Advances in prevention and treatment of cerebral palsy

In recent years there have been a number of advances in understanding of predisposing and protective factors in the development of cerebral palsy in infants. Multiple gestation births, maternal infection, and maternal and fetal thrombophilic conditions all predispose to the development of CP in the infant. Opportunities for prevention of CP may develop from an improved understanding of these factors and their mechanisms of operation. Similar progress has been made in the evaluation of treatments for CP and the effects of these treatments on the individual's impairment, function, and disability. Selective posterior rhizotomy and Botulinum toxin A are now widely used in the treatment of spasticity. The challenge remains to determine how effectively these promising interventions can alter long-term function and quality of life outcomes in children and adults with CP.     

AIDS and pediatric HIV infection: the problem of the infected mother and her newborn

The number or pediatric AIDS cases in the US was around 2000 in 1990, and children under 13 accounted for about 2% of reported cases. Pediatric cases are increasing as the number of infected women increases. Such cases are concentrated in poor urban populations, aggravating the lack of resources of already overtaxed health services. Ethnic minorities are overrepresented among AIDS cases. In the US, 52% of AIDS cases in adult women are in blacks, 27% in non-Hispanic whites, and 20% in women of Hispanic origin. Among children under 13, 53% are in blacks, 25% in Hispanics, and 22% in whites. The majority of children with AIDS were 5 and were probably infected by vertical transmission. Over 80% were born to mothers with AIDS or at risk of HIV infection, 11% received transfusions of contaminated blood, and 5% received contaminated blood products. Through December 1989, 53% of white, 91% of black, and 85% of Hispanic children with AIDS were infected vertically by their mothers. In the US, over 1/2 of cases of vertical AIDS transmission are due to maternal IV drug abuse and 1/5 to mothers who have sexual relations with IV drug abusers. The rate of infection in children born to seropositive mothers has not been established. Estimates of rates of transmission range from 20% to 50%. The factors causing HIV transmission in 1/3 of infants and protecting the other 2/3 have not been identified. Transmission to the infant may occur during pregnancy or delivery or through breast feeding. There is no evidence that cesarean delivery can protect against infection. The risk of intrauterine infection is probably much greater than that of infection during delivery. Diagnosis of HIV infection in young infants is difficult. There are no physical characteristics distinguishing infected newborns, and laboratory diagnosis is unhelpful because maternal HIV antibodies cross the placental barrier to the fetus. There is as yet no vaccine or curative treatment for HIV infection. Prevention of pediatric HIV infection requires prevention of the infection and the disease in pregnant women. Primary prevention in women depends on their being adequately informed about risks and able to change risk behaviors. Secondary prevention is achieved through use of AZT, which slows the progression of the disease, and prevention or treatment of complications. There is no conclusive evidence as yet that pregnancy hastens the progression of maternal HIV infection. Seropositive mothers should avoid breast feeding if adequate substitute foods are available. The average age at appearance of symptoms in infected children is 8 months. Mortality is higher among children manifesting the disease in the 1st year, with a median survival of 38 months. Full information about HIV infection and voluntary and confidential screening should be available to all women contemplating pregnancy.     

Group interventions for patients with cancer and HIV disease: Part II. Effects on immune, endocrine, and disease outcomes at different phases of illness

There has been great interest in the potential impact of group interventions on medical outcomes. This article reviews the effects of professionally-led groups on immune activity, neuroendocrine function, and survival among patients with cancer or HIV disease. We examine findings concerning different types of group services at different phases of illness. Results are mixed, but the most prominent changes in immune and endocrine activity were associated with structured group interventions for patients with early-stage disease. These findings offer provocative illustrations of relevant mind-body interactions, but their clinical importance has yet to be demonstrated empirically. Group interventions have not been tied consistently to improved survival rates for patients with advanced cancer; few studies as yet have focused on survival outcomes among patients with early-stage cancer or HIV disease.     

Infant-directed language following a brief behavioral parenting intervention: The importance of language quality

Behavioral parenting interventions decrease early childhood behavior problems and increase positive parenting skills. However, few studies have examined the impact of low intensity interventions for infants at risk for behavior problems on changes in parent language. This study examined the effect of a brief parenting intervention, the Infant Behavior Program, on changes in parent linguistic input and its influence on infant language. Participants were 58 mothers and their12- to 15-month-olds, with elevated levels of behavioral problems. Mothers and their infants were from primarily Hispanic and low-income backgrounds. Mother-infant dyads were randomly assigned to receive the Infant Behavior Program or standard pediatric primary care. Mothers receiving the Infant Behavior Program provided more linguistic input, which indirectly influenced infant language, and suggest targeting infants at risk for behavior problems can have a broader impact on language development.     

Infection markers and early signs of neonatal encephalopathy in the term infant

Recent evidence points to an association between intrauterine infection and cerebral palsy (CP) in the preterm as well as the term infant. The mechanisms that link these two conditions are unclear. Chorioamnionitis is a common clinical problem complicating 5-10% of pregnancies, whereas the incidence of CP attributed to intrapartum asphyxia is rare. Chorioamnionitis may result in brain injury as a result of interruption of placental blood flow (asphyxia), or via fever and/ or the cytokine release associated with infection. This review will attempt to establish the link between perinatal infection and brain damage in term infants. The characteristics of the perinatal inflammatory response, the potential mechanisms of brain injury associated with infection, and the clinical characteristics of neonatal encephalopathy will be discussed.     

Parenting of low birth weight infants: A review of issues and interventions

Factors that may adversely affect parenting of low birth weight infants, including infant characteristics, parental emotional responses to premature birth, and patterns of parent-infant interaction, are reviewed. In addition, intervention studies designed to improve infant developmental outcomes through influencing parenting behaviors are examined. There was great diversity in theoretical frameworks, in timing of onset and frequency of interventions, and in measurement of outcomes. The interventions that were most effective in influencing behaviors and infant developmental outcomes were those in which there were multiple long-term contacts with parents and/or those that actively involved them in the intervention. The specific theoretical framework upon which the interventions were based appeared to be of less importance in influencing results. In order to increase our knowledge and ability to provide costeffective programs, there is a need to focus attention and data collection efforts on the process and intermediary steps of intervention as well as on outcome measures. There is also a need to improve our ability to recruit and retain those families who are most at risk for parenting and infant developmental problems including those with very low birth weight infants, those whose infants have serious perinatal complications, and those with indications of high social risk such as poverty-level incomes and problems of substance abuse.     

Public health issues related to infection in pregnancy and cerebral palsy

Cerebral palsy is the most common neuromotor developmental disability of childhood, affecting as many as 8,000 to 12,000 children born in the U.S. each year (corresponding to a prevalence rate of between 2 and 3 per 1000 children). Recent improvements in neonatal care have not resulted in a decline in the overall prevalence of cerebral palsy and, in fact, greater numbers of very preterm/very low birth weight infants are surviving with cerebral palsy and other developmental problems. Infection in pregnancy may be an important cause of the disorder. In preterm infants, there appears to be about a 2-fold increased risk for cerebral palsy from chorioamnionitis, and in term infants the estimated increased risk is about 4-fold. Provisionally, chorioamnionitis might account for 12% of spastic cerebral palsy in term infants and 28% of cerebral palsy in preterm infants. Studies of biochemical markers of fetal inflammation typically associated with infection also suggest that an inflammatory response may be an important independent etiologic factor. If a substantial proportion of cerebral palsy is attributable to acute amnionitis infection and/or neonatal sepsis, cerebral palsy should have decreased in the United States after administration of intrapartum antibiotics became widespread in response to publication of public health consensus guidelines for Group B streptococcus in 1996. However, failure to detect declines could have a number of explanations and these explanations illustrate the many public health challenges related to intrauterine infection and cerebral palsy. Given the gaps in our current knowledge about intrauterine infection and cerebral palsy, public health recommendations for timely and specific prevention activities are limited at this time.     

A Systematic Review of Suicide Prevention Programs for Military or Veterans

Military personnel and veterans have important suicide risk factors. After a systematic review of the literature on suicide prevention, seven (five in the U.S.) studies of military personnel were identified containing interventions that may reduce the risk of suicide. The effectiveness of the individual components was not assessed, and problems in methodology or reporting of data were common. Overall, multifaceted interventions for active duty military personnel are supported by consistent evidence, although of very mixed quality, and in some cases during intervals of declines in suicide rates in the general population. There were insufficient studies of U.S. Veterans to reach conclusions.     

Intermodal enhancement of stimulus localisation in infants born prematurely

The interaction of auditory and visual modalities in the enhancement of orientation was examined in premature and near-term infants by presenting them auditory or visual stimuli or auditory-visual stimulus combinations at various positions in sensory space. In 4.5--15-mo-olds, brisk orienting responses could be elicited to very peripheral stimulus positions but only when the stimulus consisted of a spatially coherent auditory-visual combination (i.e., where a sound and a light occurred at the same point in space). This occurred for all infants, irrespective of age or gestational age at birth. First, the result shows that infants can respond to visual stimuli at eccentric positions, beyond the supposed limits of their effective visual fields as measured by standard perimetry. Second, the result extends earlier studies showing that intersensory integration and stimulus localisation develop relatively normally in prematurely born infants. The auditory-visual enhancement test as used here may have a number of further uses and applications in the clinic and laboratory.     

Preventing HIV infection in heterosexual women: What do we know? What must we learn?

Women are becoming infected with HIV via heterosexual activity at an accelerating rate, both in the United States and globally. Although a number of evaluations of behavioral risk-reduction interventions for women have been reported, many suffer from methodological problems that weaken confidence in their findings, and furthermore it is clear that many women are unable to respond to the interventions that have been tested. Most women infected through heterosexual activity are infected by their primary partner, yet achieving consistent condom use with this partner can be highly challenging for women. The present article presents recent work and innovative ideas for intervention strategies that may be more feasible, and thus more effective, for women at risk for HIV infection by their primary male partner.     

Interactions between anxious mothers and their infants: An integration of theory and research findings

Children of highly anxious mothers are at risk for developmental difficulties including anxiety disorders, and “anxious maternal behavior” and disturbed mother–infant interactions have been implicated in the transmission of risk. In this article, we describe interactions between mothers who are highly anxious and their young infant, based on the few directly relevant observation studies that are available. For more detail, we draw on a broader literature including studies of depressed mothers and developmental theory. Our goal is to describe how the interactions between anxious mothers and infants look to an outside observer and how they may feel to mothers and infants. We also discuss possible bases for their disturbed interactive behavior, the impact that the disturbances can have on both mothers and infants, buffers and risk factors, and routes to short‐term intervention. Finally, we suggest directions for future research on maternal anxiety and anxious maternal behavior and the significance of such research for clinicians and researchers.     

Face-to-face interaction in term and preterm infants

Previous research has found that mothers of preterm infants work harder in a face-to-face situation with their infants than mothers of term infants. Data have also revealed that preterm infants are less responsive than term infants in a social interaction. To date, there have been few studies that have attempted to determine the range of facial expressive cues that preterms may be emitting or the possible physiological basis for this behavior. In an attempt to investigate these questions, preterm and term infants were observed in a face-to-face situation. Prior to the session, three minutes of resting EKG was recorded. The infant's facial behavior was coded with a discrete facial action coding system. Maternal behavior was also coded. Measures of heart rate as well as short and long term variability were computed. Results revealed no differences in facial lability or in facial expressiveness between term and preterm infant. In addition, there were no differences in maternal behavior to either term or preterm. There were, however, reliable contingent relationships between facial expression of the infant and maternal behavior. In addition, there was a significant association between short term variability (vagal tone) and infant facial behavior.     

Do We Know Which Interventions are Effective for Disruptive and Delinquent Girls?

Disruptive and delinquent girls are not well served by the mental health and juvenile justice systems. Interventions that have been developed for the behavior problems of boys are frequently applied to girls despite growing evidence for a female-specific phenotype, developmental course, and set of risk factors from middle childhood onwards. The current review demonstrates that evidence of the effectiveness of treatments for girls with disruptive and delinquent behaviors is extremely limited, with relatively few studies including sufficient numbers of females or reporting on treatment effects by gender. However, a small body of evidence suggests that interventions specifically designed to address female behavior problems or risk factors can be effective in ameliorating disruptive and delinquent behaviors in both pre-adolescence and adolescence. Multi-modal interventions that target interacting domains of risk also show promise. Methodological issues are discussed and recommendations are made for the development and evaluation of future interventions to prevent and reduce girls’ disruptive and delinquent behavior.     

Are postural adjustments during reaching related to walking development in typically developing infants and infants at risk of cerebral palsy?

BackgroundIn typical development, postural adjustments during reaching change in the second half of infancy, including increasing rates of direction-specific adjustments. These changes are absent or different in infants at risk of cerebral palsy (CP). To discover whether these changes are related to acquisition of independent walking, we studied postural adjustments during reaching in infants before and after they learned to walk.MethodsTen typically developing (TD) infants and 11 infants at very high risk (VHR) of CP were assessed before and after they learned to walk. Reaching movements were elicited during supported sitting, while surface electromyography was recorded of arm, neck, and trunk muscles. Percentages of direction-specific adjustments (first level of control), and recruitment patterns and anticipatory activation (second level of control) were calculated.ResultsIn both groups, postural adjustments during reaching were similar before and after acquisition of independent walking. Direction-specificity increased with age in typically developing infants but not in VHR-infants.ConclusionIncreasing age rather than the transition to independent walking is associated with increasing direction-specificity of TD-infants during reaching while sitting, while infants at very high risk of CP show no increase in direction-specificity, suggesting that they gradually grow into a postural deficit.     

Parent‐selected interventions for infants at‐risk for autism spectrum disorders and their affected siblings

Infants with older siblings having Autism Spectrum Disorders (ASD) are at genetically increased risk for showing characteristics of ASD in the first 2 years of life. Parents, who already have at least one child with ASD, may closely monitor their later born children and implement interventions as soon as the children begin to show what the parents believe is aberrant behavior or development that may be early stages of ASD. To date, no study has examined the number and types of services and interventions these parents access for their at‐risk infants. Using a Service and Intervention Questionnaire developed for this study, we interviewed 23 parents involved in a larger prospective study of genetically at‐risk infants who reported developmental and/or behavior problems in their at‐risk infants. Parents reported utilizing a mean of 1.83 and 7.26 services and/or interventions for their at‐risk infants and older children with ASD, respectively. Two‐thirds of the interventions received by the infants were also given to their older affected siblings. The interventions included empirically validated approaches (e.g., early intensive behavioral intervention), professional services (speech–language therapy, occupational therapy), and non‐validated treatments (e.g., diet and vitamin therapies). Overall, 81 non‐validated and 18 validated interventions were used. On a Likert‐type rating scale, parents reported being involved and satisfied with what they generally thought were effective services. They felt more involved and satisfied with ABA, and felt it was more effective than non‐validated interventions. The findings suggest that parents with infants at‐risk for ASD and an older affected child will access a variety of autism services for both children, but the parents will implement primarily non‐validated interventions. Parent education is recommended to help parents make informed treatment decisions for their children. Copyright © 2009 John Wiley & Sons, Ltd.     

Calming an aggressor through spontaneous post‐conflict triadic contacts: Appeasement in Macaca tonkeana

Peaceful third‐party interventions usually occur after an aggressive encounter and can be directed toward the victim or the aggressor. Macaca tonkeana, a cercopithecine species characterized by high levels of tolerance, frequently engage in consolatory contacts, which both calm the victim and reduce the probability of further attacks against him/her. Other post‐conflict affiliative interventions such as reconciliation and quadratic affiliation are also common in this species. However, little attention has been given to contacts directed toward the aggressor. Here, we explore the role of bystander affiliative interventions toward the aggressor in influencing the affective state of the aggressor and the consequences of triadic interventions at group level. We found that triadic post‐conflict affiliation occurred independently from the intensity of the conflict and that it was more frequent in absence of the conciliatory contact between the opponents (reconciliation). Bystanders showed a higher amount of post‐conflict affiliation toward low ranking aggressors. Post‐conflict triadic affiliation functioned as a tension reduction mechanism by lowering the arousal of the aggressor, which less frequently engaged in renewed aggression. All these findings suggest that post‐conflict triadic contacts in Tonkean macaques can be considered as a strategic mechanism to calm the aggressor and reduce the risk of retaliatory aggression.

     

Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial

Few interventions have succeeded in reducing psychosocial risk among pregnant women. The objective of this study was to determine whether an integrated group prenatal care intervention already shown to improve perinatal and sexual risk outcomes can also improve psychosocial outcomes compared to standard individual care. This randomised controlled trial included pregnant women ages 14-25 from two public hospitals (N = 1047) who were randomly assigned to standard individual care, group prenatal care or integrated group prenatal care intervention (CenteringPregnancy Plus, CP+). Timing and content of visits followed obstetrical guidelines, from 18-week gestation through birth. Each 2-h group prenatal care session included physical assessment, education/skills building and support via facilitated discussion. Using intention-to-treat models, there were no significant differences in psychosocial function; yet, women in the top tertile of psychosocial stress at study entry did benefit from integrated group care. High-stress women randomly assigned to CP+ reported significantly increased self-esteem, decreased stress and social conflict in the third trimester of pregnancy; social conflict and depression were significantly lower 1-year postpartum (all p-values < 0.02). CP+ improved psychosocial outcomes for high-stress women. This 'bundled' intervention has promise for improving psychosocial outcomes, especially for young pregnant women who are traditionally more vulnerable and underserved.     

Beneficial effects of a music listening intervention on neural speech processing in 0–28-month-old children at risk for dyslexia

Familial risk for developmental dyslexia can compromise auditory and speech processing and subsequent language and literacy development. According to the phonological deficit theory, supporting phonological development during the sensitive infancy period could prevent or ameliorate future dyslexic symptoms. Music is an established method for supporting auditory and speech processing and even language and literacy, but no previous studies have investigated its benefits for infants at risk for developmental language and reading disorders. We pseudo-randomized N∼150 infants at risk for dyslexia to vocal or instrumental music listening interventions at 0–6 months, or to a no-intervention control group. Music listening was used as an easy-to-administer, cost-effective intervention in early infancy. Mismatch responses (MMRs) elicited by speech-sound changes were recorded with electroencephalogram (EEG) before (at birth) and after (at 6 months) the intervention and at a 28 months follow-up. We expected particularly the vocal intervention to promote phonological development, evidenced by enhanced speech-sound MMRs and their fast maturation. We found enhanced positive MMR amplitudes in the vocal music listening intervention group after but not prior to the intervention. Other music activities reported by parents did not differ between the three groups, indicating that the group effects were attributable to the intervention. The results speak for the use of vocal music in early infancy to support speech processing and subsequent language development in infants at developmental risk.

Research Highlights

• Dyslexia-risk infants were pseudo-randomly assigned to a vocal or instrumental music listening intervention at home from birth to 6 months of age.
• Neural mismatch responses (MMRs) to speech-sound changes were enhanced in the vocal music intervention group after but not prior to the intervention.
• Even passive vocal music listening in early infancy can support phonological development known to be deficient in dyslexia-risk.

     

Parent Training Outcomes Among Young Children with Callous–Unemotional Conduct Problems with or at Risk for Developmental Delay

School-aged children with conduct problems and high levels of callous–unemotional (i.e., lack of empathy, guilt, and lack of caring behaviors) traits (CP + CU) tend to yield less benefit from traditional interventions than do their low-CU counterparts, particularly with respect to conduct problem (CP) outcomes. To date, little is known about treatment response among young children with CP + CU, particularly those with or at risk for developmental delay. Components of parent–child interaction therapy (PCIT), a parent training program effective at reducing CP in young children, have compelling theoretical support for addressing core deficits unique to children with CP + CU and have been used successfully with young children with developmental delay. Our first aim was to test the psychometric properties of a measure of CU traits in preschool children with and without developmental delay. Our second aim was to test whether CU traits predicted post-treatment CP after controlling for initial levels of CP. Participants were 63 families of young children (mean age = 3.87 years), with or at risk for developmental delay, who presented with elevated CP and were treated in a hospital-based outpatient clinic. Results indicated that developmentally delayed children with high levels of CU traits, but not children at risk for delay due to premature birth, showed significantly poorer CP outcomes following treatment with PCIT than did children scoring low on CU traits, even after controlling for initial CP severity. The implications of these findings with regard to treating and preventing severe disruptive behaviors among young children with CP + CU are discussed.