Medical and social factors associated with cognitive outcome in individuals with myelomeningocele

Culturally-informed neuropsychological evaluations of patients with spina bifida: Application of the ECLECTIC framework to a complex pediatric medical condition

Objective: The pediatric patient populations in the United States are becoming increasingly diverse in culture. In addition to medical factors, a variety of sociocultural factors (including educational systems, language, immigration status, etc.) can impact a child's cognitive development, performance on traditional neuropsychological measures, provider interactions, differential diagnosis, and recommendations. A culturally-informed neuropsychological evaluation aims to understand the impact of sociocultural factors and integrate them into the assessment approach. Fujii's ECLECTIC framework (acronym for Education & Literacy, Culture/Acculturation, Language, Economic Issues, Communication Style, Testing Situation, Intelligence Conceptualization, and Context of Immigration) can be used to guide culturally-informed neuropsychological evaluations of children with complex medical conditions. Method: Using the ECLECTIC framework, this paper describes clinical considerations and offers practical solutions for providing culturally-informed pediatric neuropsychology evaluations. Four diverse patients with spina bifida are reviewed. Results: The case presentations highlight the application of the ECLECTIC framework within a medically complex pediatric patient population. Conclusions: Spina bifida is one example of a pediatric medical population in which both medical and sociocultural factors can impact cognitive development and the evaluation process. The ECLECTIC framework defines a variety of sociocultural factors that can influence cognitive development and multiple aspects of a pediatric neuropsychological evaluation. Pediatric neuropsychologists should use the ECLECTIC framework to provide culturally-informed evaluations for our increasingly diverse patient populations.

Assessment of Ventricular Size and Neurocognitive Outcomes in Children with Postnatal Closure of Myelomeningocele

OBJECTIVE

To assess if ventricular size before shunting is correlated with neurodevelopmental outcomes in children with postnatal myelomeningocele closure.

STUDY DESIGN

This retrospective review included children with postnatal surgical closure of myelomeningocele and neuropsychological testing between 2018 and 2023 at the University of California, San Francisco. Frontal-occipital horn ratio (FOHR) was measured immediately before shunt placement or on the first study that reported ventricular stability for nonshunted patients. The primary outcome was full scale IQ (FSIQ) on the Weschler Intelligence Scale. Secondary outcomes included indices of the Weschler scale, the Global Executive Composite from the Behavior Rating Inventory of Executive Function, and the general adaptive composite from the Adaptive Behavior Assessment Scale. Univariable and multivariable regression was used to determine if FOHR was correlated with neuropsychological scores.

RESULTS

Forty patients met the inclusion criteria; 26 (65%) had shunted hydrocephalus. Age at neuropsychological testing was 10.9 ± 0.6 years. FOHR was greater in the shunted group (0.64 vs 0.51; P < .001). There were no differences in neuropsychological results between shunted and nonshunted groups. On univariable analysis, greater FOHR was associated with lower FSIQ (P = .025) and lower Visual Spatial Index scores (P = .013), which remained significant on multivariable analysis after adjusting for gestational age at birth, lesion level, shunt status, and shunt revision status (P = .049 and P = .006, respectively). Separate analyses by shunt status revealed that these effects were driven by the shunted group.

CONCLUSIONS

Greater FOHR before shunting was correlated with lower FSIQ and the Visual Spatial Index scores on the Weschler Intelligence Scales. Larger studies are needed to explore further the relationship between ventricle size, hydrocephalus, and neurodevelopmental outcomes.

Activity level, functional health, and quality of life of children with myelomeningocele as perceived by parents

BACKGROUND

To provide the best health care for individuals with myelomeningocele (MM), clinicians and researchers need to understand their health and functional status as well as quality of life. The literature is mixed regarding the relationship between motor level and health-related quality of life (HRQOL) for these individuals.

QUESTIONS/PURPOSES

We compared the HRQOL of children with MM at the L2 and above and L3-5 motor level and to demonstrate how having a shunt, age, and body mass index affect HRQOL instruments for these two motor level groups.

METHODS

We recruited 50 patients with MM (24 male, 26 female) with a mean age of 11.5 years (range, 5-18 years) and motor levels of L2 and above (n = 15) and L3-5 (n = 35). Guardians were interviewed using standardized functional and HRQOL tools (the Pediatric Quality of Life and the Pediatric Outcomes Data Collection Instrument); height, weight, presence of a shunt, ambulatory level, and body mass index were also collected.

RESULTS

We found a decreased HRQOL score for children with MM in the L2 and above motor level compared with those in the L3-5 motor level group. HRQOL had no correlation with body mass index and limited correlation with age. The presence of a shunt correlated with a decreased HRQOL.

CONCLUSIONS

Children with MM had deficits in HRQOL and that was associated with neurologic level and presence of a shunt.

Adolescent predictors of emerging adulthood milestones in youth with spina bifida

OBJECTIVE

To examine the predictive utility of demographic (illness status and SES), individual (neurocognitive functioning and intrinsic motivation), and family-based (parental intrusiveness) factors during adolescence on the achievement of emerging adulthood milestones in youth with and without spina bifida (SB).

METHODS

Questionnaire and observational data were collected from 14/15-year-old adolescents with SB, typically developing peers, mothers, and teachers. Emerging adulthood milestones (i.e., leaving home, attending college, employment, romantic relationship experience, and number of friendships) were assessed at ages 18/19 years in the full sample and subset of youth who graduated from high school.

RESULTS

Typically, developing youth were more likely to achieve milestones compared to youth with SB in the full sample but not when only high school graduates were compared. Executive function, SES, intrinsic motivation, and parental intrusiveness emerged as significant predictors for particular milestones.

CONCLUSIONS

Interventions targeting executive function, intrinsic motivation, and parenting behavior may facilitate achievement of emerging adulthood milestones.

Paternal correlates of cognitive and behavioral functioning in children with myelomeningocele

This study examined paternal correlates of the cognitive and behavioral functioning of children with myelomeningocele, when controlling for maternal and biological/child correlates as possible sources of variance. Participants were 48 parent dyads of children with myelomeningocele (21 males, 27 females) between the ages of 4 and 12 years (mean 8y, 2mo, SD 2y 3mo). Lesion levels of participants ranged from the thoracic to sacral (thoracic-L3: n=15; L4-L5: n=15; sacral or lipomeningocele: n=18), of whom 38 had been shunted for hydrocephalus. Half of the participants (n=24) were community ambulators. Potential predictors of cognitive and behavioral functioning included paternal and maternal parenting stress, as assessed by the Parenting Stress Index - Short Form paternal, and maternal perceptions of support and resources, as assessed by the Family Resource Scale and the Family Support Scale, and child medical severity. Paternal variables significantly correlated with behavioral functioning but not with cognitive functioning. Regression analyses revealed that paternal personal distress and maternal perceived adequacy of social support accounted for significant variance in overall child behavioral functioning. Only child medical severity and annual household income explained significant variance in overall child cognitive functioning. These findings add to the growing body of theory and research documenting that fathers make unique and significant contributions to child adjustment in children with myelomeningocele. Both fathers and mothers need to be considered in interventions supporting development and adjustment of children with myelomeningocele and their families.

Factors of biological risk and reserve associated with executive behaviors in children and adolescents with spina bifida myelomeningocele

This study examined differences between healthy children (n = 35) and those with spina bifida myelomeningocele (SBM; n = 42) on the Behavior Rating Inventory of Executive Function (BRIEF), a measure of executive function behaviors. It also examined whether aspects of biological risk associated with SBM and reserve factors within the family could account for variability in BRIEF scores for children and adolescents with SBM. Patients in the SBM group exhibited more problems than both published norms and a local comparison group of healthy children in metacognition but not behavior regulation. Behavior regulation problems in children with SBM were predicted by parent psychological distress. More shunt-related surgeries and history of seizures predicted poorer metacognitive abilities.

Myelomeningocele: a Brazilian University Hospital experience

We analyzed 31 children with myelomeningocele born between July 1990 and July 2000. Follow-up median was 24 months (6-68 months). Only 2 mothers had a known etiologic factor (diabetes mellitus). Twelve had the correct prenatal diagnosis. All children were born at term; 23 by cesarean; 13 had rupture of the membrane. Surgical correction had a 4 days median (1 to 44 days). Lumbosacral lesions were the most frequent (46%). Thirty patients were hydrocephalic, shunt was placed in 27. Meningitis was 4 times more frequent in shunted patients. Seven became epileptic (19.4%). Denver II test showed significant delay in gross motor development. Neurogenic bladder was diagnosed in 12 patients. Congenital clubfoot was the main orthopedic malformation (53%). Six infants died. Nowadays, 17 patients are being followed. A multidisciplinary approach probably helps for a better quality of life.

Secondary impairments in young adults with spina bifida

The aim of this study was to examine the prevalence of secondary impairments in young adults with spina bifida and to relate the prevalence to the type of spina bifida and the level of lesion. This cross-sectional study is part of the ASPINE (Adolescents with Spina Bifida in the Netherlands) study. Data were collected on medical history, hydrocephalus (shunt: yes/no), neurological level of lesion (International Standards for Neurological and Functional Classification of Spinal Cord Injury), visual acuity (Landolt rings), spasticity (Modified Ashworth Scale), contractures (range of motion), scoliosis (deviation from perpendicular), ambulation (Hoffer criteria), pressure sores and blood pressure (physical examination), epilepsy, pain, incontinence and sexuality (questionnaire), and cognitive functioning (Raven Standard Progressive Matrices). In total, 179 patients with spina bifida participated (41% male, age range 16 to 25 years, mean 20 years 9 months, SD 2 years 11 months). These were 37 patients with spina bifida occulta, 119 patients with spina bifida aperta and hydrocephalus (AHC+) and 23 patients with spina bifida aperta without hydrocephalus (AHC-). Of our patient group, 73 had a high-level lesion (L2 and above), 68 a mid-level lesion (L3 to L5), and 38 a low-level lesion (S1 and below). Both subdivisions were strongly related with patients with higher lesions more often having hydrocephalus. Most secondary impairments were found for patients with AHC+, and patients with AHC- were mostly comparable to patients with spina bifida occulta. According to level of lesion, most medical problems were found in the high-level lesion group. However, all subgroups suffered from health problems.

Neuropsychological findings in congenital and acquired childhood hydrocephalus

Hydrocephalus is an increase in cerebrospinal fluid volume that can be caused by a variety of etiologies. The most common connatal and acquired causes of hydrocephalus are spina bifida, aqueduct stenosis, and preterm low birthweight infants with ventricular hemorrhage. In general, the literature suggests mild neuropsychological deficits associated with hydrocephalus, which are predominant in visuospatial and motor functions, and other nonlanguage skills. Although the precise nature of the neuropsychological deficits in hydrocephalus are not completely known, several factors such as etiology, raised intracranial pressure, ventricular size, and changes in gray and white matter tissue composition as well as shunt treatment complications have been shown to influence cognition. In fact, the presence of complications and other brain abnormalities in addition to hydrocephalus such as infections, trauma, intraventricular hemorrhage, low birthweight, and asphyxia are important determinants of the ultimate cognitive status, placing the child at a high risk of cognitive impairment.