Harnessing neuroplasticity to improve motor performance in infants with cerebral palsy: a study protocol for the GAME randomised controlled trial

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability of childhood worldwide. Historically the diagnosis was made between 12 and 24 months, meaning data about effective early interventions to improve motor outcomes are scant. In high-income countries, two in three children will walk. This evaluator-blinded randomised controlled trial will investigate the efficacy of an early and sustained Goals-Activity-Motor Enrichment approach to improve motor and cognitive skills in infants with suspected or confirmed CP.

METHODS AND ANALYSIS

Participants will be recruited from neonatal intensive care units and the community in Australia across four states. To be eligible for inclusion infants will be aged 3-6.5 months corrected for prematurity and have a diagnosis of CP or 'high risk of CP' according to the International Clinical Practice Guideline criteria. Eligible participants whose caregivers consent will be randomly allocated to receive usual care or weekly sessions at home from a GAME-trained study physiotherapist or occupational therapist, paired with a daily home programme, until age 2. The study requires 150 participants per group to detect a 0.5 SD difference in motor skills at 2 years of age, measured by the Peabody Developmental Motor Scales-2. Secondary outcomes include gross motor function, cognition, functional independence, social-emotional development and quality of life. A within-trial economic evaluation is also planned.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Sydney Children's Hospital Network Human Ethics Committee in April 2017 (ref number HREC/17/SCHN/37). Outcomes will be disseminated through peer-reviewed journal publications, presentations at international conferences and consumer websites.

TRIAL REGISTRATION NUMBER

ACTRN12617000006347.

Factors associated with early childhood development in municipalities of Ceará, Brazil: a hierarchical model of contexts, environments, and nurturing care domains in a cross-sectional study

Background

This study aims to identify the contexts, environments, and nurturing care predictors that determine whether a child is developmentally on track in Ceará, Brazil.

Methods

We analysed data from a cross-sectional study conducted with caregivers of 6,447 children aged 0-59 months during a vaccination campaign in Ceará in October 2019. The validated Child Development Assessment Questionnaire was used to assess early childhood development (ECD) and children with a z-score ≥ -1 SD were considered developmentally on track. We conducted logistic regression models to understand the effects of contexts, environments, and nurturing care domains on ECD.

Findings

Children in the early years (< 36 months) were more likely to meet the ECD milestones if they were not born with low birth weight (AOR: 0·64; 95% CI: 0·42-0·97), were exposed to manufactured toys in their house (2·68; 1·97-3·66), their heads of household were employed (1·61; 1·16-2·23), and their caregivers had read the Child Health Handbook (1·42; 1·13-1·77) and engaged them in stimulating activities (1·71; 1·26-2·32). Children aged 36-59 months were more likely to meet the ECD milestones if they were breastfed (never: ref. / < 3 months: 3·72; 1·91-7·26 / 3-5 months: 3·21; 1·74-5·93 / 6-11 months: 3·73; 1·95-7·16 / ≥ 12 months: 3·89; 2·25-6·72), had books at home (0: ref / 1-3: 1·71; 1·22-2·40 / 4-6: 2·24; 1·27-3·94 / 7+: 2·71; 1·05-7·00), and their caregivers received information about ECD (1·49; 1·11-2·01) and engaged them in stimulating activities (1·80; 1·27-2·56). Children aged 36-59 months were less likely to meet developmental milestones if they watched TV or used tablets/smartphones for more than two hours per day (0·61; 0·44-0·84), played with household objects (0·62; 0·41-0·92), participated in governmental early childhood programmes aimed at vulnerable families (0·62; 0·45-0·86), had families that participated in income transfer programmes (0·68; 0·47-0·99) (families living in poverty or extreme poverty), and their caregivers considered slapping (0·67; 0·48-0·94) a necessary disciplinary method.

Interpretation

Having favourable socioeconomic conditions, breastfeeding, the absence of harsh discipline, caregivers who provide responsive care, and the provision of opportunities for early learning are the key factors that increase the likelihood of a child achieving their full developmental potential in Ceará, Brazil.

Funding

This study was supported by the Maria Cecília Souto Vidigal Foundation (F0245), Brazil. The funder had no role in the design, analysis, or writing of this article.

Intelligence Can Be Used to Make a More Equitable Society but Only When Properly Defined and Applied

In the US, undeniable evidence shows that socioeconomic inequities explain a high proportion of individual differences in school achievement. Although not all countries show this same effect due to socioeconomic status, it is consistently found that social inequities lead to achievement gaps. These achievement gaps then manifest into trajectories that set some individuals on a path of lower incomes, poorer health and higher mortality, lower wellbeing, and other poor adult outcomes. Like James Flynn so handily reminded the scientific literature that achievement gaps are explainable by environmental factors, the inequities we see around the world are based on environments some children are exposed to. In his work, Flynn stated his belief that the suppression of scientific work on intelligence would continue to lead to social inequities. We wish to take this idea and move it forward. We believe that the scientific construct of intelligence plays a key role in helping create a more equitable society through science. We also believe that the poor perception of intelligence, rooted in historical realities, means that it will continue to be misunderstood, feared, and misused, limiting how effective it could be in helping to close gaps in achievement and in creating a more equitable society.

Heterogeneity in the conceptions of intelligence of university teaching staff

Using Cultural Psychology as a framework, this research project aims to measure and analyze the heterogeneity of university teachers’ conceptions of intelligence. To this end, we have developed a new method of analysis: Heterogeneity by Contradiction Analysis (HCA). We conducted semi-structured interviews with 20 university teachers, presenting them with a series of short cases or vignettes depicting different facets of intelligence. Based on the discourse elicited, we first created a category system. Then, we pre-defined a series of possible contradictions among pairs of categories. Using these pre-defined contradictions, a systematic sampling of theoretical contradictions could be obtained from the discourse. Finally, a researcher reviewed these sampled contradictions in order to find and code real contradictions, which were later analyzed. 85% of all participants presented at least some heterogeneity in their discourse by expressing an idea and its opposite in different parts of the interview. The content of the discourse and its context are analyzed in the expression of heterogeneity, which yields future implications for research, intervention, and teacher training.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy

PURPOSE OF REVIEW

Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.

RECENT FINDINGS

Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

Socioeconomic background, nonverbal IQ and school absence affects the development of vocabulary and reading comprehension in children living in severe poverty

Few studies have examined how socioeconomic status (SES) affects two essential parts of human development, namely vocabulary and reading comprehension, in children facing severe poverty. The Roma population is the largest minority group in Europe, the majority of whom live in severe poverty. This study compared the development of 322 Roma children with the development of 178 non-Roma children, between the ages of 7 and 10 years, living in Romania. The Roma children had poorer initial vocabulary and reading comprehension skills as well as slower growth rates for both compared to the non-Roma children. Importantly, SES had a direct influence on growth in both reading comprehension and vocabulary. The effect of SES was partly mediated by school absence and nonverbal IQ. This is a powerful finding since it suggests that poverty may have detrimental effects not only on reading but also on the development of verbal abilities.

High-risk follow-up: Early intervention and rehabilitation

Early detection of childhood disability is possible using clinically available tools and procedures. Early detection of disability enables early intervention that maximizes the child's outcome, prevents the onset of complications, and supports parents. In this chapter, first we summarize the best-available tools for accurately predicting major childhood disabilities early, including autism spectrum disorder, cerebral palsy, developmental coordination disorder, fetal alcohol spectrum disorder, intellectual disability, hearing impairment, and visual impairment. Second, we provide an overview of the preclinical and clinical evidence for inducing neuroplasticity following brain injury. Third, we describe and appraise the evidence base for: (a) training-based interventions that induce neuroplasticity, (b) rehabilitation interventions not focused on inducing neuroplasticity, (c) complementary and alternative interventions, (d) environmental enrichment interventions in the neonatal intensive care and community settings, and (e) parent-child interaction interventions in the neonatal intensive care and community settings. Fourth, we explore emergent treatment options at clinical trial, designed to induce brain repair following injury. In conclusion, early diagnosis enables early intervention, which improves child and parent outcomes. We now know which interventions provide the biggest gains and the information can be used to help inform parental decision making when designing treatment plans for their children.

Neural Mechanisms and Children’s Intellectual Development

Human psychometric intelligence can predict a number of important social and academic outcomes. Substantial parts of the variances of human intelligence and the brain volume supporting those abilities are explained by environmental factors, and during childhood, human brains have higher plasticity and also 60% of variance of intelligence that is explained by environmental factors. Here, we review the representative environmental factors known to affect human intellectual development during each developmental stage. We describe what is (and what is not) being investigated to determine how these factors affect human brain development through analyses of volumetrical and cortical structures. In conclusion, environmental factors that affect children’s intellectual development lead to three patterns of brain structural change. The first is global change in the brain structure, observed more often in the earlier phase of development. The second is structural changes concentrated in the medial prefrontal and adjacent areas and medial temporal areas, which are likely to be induced by stress in many cases. The third is sporadic region-specific change, likely to be primarily caused by use-dependent plasticity of the areas that is often observed in the later phase of development. These changes may underlie the alterations in children’s intellectual development that is induced by environmental factors.

Future Cognitive Ability: US IQ Prediction until 2060 Based on NAEP

The US National Assessment of Educational Progress (NAEP) measures cognitive competences in reading and mathematics of US students (last 2012 survey N = 50,000). The long-term development based on results from 1971 to 2012 allows a prediction of future cognitive trends. For predicting US averages also demographic trends have to be considered. The largest groups' (White) average of 1978/80 was set at M = 100 and SD = 15 and was used as a benchmark. Based on two past NAEP development periods for 17-year-old students, 1978/80 to 2012 (more optimistic) and 1992 to 2012 (more pessimistic), and demographic projections from the US Census Bureau, cognitive trends until 2060 for the entire age cohort and ethnic groups were estimated. Estimated population averages for 2060 are 103 (optimistic) or 102 (pessimistic). The average rise per decade is dec = 0.76 or 0.45 IQ points. White-Black and White-Hispanic gaps are declining by half, Asian-White gaps treble. The catch-up of minorities (their faster ability growth) contributes around 2 IQ to the general rise of 3 IQ; however, their larger demographic increase reduces the general rise at about the similar amount (-1.4 IQ). Because minorities with faster ability growth also rise in their population proportion the interactive term is positive (around 1 IQ). Consequences for economic and societal development are discussed.

What counts as evidence for working memory training? Problems with correlated gains and dichotomization

The question of whether computerized cognitive training leads to generalized improvements of intellectual abilities has been a popular, yet contentious, topic within both the psychological and neurocognitive literatures. Evidence for the effective transfer of cognitive training to nontrained measures of cognitive abilities is mixed, with some studies showing apparent successful transfer, while others have failed to obtain this effect. At the same time, several authors have made claims about both successful and unsuccessful transfer effects on the basis of a form of responder analysis, an analysis technique that shows that those who gain the most on training show the greatest gains on transfer tasks. Through a series of Monte Carlo experiments and mathematical analyses, we demonstrate that the apparent transfer effects observed through responder analysis are illusory and are independent of the effectiveness of cognitive training. We argue that responder analysis can be used neither to support nor to refute hypotheses related to whether cognitive training is a useful intervention to obtain generalized cognitive benefits. We end by discussing several proposed alternative analysis techniques that incorporate training gain scores and argue that none of these methods are appropriate for testing hypotheses regarding the effectiveness of cognitive training.

COGNITIVE ABILITY OF PRESCHOOL, PRIMARY AND SECONDARY SCHOOL CHILDREN IN COSTA RICA

Cognitive abilities of children in Costa Rica and Austria were compared using three age groups (N=385/366). Cognitive ability tests (mental speed, culture reduced/fluid intelligence, literacy/crystallized intelligence) were applied that differed in the extent to which they refer to school-related knowledge. Preschool children (kindergarten, 5–6 years old,NCR=80,NAu=51) were assessed with the Coloured Progressive Matrices (CPM), primary school children (4th grade, 9–11 years old,NCR=71,NAu=71) with ZVT (a trail-making test), Standard Progressive Matrices (SPM) and items from PIRLS-Reading and TIMSS-Mathematics, and secondary school students (15–16 years old,NCR=48,NAu=48) with ZVT, Advanced Progressive Matrices (APM) and items from PISA-Reading and PISA-Mathematics. Additionally, parents and pupils were given questionnaires covering family characteristics and instruction. Average cognitive abilities were higher in Austria (Greenwich-IQMCR=87 andMAu=99,dIQ=12 points) and differences were smaller in preschool than in secondary school (dIQ=7 vs 20 points). Differences in crystallized intelligence were larger than in fluid intelligence (mental speed:dIQ=12, Raven:dIQ=10, student achievement tests:dIQ=17 IQ points). Differences were larger in comparisons at the level ofg-factors. Austrian children were also taller (6.80 cm,d=1.07 SD), but had lower body mass index (BMICR=19.35 vs BMIAu=17.59,d=−0.89 SD). Different causal hypotheses explaining these differences are compared.

Developmental Science and Preventive Interventions for Children at Environmental Risk

The current status of preventive intervention programs for young children at environmental risk designed to reduce the school readiness gap is examined in the context of developmental science. A review of program effectiveness suggests that future progress may depend upon committing to a specific developmental approach consistent with the knowledge base of developmental science and establishing a generally agreed upon and unambiguous framework, set of goals, and associated mechanisms. The Developmental Systems Approach is suggested as one model that is consistent with developmental and existing intervention science, supporting an emphasis on program continuity, relationships, and comprehensiveness. A long-term plan for community-based systems development is presented.