Social outcome of handicapped children as adults

Living Conditions and Social Outcomes in Adults With Cerebral Palsy

Objectives: To analyse the living conditions and social outcomes (housing, engagement in employment or higher education, access to personal assistance and having a partner) in adults with cerebral palsy (CP) relative to their age, sex, communication ability, and motor skills.

Methods: Cross-sectional registry-based study of 1,888 adults (1,030 males/858 females) with CP in the Swedish CP follow-up programme, median age 25 years (range 16–78 y). Type of housing, occupation, access to personal assistance and having a partner were analysed relative to their age, sex, and the classification systems for Gross Motor Function (GMFCS) and Communication Function (CFCS). Binary logistic regression models were used to calculate odds ratios (OR) for independent living, competitive employment, and having a partner.

Results: Most of the 25- to 29-year olds (55.6%) lived independently, increasing to 72.4% in 40- to 49-year olds, while the majority (91.3%) of those under 20 years lived with their parents. Independent living was almost equal in adults at GMFCS levels I (40.2%) and V (38.6%). This parity was explained by access to personal assistance, which increased with higher GMFCS and CFCS levels. Personal assistance of >160 hours/week was associated with a high probability of independent living (OR 57). In the age span 20–64 years, 17.5% had competitive employment and 45.2% attended activity centres for people with intellectual disabilities. In the younger age group up to 24 years old, 36.9% went to mainstream/higher education and 20.5% went to special schools. In total, 13.4% had a partner and 7.8% lived together. Slightly more women than men had a partner, and most individuals were classified at CFCS level I.

Conclusion: Only one in eight adults with CP has a partner, and one in six has competitive employment. Access to personal assistance is the single most important factor for independent living. It is vital to support adults with CP throughout their lifespan to achieve the best possible outcomes in all aspects of life.

Social and sexual relationships of adolescents and young adults with cerebral palsy: a review

Objective: To investigate possible barriers to successful social and sexual relationships in adolescents and young adults of normal intelligence with cerebral palsy.

Design: A literature review based on a PubMed and PsycINFO search for the period 1990–2003. Included were studies focusing on one or more of the outcome parameters (i.e. social, intimate and sexual relationships) or on associated factors that described relationships with the outcome parameters.

Results: Fourteen papers were selected. Two studies investigated exclusively people with cerebral palsy whereas 12 concerned people with a congenital disability and/or physical disabilities, including people with cerebral palsy. All studies addressed adolescents or adults of normal intelligence. A. Social and sexual relationships: In social relationships adolescents and young adults with cerebral palsy were less active than their age mates, and dating was often delayed and less frequent. Adolescents with congenital disabilities indicated that sexuality is an important aspect of their lives, but they experienced difficulties developing a sexual relationship. B. Associated factors: Psychological maladjustment, insufficient self-efficacy and low sexual self-esteem may impair the development of social and sexual relationships. Overprotection in raising children with cerebral palsy and the negative attitudes of other people may have a negative influence on the self-efficacy of people with cerebral palsy.

Conclusion: The reviewed studies suggest many factors that may influence the development of social and sexual relationships in adolescents and young adults with cerebral palsy. However, evidence was found only for the personal factors self-efficacy and sexual self-esteem and their interrelationships with the parents' way of raising their children and successful experiences in social situations.

A study of the North Staffordsh i re you ng adult service forthe physically handicapped school leaver and young adult

Studies have shown that the expectations of physically disabled school leavers are low when they have nothing to do and they fail to develop even further. It has also been shown that where there is a service for young physically disabled school leavers, there is benefit for the young people. We performed an evaluation of our own service using a questionnaire and additionally looked at areas of unmet need. The study showed that the team's activities were useful, and young people obtained benefit from the service which they would not otherwise have had, for lack of proper assessment. It was realized that a number of services, which were requested, did not take place and these related to communication between our team and the community health service. We have adapted our service to address these problems and now plan to look more formally at ways to promote clients' desired lifestyles.

Brazilian Portuguese translation and cross-cultural adaptation of the "Caregiver Priorities and Child Health Index of Life with Disabilities" (CPCHILD) questionnaire

Background

Consideration of the quality of life in relation to individual health status is crucial for planning and maintaining a system of patient-centered care. Until recently, there have been no suitable instruments to assess health-related quality of life (HRQoL,) of children and adolescents with severe, non-ambulant cerebral palsy (GMFCS functional levels IV and V). The “Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire” (CPCHILD^©) was developed in English specifically for this population, and has been validated in Canada. The aim of this study was to translate and adapt the CPCHILD^© Questionnaire into Brazilian Portuguese, thus permitting researchers in Brazil to access this important tool for measuring HRQoL in this population, as well as the possibility of making comparisons with other studies that use the same questionnaire in other languages.

Method

The cross-cultural adaptation included two forward translations by independent translators, their synthesis, two back-translations by independent translators, an assessment of the versions by an expert committee and the development of a pre-final version, which was tested on 30 caregivers of children (5 -18) with severe cerebral palsy (GMFCS IV & V).

Results

Despite the relative equivalence between the two translations, some items required adaptations for the synthesized version. Certain modifications were necessary in the pre-final version to achieve idiomatic equivalence. The modifications were required to account for the socioeconomic and cultural levels of the target population.

Conclusion

The translation and cross-cultural adaptation of the CPCHILD^© questionnaire provides a Brazilian Portuguese equivalent to measure the HRQoL of children with severe developmental disabilities, with the potential to measure the benefits of various procedures that are indicated for these patients. This adaptation exhibited a satisfactory level of semantic equivalence between the Portuguese target and the original English source versions. The validity of the Brazilian version of the instrument must be established in the future by assessing its psychometric properties on Brazilian epidemiological samples.

Cerebral palsy--long-term medical, functional, educational, and psychosocial outcomes

Cerebral palsy, typically diagnosed in childhood, clearly continues into adulthood. This study describes the long-term medical, functional, educational, and psychosocial outcomes of people with cerebral palsy. Of the 203 people with cerebral palsy diagnosed and treated at the Child Development Center in Tel Aviv between 1975 and 1994, 163 (80%; age range 8-30 years, mean age 18.9 years, and median age 19 years) participated in a cross-sectional telephone survey. Half the respondents have chronic health problems: 78% report they experience gross motor disability, of whom 22% are wheelchair users; 30% to 50% need help in various activities of daily living; 35% have mental retardation; 79% completed 12 years or more of schooling; 78% live with their parents; 25% have served in the army; 23% have a driver's license; and 23% work in competitive employment. The large majority is involved in varied leisure activities and report a high level of life satisfaction.

Activity limitations in personal, domestic and vocational tasks: a study of adults with inborn and early acquired mobility disorders

PURPOSE

To compare activity limitations at the workplace with those in the home situation.

SUBJECTS AND METHODS

Sixty-nine subjects, 22-49 years of age, with inborn or early acquired mobility disorders and with experience of vocational employment were studied. They were interviewed to assess their level of dependence according to the Functional Independence Measure (FIM) and Instrumental Activity Measure (IAM) and in 22 vocation-related items. Rasch analysis was perfomed in order to assess the relative difficulty of the items. In the vocational items the subjects rated perceived difficulty on a 4-level scale. Satisfaction in one general and six domain-specific areas was rated on a 6-level scale.

RESULTS

Forty-six per cent of the subjects were dependent in one or several FIM items, 90% in IAM items and 38% in the vocation-related items. In 15 of these items great difficulty was reported by few subjects. Collapsing the 7-category scale for dependence to four categories gave the best Rasch model. Most of the IAM items were the hardest to manage without assistance. FIM social-cognitive and cognitive vocation-related items were the easiest items. Most subjects were satisfied in the general and domain-specific areas.

CONCLUSIONS

Activities related to household tasks and transportation demonstrated the highest level of dependence, whereas it was easier to acquire independence in most vocation-related tasks.

Dependence in daily activities and life satisfaction in adult subjects with cerebral palsy or spina bifida: A follow-up study

PURPOSE

To study dependence in daily activities in adults with congenital disorders living in the community by interviewing them with an interval of 5 years.

SUBJECTS AND METHODS

Thirty-one subjects (20 men, 11 women) aged 24-43 years at the second assessment. Twenty-two subjects had cerebral palsy, and nine had spina bifida. Interviews in the subjects' homes were conducted using Functional Independence Measure (FIM), Instrumental Activity Measure (IAM), and a questionnaire concerning life satisfaction. Rasch analysis was used for joint calibration of physical FIM- and IAM-items to obtain measure values (logits) for items and persons.

RESULTS

Most subjects were independent in FIM items, but usually dependent in IAM items, except Mobility outdoors and Simple meal. The level of dependence increased significantly between the two assessments for four self-care items in FIM, Stairs and all IAM items except Mobility outdoors and Cleaning. For 13 subjects the overall level of dependence increased significantly for self-care between the two assessments. Most subjects were satisfied in life in general, but satisfaction in self-care ADL decreased between the two assessments.

CONCLUSIONS

The increased dependence in daily activities demonstrated may reflect reduced capacity but also changes in preferences and interests as well as the social situation.

[Transition from childhood to adulthood and management of spasticity]

The authors report specific concerns on the transition to adulthood in cerebral palsy patients, with particular attention devoted to spasticity treatment follow-up.

Active citizens or passive recipients: how Australian young adults with cerebral palsy define citizenship

BACKGROUND

Citizenship participation by young adults has reciprocal benefits both for the individual and for society. This paper provides an insight into the ways young people with cerebral palsy (CP) perceive their citizenship experiences, and also examines factors which may influence citizenship participation for this group.

METHOD

Qualitative methodology was used to explore perceptions of citizenship experiences in young people with CP. Nine participants (aged 18-30 years), were interviewed using a semi-structured interview format.

RESULTS

Four themes emerged: (i) contribution, (ii) inclusion, (iii) equal opportunity, and (iv) a barrier-free context.

CONCLUSION

The nine participants indicated that they aspired to make a contribution to society, play an active role, be accepted by others, and live with dignity and respect, as well as pursue their dreams and passions.

Cerebral palsy

Cerebral palsy (CP) is the leading cause of childhood disability. This article reviews common presentations of CP and its possible causes. The management of common problems seen in affected children is discussed in a system-based approach. Many treatment options are available for CP, with varying degrees of evidence and acceptance. As individuals who have CP transition into adulthood, they face unique issues that are not well recognized in the medical community. This article briefly reviews the psychosocial impact of this chronic disease on individuals and their caregivers and family.

Determinants of functioning of adolescents and young adults with cerebral palsy

PURPOSE

To describe the level of functioning of adolescents and young adults with cerebral palsy (CP) and study determinants of their level of functioning.

METHOD

In the CP Transition study, adolescents and young adults aged 16-20 years, diagnosed with CP without severe learning disabilities (n =103) participated. In this group we assessed subject characteristics, i.e., age, type of CP, gross motor function (GMFCS), level of education as well as outcome measures on functioning in daily activities and social participation (Life Habits questionnaire, Vineland Adaptive Behavior Scale, Functional Independence Measure). Multivariate regression analyses were performed.

RESULTS

About 20-30% of the participants encountered restrictions in daily activities (mobility, self-care, nutrition) and social participation (taking responsibility, community living, leisure activities and employment). The GMFCS level, level of education, and age proved to be important determinants of functioning in daily activities and social participation, explaining 70% and 66% of the variance in outcome respectively.

CONCLUSION

A significant number of adolescents and young adults with CP without severe learning disabilities are restricted in daily activities and social participation. These problems are mainly attributable to restricted gross motor functioning, a low level of education and younger age.

A Long-term, epidemiological survey of outcome and adjustment of children with developmental disabilities

The medical, educational, and psychosocial outcomes of 3224 subjects (age range, 7-33 years; mean age, 20.06 years; SD, 5.74) diagnosed and treated in the Institute for Child Development in Tel Aviv between the years 1975 and 1994 were assessed by a telephone interview. Results indicate that only 9% of the subjects are seriously disabled, and 8% are mentally retarded. Over the years, subjects were referred to the Child Development Center at an increasingly younger age, probably reflecting greater professional and parental awareness of the importance of early intervention. The nature of interventions changed, so that physiotherapy, occupational therapy, and psychological guidance were more often provided. While more children were referred to special education at kindergarten, the percentage of those graduating from regular schools has increased. Most completed 12 years of schooling and successfully acquired full or partial matriculation certificates. As adults, most function independently; fulfill civic obligations, such as their army service; are fully employed; and express satisfaction with their life. These results suggest that children with developmental disabilities who receive early intervention are likely to be functionally independent and to be satisfied with their lives, although they continue to need medical services and require some government support. Further studies are essential to examine the correlation of specific risk factors and early interventions with outcome.

Educational career and predictors of type of education in young adults with spina bifida

Children with spina bifida (SB) often require special education. To date, little information is available about the educational career of these children. This study focuses on educational career and predictors of attending special education of young adults with SB, using a cross-sectional study including 178 young Dutch adults with SB aged from 16-25. The main outcome was attending regular versus special education. For searching predictive power we selected age, gender, type of SB, level of lesion, hydrocephalus (HC), number of surgical interventions, ambulation, continence and cognitive functioning. Chi-square tests and binary logistic regression were used in the data analysis. Participants with HC attended special primary education more often (59%) than participants without HC (17%). For those participants with HC, the necessity of special primary education was associated with below average intelligence (75% versus 35%), wheelchair dependence (82% versus 39%) and surgical interventions (74% versus 44%). Only half of the participants with HC followed regular secondary education, whereas for participants with SB without HC, the outcome in secondary education was similar to that of the general population (92%). Intelligence was the main predictor of attending special secondary education (odds 5.1:1), but HC (odds 4.3:1) and wheelchair dependence (odds 2.6:1) were also a significant. Other variables were not significant predictors of special secondary education.

A test of a centre's vision

The Thames Valley Children's Centre, a regional Children's Rehabilitation Centre, was determined to assess the extent to which its Vision ("Our Clients at Their Best") was being achieved. With a sample of 50 former clients, and utilizing a specially constructed survey tool based on the important life outcomes literature, they found that they were attaining their vision for a significant proportion of the participants. They also learned about the differing expectations of the role which the Centre should play.

Social integration of juvenile amputees: comparison with a general population

The objective was to assess the social integration of juvenile amputees according to marital status, schooling and occupation, and to compare it with the population of Asturias, Spain. A retrospective study was carried out of the juvenile amputees registered from 1976 to 1999 at the Prosthetics Unit of the Asturias Central Hospital (n=281 amputees). The proportion of single women amongst the amputees was greater than in the population of Asturias (p<0.05). Amongst the male amputees, relative to the general population, there was a larger proportion of the group with primary studies (p<0.001) and a smaller proportion with secondary studies (p<0.001). At the higher level (university) there were no differences, either in men or in women. As regards occupation, amongst the amputees a larger number was found who were retired or unemployed (p<0.05 and p<0.001). In conclusion, juvenile amputees do not show differences compared to the general population with regard to their attendance at a higher or university level of education. However, if their social integration is considered through occupation, male amputees show a greater proportion of unemployment, which is a clear reflection of their handicap.

Life care planning

Physicians may be asked to help plan long-term needs of patients with catastrophic injury. It is crucial to know the life expectancy and be intimately familiar with the needs of the disabled person for whom one is planning. This article uses two diagnostic groups as models to illustrate the process: one a spinal cord injured adult and the other a child with cerebral palsy and mental retardation. We provide examples of some of the specific types of needs for these two groups of individuals.

Functional level of young adults with cerebral palsy

OBJECTIVE

To acquire insight into the level of functioning of young adults with cerebral palsy (CP).

DESIGN

Descriptive cross-sectional study.

SETTING

Rehabilitation Centre Den Haag, The Netherlands.

METHOD

A structured questionnaire, including the Barthel Index was mailed to 134 young adults (aged 21-31 years) with cerebral palsy.

RESULTS

Eighty subjects responded (60%). Of these, 60 (75%) were largely or fully independent in activities of daily living, 72 (90%) moved independently indoors, 56 (70%) outdoors. In 67 (77.5%) of the group the level of communication was adequate for telephone conversation. Twenty-four (30%) lived with their parents, 10 (12.5%) with a partner and 26 (32.5%) lived alone. Almost half lived in an unadapted house. Forty-two (53%) completed some form of secondary education and 29 (36.3%) had paid employment.

CONCLUSION

Despite their considerable impairments, the large majority of this group of young adults with cerebral palsy are independent in activities of daily living, mobility and communication. Regarding the level of education, participation in paid employment and sports activities, however, young adults with CP are poorly integrated.

Success in life for older adolescents with cerebral palsy

In this article, the psychosocial themes emerging from an exploratory qualitative study are reported. Using a constant comparative method, the authors describe how older adolescents with cerebral palsy defined success in life and the factors they viewed as helping or hindering their success. Participants were 10 adolescents with cerebral palsy between 18 and 20 years of age who took part in a semistructured interview exploring their perceptions of success. For these adolescents, success meant being happy in life. Three key psychosocial factors were related to success in life: being believed in, believing in yourself, and being accepted by others (belonging). The findings are useful in guiding the design of services to meet the life needs of individuals with disabilities.

The costs of children with sickle cell anemia: preparing for managed care

PURPOSE

To anticipate the clinical challenges and financial risks facing physicians and managed care organizations who care for children with chronic illnesses, such as sickle cell anemia (SCA), under capitated managed care arrangements.

PATIENTS AND METHODS

A cross-sectional study based on claims data from the Washington State Medicaid Program (WSMP) and the Federal Employees Health Benefits Program (FEP). Expenditure patterns were compared for children 18 years of age or younger for whom a claim with a diagnosis of SCA was submitted and paid in the State of Washington during fiscal year 1993 (FY1993) or by the FEP during FY1992 to expenditure patterns for all children.

RESULTS

Children with SCA had mean expenditures 8.8 times the mean expenditures for all children in WSMP. There was wide variation in the annual expenditures among children with SCA; the most expensive 10% of children accounted for 56% of total expenditures. Ninety-seven percent of the expenditures were concentrated in four broad categories: 72% for inpatient care, 11% for outpatient care, 11% for physician payments, and 3% for prescription drugs. Examination of expenditure and utilization patterns for children with sickle cell anemia enrolled in the FEP yielded similar results.

CONCLUSIONS

Unless managed care organizations and capitated pediatricians receive payment rates that reflect the higher expected expenditures of caring for these children, access to and quality of care may suffer. Analyses of practice guidelines and utilization patterns suggest that newborn screening, regular access to specialty facilities, and comprehensive education programs are critical areas that are vulnerable to reductions under capitation.

Relations between family environment and adjustment outcomes in young adults with spina bifida

Thirty-two young adults with spina bifida completed a questionnaire (Family Environment Scale) assessing their perceptions of family social environment while growing up. Additionally, subjects responded to a structured interview addressing their current employment status, residential situation, level of community mobility, and extent of social activity. Multiple logistic regression analyses were used to assess the relation between family environment and adjustment as a young adult. With this limited sample, results indicated that perceived family environment explained variance in employment, community mobility, and social activity as an adult, even beyond that explained by lesion level and intelligence. Regression coefficients showed positive relations between perceived family encouragement of independence and achievement and young adult outcomes. In contrast, perceived moral/religious emphasis of the family and degree of family involvement with intellectual/cultural activities evidenced negative relations with the measures of young adult adjustment.

Cerebral palsy--the transition from youth to adulthood

Service provision for those with cerebral palsy (CP) becomes fragmented after adolescence. Young people with CP in two age groups, their carers and associates, were interviewed, and use of health and social services was investigated. Leisure activities were also compared with a matched control group of able-bodied young people. Use of health and social services decreased when the children with CP left school, thereby increasing the demands upon carers. Carers expressed anxieties about the provision of services, and frustration in obtaining information about help. Findings from the questionnaires showed the young people with CP in both age groups to be socially less active than the controls. Among the subjects, the older age group was socially less active than the younger age group. Communication is poor both between the agencies providing care and between the agencies and the young person or carer. There is a need to identify those with responsibility for coordinated-care planning for adolescents with CP.

Structure of a combination of Functional Independence Measure and Instrumental Activity Measure items in community-living persons: a study of individuals with cerebral palsy and spina bifida

OBJECTIVE

To analyze the structure of a combination of physical items from the Functional Independence Measure (FIM) and seven instrumental activity items using ratings of dependence and perceived difficulty.

DESIGN

Disability in terms of dependence and subject's perceived difficulty was studied in patients with cerebral palsy (CP) and spina bifida (SB). Rasch analysis was used to construct calibrated linear measure and to identify suitable models with respect to rating steps.

SETTING

Interviews were performed at home with patients from an outpatient university rehabilitation unit for young disabled persons.

PATIENTS

Fifty-three CP and 20 SB patients (including 5 with other early acquired spinal cord lesions), 20 to 39 years of age, participated and represented 62% and 80%, respectively, of available patients. All had fulfilled an elementary school program.

RESULTS

The best scoring model using Rasch analysis was achieved using 5 levels for dependence and 4 levels for perceived difficulty. Hierarchic orders for all items are presented. The FIM items Bowel and Bladder showed different characteristics in the two groups of patients, especially for perceived difficulty, and were excluded in the joint calibrations. There was close overall agreement between the ratings of dependence and perceived difficulty. Person measure values from the Rasch analyses were separated between wheelchair users and walkers.

CONCLUSION

The combination of physical items from FIM and instrumental activity measure (IAM) are useful for disability assessment in community-living persons and should be further studied in other impairment groups.

Une recension des écrits sur l'intégration au travail des jeunes adultes présentant une déficience

Le travail joue un rôle primordial dans la vie de tous les individus. Pourtant, les jeunes adultes atteints d'une déficience sont confrontés â plusieurs situations de handicap lorsqu'ils quittent le milieu scolaire pour accéder au milieu du travail. Dans la région de Québec, un certain nombre d'entre eux se retrouvent devant aucune possibilité, et ce, dès l'âge de vingt et un ans. Le présent article vise â recenser les principaux écrits portant sur l'intégration au travail des personnes présentant une déficience. Les thèmes suivants sont abordés: l'importance du travail dans la population en géénéral et chez les individus vivant avec une déficience, les facteurs influençant l'intégration au travail, les différents programmes favorisant l'accès au marché du travail et le rôle de l'ergothérapeute face au travail. À la fin du texte, différentes pistes de recherche dans ce domaine sont proposées.

The long-term effects of children's early-onset disability on marital relationships

To investigate the long-term effects of a child's chronic illness or severe physical or intellectual disability on parents and their marital relationship, the parents of 89 children, aged 14-17, years were interviewed. The parents returned a questionnaire and a social worker interviewed them. One-fifth of the respondents had experienced the child's disability as contributing positively to the marital relationship, 25% reported impairment in some areas of the marital relationship, while only 7% felt that they had drawn apart from each other. A higher level of occupational education, insecurity at onset, heavy daily demands for care of the child, unequal distribution of tasks between the spouses and a lack of time for leisure activities were found to be risk factors for impaired marital satisfaction. Adequate information, a realistic notion of the illness or disability and practical advice for everyday life seemed to be the protective factors for the marital relationship.

Schooling, employment, and idleness in young adults with serious physical health conditions: effects of age, disability status, and parental education

PURPOSE

Education, employment, and "idleness" in young adults with ongoing physical health conditions were examined in relation to parents' education and respondent's age and co-existing disabilities.

METHODS

Telephone interviews were conducted with 421 individuals aged 20-24 years randomly drawn from public health programs in two midwestern states. In addition to a chronic health condition, 18% of the sample also had mental retardation, 21% also had a physical disability (but no retardation), and 11% also had a learning disability (but no mental retardation or physical disability). Youth were considered "idle" if they were not in school, not employed, not married, and had no children.

RESULTS

Thirty-seven percent of the sample were enrolled in an educational program, and 48% were employed either part-time or full-time. Seventeen percent were both in school and employed, 50% were in school or employed, and 33% were neither in school nor working. Overall, 23% of the sample were idle. Youth with mental retardation were two to three times more likely to be in school compared to youth with a chronic physical condition alone. Youth with mental retardation and physical disabilities were less likely to be employed and more likely to be idle compared to youth with only a chronic condition. Parental education affected rates of schooling and employment. Compared to a general population sample of youth in the same states, youth with ongoing health problems were at higher risk for idleness.

CONCLUSIONS

Youth with chronic health conditions and either mental retardation or physical disabilities are at higher risk for idleness compared to youth with a chronic condition alone or to youth in general.

Long-term prognosis for children with shunted hydrocephalus

We reviewed the previous medical history and the social status of all patients of Oulu University Central Hospital who had had in the age range 16-26 years shunted hydrocephalus (HC) during childhood. Of 42 patients selected 7 had died and another 5 had been institutionalized for severe mental handicap. Shunts had been changed a total of 103 times in 29 patients still living. The most common reason for a reoperation was blockage. Half of the patients re-examined showed neurological abnormalities or epilepsy. Both the verbal and the nonverbal IQ of the patients remained weak to average. Even though the patients' medical prognosis was fair, their social maturation did not keep up with their physical abilities. One-third were receiving or had received vocational training, but only a few were working. Up to one-quarter of the patients with shunted HC were at home without any meaningful work activities.