Mental Health Considerations With Cerebral Palsy

Original Editor -Ewa Jaraczewska based on the course by Pradeep Gunarathne

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

Cerebral palsy (CP) is a lifelong condition that affects motor function, communication, and daily living activities. While the physical aspects of cerebral palsy are widely recognised, its impact on mental health can go unnoticed.[1] Individuals with cerebral palsy are at an increased risk of mental health conditions, such as anxiety,[2] depression and post-traumatic stress disorder (PTSD). Factors that can contribute to mental health issues in individuals with cerebral palsy include biological and environmental factors, as well as the progression of musculoskeletal impairments and changes in psychological and social development.[3]

Untreated mental health issues can affect participation in social activities and academic or work performance. Screening for mental health conditions should, therefore, be an integral part of the assessment of children with cerebral palsy.[4] A multidisciplinary approach to evidence-based treatments and rehabilitation programmes with a life-span perspective for mental health issues in individuals with cerebral palsy is essential.[3] This article discusses the impact of mental health issues on individuals with cerebral palsy and introduces evidence-based interventions to help address these issues.

Definitions[edit | edit source]

Cerebral Palsy[edit | edit source]

There is no universally accepted definition of cerebral palsy, and there is no single method to classify impairments associated with cerebral palsy.[5] The following definition was accepted in 2005. It is a revised version of Bax's definition from 1964:

"Cerebral palsy describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, by epilepsy and by secondary musculoskeletal problems".[5]

Mental Health[edit | edit source]

Mental health is "a state of well-being in which the individual realises his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community.”[6]

"Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognise, express and modulate one's own emotions, as well as empathise with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium".[7]

Mental Health Disorders[edit | edit source]

"A mental disorder is a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour. It is usually associated with distress or impairment in important areas of functioning".[8]

Examples of childhood and adolescent mental health disorders include:

Epidemiology[edit | edit source]

  • Autism spectrum disorders are 2.5 times more prevalent in children with cerebral palsy compared to a control group[4]
  • Anxiety or affective disorders are 2.7 times more prevalent in children with cerebral palsy[4]; girls are twice as likely to have anxiety[2]
  • Children with cerebral are twice as likely to have ADHD[4]
  • There is a five-fold increase in psychiatric disorders in children with cerebral palsy[9]
  • There is a significant increase in emotional disorders in children with cerebral palsy aged seven to eleven years[9]
  • Long-term disability in adolescents highly correlates with depressive and anxiety symptoms[10]
  • Adolescents with disability have lower scores for self-worth, appearance satisfaction, academic competence and social acceptance when compared with adolescents without disability[10]
  • The prevalence of mental health problems remains high throughout childhood and into adulthood
  • There is a considerable overlap of mental health symptoms and psychiatric disorders in children with cerebral palsy[11]

Factors Leading to Mental Health Issues in Cerebral Palsy[edit | edit source]

Physical Limitations[edit | edit source]

Emotional distress, anxiety, and depression in children and adolescents with cerebral palsy can develop as a result of physical limitations.[1] Physical limitations can limit physical activity, which elevates the risk of depression.[12] Physical disability has also been associated with subclinical mental health problems, such as symptoms of depression and anxiety.[13]

Factors that can limit or negatively impact participation in physical activity in children with cerebral palsy include:

  • neuromuscular dysfunction, muscle weakness, and elevated demand for oxygen during physical activities[14]
  • frequent hospitalisations and surgeries

Moreover, children with cerebral palsy can experience a significant decline in mobility as they progress to adulthood.

Pain[edit | edit source]

Pain experienced by children with cerebral palsy can increase anxiety and depressive disorders:

  • musculoskeletal pain is associated with self-reported mental health problems and lower health-related quality of life (HRQL)[15] - assessment of HRQL should, therefore, become an integral part of a clinical visit as it may capture pain and mental health problems[15]
  • chronic pain caused by muscle spasticity, joint contracture, and other related issues can significantly impact a child's mental well-being and lead to anxiety, depression, and sleep disturbances[1]
  • pain negatively affects physical activity and sleep in the paediatric population
  • a lower quality of life, behaviour and emotional problems and other mental health disorders in children with cerebral palsy have been associated with pain[16]
  • pain management as a clinical priority has been proposed as it may have a "substantial impact on the physical and mental health profiles" of children with cerebral palsy.[14] Pain management might include pharmacological treatment, psychological interventions, physiotherapy, massage, thermotherapy, hydrotherapy, education, relaxation/breathing, and exercises.[17][18][19]

Communication[edit | edit source]

Communication problems can be defined as "having no speech, difficulties with pronunciation, or slow speech"[9]:

  • around 55% of children with cerebral palsy have difficulty engaging in one-on-one conversation.[20] These difficulties can include:
    • dysarthria: "results from abnormalities in speed, strength, accuracy, range, tone, or duration required for speech control".[21] Individuals present with reduced speech intelligibility (occurs in 21% to 36% of children with cerebral palsy)[22]
    • inability to speak (occurs in 19% to 32% of children with cerebral palsy)[23]
  • difficulty in expressing emotions and needs due to communication challenges can lead to frustration and emotional distress for children with cerebral palsy[1]
  • communication problems can limit participation and enjoyment in social and recreational activities for individuals with cerebral palsy, which can profoundly impact quality of life and self-concept[24]
  • speech difficulties may prevent children with cerebral palsy from verbally expressing the problems they are experiencing. In addition, around 50% of children with cerebral palsy have a learning disability, and this may overshadow or mask their mental health issues[25]

Participation[edit | edit source]

The ICF–CY defines participation as "involvement in life situations."[26] It is an important health outcome.[27] Key "life situations" include school life, family and peer group activities, and engagement in work and leisure.[27]

Participation and mental health in children and adolescents with cerebral palsy are linked. The examples below demonstrate this link:

  • children with cerebral palsy aged 8 to 12 years participate less in everyday activities than children in the "general populations"[27]
  • children with cerebral palsy have low social participation and relationships, which may contribute to poor mental health[27]
  • adolescents with cerebral palsy tend to engage less often in an organised sport
  • social factors, such as difficulty with friendships and bully victimisation, are associated with a higher occurrence of mental health disorders in children with cerebral palsy[28]

Sexual Development[edit | edit source]

According to the World Health Organization, sexuality is a “central aspect of being human”,[29] and sexual health is “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.”[29] Dating and sex are part of peer and social relationships. Any delay in dating behaviours and physical and emotional difficulties with sex negatively affect peer and social relationships for adolescents with cerebral palsy.[30]

You might like to watch this video to hear Natasha talk about her life with cerebral palsy and her mental health:

[31]

Signs and Symptoms of Mental Health Problems in Cerebral Palsy[edit | edit source]

Common signs of mental health problems in children and adolescents with cerebral palsy include changes in behaviour, such as increased irritability, withdrawal from social interactions, excessive worry or fear, difficulty concentrating, changes in eating or sleeping patterns, loss of interest in activities they once enjoyed, and regression in communication skills.[1]

Signs to watch for when suspecting depression, anxiety, and fear in children with cerebral palsy are as follows:[1]

Depression:

  • persistent sadness
  • lack of interest in activities
  • changes in appetite and weight
  • feelings of hopelessness

Anxiety:

  • excessive worry
  • restlessness
  • muscle tension
  • avoidance of situations that trigger anxiety

Fear:

  • withdrawal
  • panic attacks
  • regression in developmental milestones

Mental Health Problems in Parents of Children with Cerebral Palsy[edit | edit source]

Parents and caregivers may experience mental health problems themselves as they navigate the challenges of raising a child with cerebral palsy. Depression and anxiety are more frequently occurring in parents of children with cerebral palsy when compared with parents of children without cerebral palsy or other conditions.[32]

Risk Factors[edit | edit source]

The following risk factors for mental health problems in parents of children with cerebral palsy have been identified:[33]

  • level of independence in the child's motor functioning - the severity of motor functioning impairments is positively linked to parental mental health
  • poor parental coping strategies
  • low parental self-esteem
  • high caregiving burden
  • low parental social support
  • parental dissatisfaction with disclosure of diagnosis
  • clinical, community and social factors in the early to middle childhood period

The challenges of being a parent of a child with cerebral palsy are social and psychoemotional.[32] They include daily care challenges (having additional parenting tasks like helping with activities of daily living and mobility, family management, and comprehension of children’s functionality), internal challenges (grief related to the diagnosis and an adjustment in parental expectations, mental health issues, and achievements), and social challenges (being scrutinised as a parent of a child with a disability, lack of autonomy and not being able to fulfil professional goals).[32]

Recognising these challenges and offering resources and support can improve the overall mental health of the family unit.[1]

Assessment[edit | edit source]

Mental health problems in children with cerebral palsy should be identified and treated as early as possible. Routine care of a child with cerebral palsy should focus equally on the assessment of motor impairment and mental health.[34] There is no one effective tool for identifying the presence of mental health problems in children or young people with cerebral palsy, but the following tools have been identified in various studies:

  • Child Health Questionnaire (CHQ)[35]
  • Strengths and Difficulties Questionnaire (SDQ): a brief screening questionnaire for mental health problems. The 25-item tool includes versions for self-report, parent report and teacher report.[36] However, it has been found that the SDQ identified less than 50% of individuals with specific phobias, separation anxiety and eating disorders.[37]
  • Screen for Child Anxiety Related Disorders (SCARED) is a 41-item questionnaire used to screen for anxiety disorders.[2]

Multidisciplinary Treatment Approach[edit | edit source]

Mental health disorders in children and adolescents with cerebral palsy cannot be underestimated and must be identified, as they can hinder a child's community integration. A multidisciplinary team of experts should take a holistic approach to assess and care for these individuals:

  • the most comprehensive approach can be provided in the child's school because of its natural, inclusive setting: it is a "familiar meeting place for most children, providing a more accessible and comfortable site for students to receive mental health services than hospital or community mental health settings."[38]
  • the specialised team addressing mental health problems in children with cerebral palsy should include school counsellors and psychologists, supported by a speech-language pathologist/therapist, educational therapist, occupational therapist and physiotherapist / physical therapist
  • children with cerebral palsy are often the target of bullying. It is important to recognise red flags indicating the presence of harassment and address these problems early on[39]
  • preventative strategies which address mental and physical health outcomes as a child transitions to young adulthood can help diminish the impact of social and psychological factors on health and well-being during times of development[3]

Please consider the following recommendations:[1]

  • use simple language tailored to the individual's comprehension level
  • incorporate non-verbal cues such as gestures, facial expressions, and augmentative communication devices to enhance communication and help children express their thoughts and feelings
  • use active listening to ensure the child feels heard and understood - take time to listen attentively and respond empathetically to help foster a sense of trust and rapport
  • incorporate pain management strategies into treatment plans - these can significantly improve the mental well-being of children with cerebral palsy, leading to reduced anxiety, improved sleep patterns, and enhanced overall quality of life
  • offer emotional support for individuals with cerebral palsy and their families

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Gunarathne P. Mental Health Considerations With Cerebral Palsy Course. Plus, 2024.
  2. ↑ 2.0 2.1 2.2 McMahon J, Harvey A, Reid SM, May T, Antolovich G. Anxiety in children and adolescents with cerebral palsy. J Paediatr Child Health. 2020 Aug;56(8):1194-1200.
  3. ↑ 3.0 3.1 3.2 Sienko SE. An exploratory study investigating the multidimensional factors impacting the health and well-being of young adults with cerebral palsy. Disabil Rehabil. 2018 Mar;40(6):660-666.
  4. ↑ 4.0 4.1 4.2 4.3 Rackauskaite G, Bilenberg N, Uldall P, Bech BH, Østergaard J. Prevalence of mental disorders in children and adolescents with cerebral palsy: Danish nationwide follow-up study. Eur J Paediatr Neurol. 2020 Jul;27:98-103.
  5. ↑ 5.0 5.1 The Definition and Classification of Cerebral Palsy. Dev Med Child Neurol. 2007 Feb;49(s109):1-44.
  6. ↑ World Health Organization. Promoting mental health: concepts, emerging evidence, practice (Summary Report) Geneva: World Health Organization; 2004.
  7. ↑ Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World Psychiatry. 2015 Jun;14(2):231-3.
  8. ↑ Mental disorders. World Health Organization 2022. Available from https://www.who.int/news-room/fact-sheets/detail/mental-disorders [last access 23.12.2023]
  9. ↑ 9.0 9.1 9.2 Bjorgaas HM, Elgen IB, Hysing M. Trajectories of psychiatric disorders in a cohort of children with cerebral palsy across four years. Disabil Health J. 2021 Jan;14(1):100992.
  10. ↑ 10.0 10.1 Helseth S, Abebe DS, Andenæs R. Mental health problems among individuals with persistent health challenges from adolescence to young adulthood: a population-based longitudinal study in Norway. BMC Public Health. 2016 Sep 15;16:983.
  11. ↑ Bjorgaas HM, Elgen I, Boe T, Hysing M. Mental health in children with cerebral palsy: does screening capture the complexity? ScientificWorldJournal. 2013 Apr 3;2013:468402.
  12. ↑ Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. Am J Prev Med 2013; 45: 649–57.
  13. ↑ Lal S, Tremblay S, Starcevic D, Mauger-Lavigne M, Anaby D. Mental health problems among adolescents and young adults with childhood-onset physical disabilities: A scoping review. Front Rehabil Sci. 2022 Sep 6;3:904586.
  14. ↑ 14.0 14.1 Whitney DG, Warschausky SA, Peterson MD. Mental health disorders and physical risk factors in children with cerebral palsy: a cross-sectional study. Dev Med Child Neurol. 2019 May;61(5):579-585.
  15. ↑ 15.0 15.1 Ramstad K, Jahnsen R, Skjeldal OH, Diseth TH. Mental health, health-related quality of life and recurrent musculoskeletal pain in children with cerebral palsy 8-18 years old. Disabil Rehabil. 2012;34(19):1589-95.
  16. ↑ Riquelme I, Sabater-Gárriz Á, Montoya P. Pain and Communication in Children with Cerebral Palsy: Influence on Parents' Perception of Family Impact and Healthcare Satisfaction. Children (Basel). 2021 Jan 27;8(2):87.
  17. ↑ Ostojic K, Paget S, Kyriagis M, Morrow A. Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference, and management. Arch Phys Med Rehabil. 2020 Feb;101(2):213-219.
  18. ↑ McKinnon CT, White JH, Morgan PE, Antolovich GC, Clancy CH, Fahey MC, Harvey AR. The lived experience of chronic pain and dyskinesia in children and adolescents with cerebral palsy. BMC Pediatr. 2020 Mar 17;20(1):125.
  19. ↑ Ostojic K, Sharp NL, Paget SP, Morrow AM. Lived experiences of pain in children and young people with cerebral palsy. Dev Med Child Neurol. 2022 Mar;64(3):364-371.
  20. ↑ Pennington L, Dave M, Rudd J, Hidecker MJC, Caynes K, Pearce MS. Communication disorders in young children with cerebral palsy. Dev Med Child Neurol. 2020 Oct;62(10):1161-1169.
  21. ↑ Jayaraman DK, M Das J. Dysarthria. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK592453/
  22. ↑ Zhang JY, Oskoui M, Shevell M. A population-based study of communication impairment in cerebral palsy. J Child Neurol. 2015 Mar;30(3):277-84.
  23. ↑ Nordberg A, Miniscalco C, Lohmander A, Himmelmann K. Speech problems affect more than one in two children with cerebral palsy: Swedish population-based study. Acta Paediatr. 2013 Feb;102(2):161-6.
  24. ↑ Whitney DG, Peterson MD, Warschausky SA. Mental health disorders, participation, and bullying in children with cerebral palsy. Dev Med Child Neurol. 2019 Aug;61(8):937-942.
  25. ↑ Oakes L. Why is mental health being overlooked in those with cerebral palsy? HSR Psychology 2019. Available from https://hsrpsychology.co.uk/blog/why-is-mental-health-being-overlooked-in-those-with-cerebral-palsy/ [last access 26.12.2023]
  26. ↑ WHO. International classification of functioning, disability and health. Children and youth version 2007.
  27. ↑ 27.0 27.1 27.2 27.3 Michelsen SI, Flachs EM, Damsgaard MT, Parkes J, Parkinson K, Rapp M, Arnaud C, Nystrand M, Colver A, Fauconnier J, Dickinson HO, Marcelli M, Uldall P. European study of frequency of participation of adolescents with and without cerebral palsy. Eur J Paediatr Neurol. 2014 May;18(3):282-94.
  28. ↑ Whitney DG, Peterson MD, Warschausky SA. Mental health disorders, participation, and bullying in children with cerebral palsy. Dev Med Child Neurol. 2019 Aug;61(8):937-942.
  29. ↑ 29.0 29.1 Defining sexual health. World Health Organisation. Available from https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health [last access 27.12.2023]
  30. ↑ Power R, Heanoy E, Das MC, Karim T, Muhit M, Badawi N, Khandaker G. The Sexual and Reproductive Health of Adolescents with Cerebral Palsy in Rural Bangladesh: A Qualitative Analysis. Arch Sex Behav. 2023 May;52(4):1689-1700.
  31. ↑ headspaceAustralia. Mental Health & Disabilities - Natasha's Story. Available from: https://www.youtube.com/watch?v=FnTaKgQ0Mzs [last accessed 28/12/2023]
  32. ↑ 32.0 32.1 32.2 Guimarães A, Pereira A, Oliveira A, Lopes S, Nunes AR, Zanatta C, Rosário P. Parenting in Cerebral Palsy: Understanding the Perceived Challenges and Needs Faced by Parents of Elementary School Children. Int J Environ Res Public Health. 2023 Feb 21;20(5):3811.
  33. ↑ Sivaratnam C, Devenish B, Howells K, Chellew T, Reynolds K, Rinehart N. (2021) Risk factors for mental health difficulties in parents of children with cerebral palsy: a systematic review and meta-analysis. Clinical Psychologist 2021; 25 (1): 1-18.
  34. ↑ National Guideline Alliance (UK). Cerebral palsy in under 25s: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jan. (NICE Guideline, No. 62.) 24, Assessment of mental health problems.Available from https://www.ncbi.nlm.nih.gov/books/NBK533247/ [last access 27.12.2023]
  35. ↑ McCullough N, Parkes J. Use of the child health questionnaire in children with cerebral palsy: a systematic review and evaluation of the psychometric properties. Journal of pediatric psychology. 2008 Jan 1;33(1):80-90.
  36. ↑ Bjorgaas HM, Elgen IB, Hysing M. Mental Health in Pre-Adolescents with Cerebral Palsy: Exploring the Strengths and Difficulties Questionnaire as a Screening Tool in a Follow-Up Study including Multi-Informants. Children (Basel). 2022 Jul 6;9(7):1009.
  37. ↑ Goodman R, Renfrew D, Mullick M. Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. Eur Child Adolesc Psychiatry. 2000 Jun;9(2):129-34.
  38. ↑ Atkins MS, Hoagwood KE, Kutash K, Seidman E. Toward the integration of education and mental health in schools. Adm Policy Ment Health. 2010 Mar;37(1-2):40-7.
  39. ↑ Cantero MJ, Medinilla EE, Martínez AC, Gutiérrez SG. Comprehensive approach to children with cerebral palsy. Anales de Pediatría (English Edition). 2021 Oct 1;95(4):276-e1.
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