CTD and
Table I: Characteristics of participants Characteristics Sex, n (%) Male Female Preterm birth (
