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Prevalence and functioning of children with cerebral palsy in four areas of the United States in 2006: A report from the Autism and Developmental Disabilities Monitoring Network

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Prevalence and functioning of children with cerebral palsy in four areas of the United States in 2006: A report from the Autism and Developmental Disabilities Monitoring Network
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  Prevalence and functioning of children with cerebral palsy in fourareas of the United States in 2006: A report from the Autism andDevelopmental Disabilities Monitoring Network § Russell S. Kirby a, *, Martha S. Wingate b , Kim Van Naarden Braun c , Nancy S. Doernberg c ,Carrie L. Arneson d , R uth E. Benedict d,e , Beverly Mulvihill b , Maureen S. Durkin d,f  ,Robert T. Fitzgerald g , Matthew J. Maenner d,f  , Jean A. Patz d,e , Marshalyn Yeargin-Allsopp c a DepartmentofCommunityandFamilyHealth,CollegeofPublicHealth,UniversityofSouthFlorida,13201BruceB.DownsBlvd,MDC56,Tampa,FL33612,UnitedStates b Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, United States c Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities,Centers for Disease Control and Prevention, United States d Waisman Center, University of Wisconsin-Madison, United States e Occupational Therapy Program, Department of Kinesiology, University of Wisconsin-Madison, United States f  Department of Population Health Sciences, University of Wisconsin-Madison, United States g Department of Psychiatry, Washington University in St. Louis, United States 1. Introduction Cerebral palsy (CP) is the most common cause of motor disability in childhood. Population-based estimates of CPprevalence range from 1.5 to more than 4 per 1000 live births or per children of a defined age range (Arneson et al., 2009; Research in Developmental Disabilities 32 (2011) 462–469 A R T I C L E I N F O  Article history: Received 23 December 2010Accepted 29 December 2010 Available online 26 January 2011 Keywords: Cerebral palsySurveillanceDevelopmental disabilityGross motor function A B S T R A C T  Aim:  To estimate the prevalence of cerebral palsy (CP) and the frequency of co-occurringdevelopmental disabilities (DDs), gross motor function (GMF), and walking ability usingthe largest surveillance DD database in the US. Methods:  We conducted population-based surveillance of 8-year-old children in 2006( N  =142,338), in areas of Alabama, Georgia, Wisconsin, and Missouri. This multi-sitecollaboration involved retrospective record review at multiple sources. We reported CPsubtype,co-occurringDDs,GrossMotorFunctionClassificationSystem(GMFCS)level,andwalking ability as well as CP period prevalence by race/ethnicity and sex. Results:  CP prevalence was 3.3 (95%confidence interval [CI]:3.1–3.7) per 1000 and variedby site, ranging from 2.9 (Wisconsin) to 3.8 (Georgia) per 1000, 8-year olds (  p < 0.02).Approximately 81% had spastic CP. Among children with CP, 8% had an autism spectrumdisorder and 35% had epilepsy. Using the GMFCS, 38.1% functioned at the highest level (I),with 17.1% at the lowest level (V). Fifty-six percent were able to walk independently and33% had limited or no walking ability. Interpretation:  Surveillance data are enhanced when factors such as functioning and co-occurring conditions known to affect clinical service needs, quality of life, and health careare also considered.   2011 Elsevier Ltd. All rights reserved. § ThefindingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialviewsoftheCentersforDiseaseControland Prevention.* Corresponding author. Tel.: +1 813 396 2347. E-mail address:  rkirby@health.usf.edu (R.S. Kirby). Contents lists available at ScienceDirect Research in Developmental Disabilities 0891-4222/$ – see front matter    2011 Elsevier Ltd. All rights reserved.doi:10.1016/j.ridd.2010.12.042  Bhasin,Brocksen,Avchen,&VanNaardenBraun,2006;Paneth,Hong,&Korzeniewski,2006;SurveillanceofCerebralPalsyinEurope, 2002; Winter, Autry, Boyle, & Yeargin-Allsopp, 2002; Yeargin-Allsopp et al., 2008) The presence and severity of CPamong children is associated with increased health care and special education services (Boulet, Boyle, & Schieve, 2009;Bramlett, Read, Bethell, & Blumberg, 2009) Population-based data on clinical characteristics of children with CP such assubtype,co-occurringdevelopmentaldisabilities(DDs),andthelevelofmotorfunctioningcanimproveourunderstandingof the complexities of this disorder and are needed for services and policies that promote participation of these children andtheir families in community and family life.The Autism and Developmental Disabilities Monitoring (ADDM) Network is a multi-site program funded by the Centersfor Disease Control and Prevention (CDC) to monitor CP prevalence, evaluate socio-demographic correlates, and assesstrendsinCPseverityovertimeintheUS.In2002and2004,theADDMNetworkreportedtheaverageprevalenceofCPamong8-year-oldchildreninthreeareasoftheUStobe3.6per1000(95%confidenceinterval[CI],3.3–4.0)and3.3per1000(95%CI,2.9–3.8) respectively (Arneson et al., 2009; Yeargin-Allsopp et al., 2008). In addition to presenting the most recent CPprevalence results from the ADDM Network, this is the first report from this Network on the co-occurrence of selected DDs,gross motor functioning (GMF) and walking ability among children with CP. 2. Methods  2.1. Study area TheADDMNetworkmonitoredCPamong142,338,8-yearoldslivinginareasofnorthernAlabama;metropolitanAtlanta,Georgia; metropolitan St. Louis, Missouri; and southeastern Wisconsin in 2006, covering approximately 4% of the total USpopulationof8-yearolds(Table1).Eachstudyareaconsistedofcontiguouscountiesfromwhichpopulation-basedestimatescould be made. Sites were selected through a competitive process on the basis of their ability to conduct developmentaldisabilities surveillance. Each site met applicable local institutional review board or other privacy and confidentialityrequirements.  2.2. Case definition TheADDMNetworkimplementedmethodsbasedon thosedevelopedbytheCDC’s MetropolitanAtlantaDevelopmentalDisabilities Surveillance Program, an ongoing, population-based, multisource surveillance program that monitors theoccurrence of DDs among 8-year-old children in metropolitan Atlanta (Arneson et al., 2009; Bhasin et al., 2006; Centers forDisease Control & Prevention, 2007; Rice et al., 2007; Yeargin-Allsopp et al., 2008). These methods, including those used forsurveillance of autistic spectrum disorders, are described in detail elsewhere (Yeargin-Allsopp et al., 2008). For surveillancepurposes, we defined CP as a group of permanent disorders of movement and posture that are attributed to nonprogressivedisturbances in the developing brain. CP is more than a motor impairment: it is a disorder often accompanied bydisturbances of sensation, perception, cognition, communication, and behavior; by epilepsy; and by secondarymusculoskeletal problems (Rosenbaum et al., 2007). Children with postneonatally acquired CP ( > 28 days after birth toage 8) were included.Caseinclusioncriteriawere:birthin1998;residenceinoneoftherespectivesurveillanceareasatanytimeduring2006;anddocumentationofaCPdiagnosisorphysicalfindingsconsistentwithCPinanevaluationbyaqualifiedprofessionalatorafter 2 years of age, or both. Children suspected of having CP were identified by screening comprehensive evaluations at  Table 1 Population characteristics for 8-year-old children by site, Autism and Developmental Disabilities Monitoring Network, 2006.Site Site institution SurveillanceareaTotal numberof 8-year-oldchildren insurveillancearea a White,non-HispanicBlack orAfricanAmerican,non-HispanicHispanic AmericanIndian,Alaska native,non-HispanicAsian/PacificIslander,non-Hispanic8-year old children in surveillance area,  n  (%)Alabama University of Alabama atBirmingham32 counties innorth andcentral Alabama35,126 23,967 (68.2) 9,028 (25.7) 1,607 (4.6) 153 (0.4) 371 (1.1)Georgia Centers forDisease Controland Prevention5 counties inmetropolitanAtlanta46,621 17,871 (38.3) 19,877 (42.6) 6,015 (12.9) 148 (0.3) 2,710 (5.8)Missouri WashingtonUniversityin St. Louis5 counties inmetropolitanSt. Louis26,533 18,199 (68.6) 6,702 (25.3) 777 (2.9) 82 (0.3) 773 (2.9)Wisconsin University of Wisconsin—Madison10 counties insoutheasternWisconsin34,058 22,361 (65.7) 6,157 (18.1) 4,153 (12.2) 181 (0.5) 1,206 (3.5)All sites – – 142,338 82,398 (57.9) 41,764 (29.3) 12,552 (8.8) 564 (0.4) 5,060 (3.6) a Data obtained from National Center on Health Statistics’ bridged-race postcensal population estimates for 2006. R.S. Kirby et al./Research in Developmental Disabilities 32 (2011) 462–469  463  multiplenonschoolsources,includinghospitals,clinics,diagnosticcenters,healthcareproviders,andstatepublichealthandrehabilitationagencies.PotentialCPcasesinGeorgiaalsowereidentifiedthroughpublicschoolspecialeducationprograms.Indicatorsfor abstraction included confirmed or suspected CP diagnosis or descriptions of physical findings associated withCP.  2.3. Data collection Demographic data, diagnostic summaries, descriptions of physical findings and GMF, psychometric test results, andinformation about co-occurring disabilities were collected. Data were abstracted into one composite record per child andsubsequentlyreviewed bytrained cliniciansusinga specifiedprotocoltodeterminecase status.CP clinician reviewersfromthe four sites included two developmental pediatricians, one pediatric neurologist, four senior physical therapists, and twosenior occupational therapists. In the absence of excludable conditions, such as progressive disorders and neuromusculardiseases, children were classified as confirmed CP cases based on diagnostic information and physical finding descriptionsconsistent with CP in the abstracted records.Before independent review of abstracted records for case determination, initial inter-rater reliability was establishedamongthereviewerstominimumstandardsof90%agreementoncasestatus.Ongoingreliabilitywasevaluatedinablinded,random 10% sample of abstracted records scored independently by two reviewers. Average percentage inter-rateragreement on final case status was 96% (linear weighted Kappa=0.91). Project staff performed no clinical examinations of children.  2.4. Gross motor function classification TwomethodsforclassifyingGMFwereincorporatedintoclinicianreview.WhensufficientinformationonGMFatorafter4 years of age was abstracted, clinician reviewers used the Gross Motor Function Classification System (GMFCS) (Palisanoetal.,1997)toassignaGMFCSlevel.GMFCSisbasedonthegrossmotorskillsneededforself-initiatedmovement,includingsitting, transferring, and mobility. Due to reliance on the documented findings in the source files, we were unable to assignGMFCS level for all case children.MotorfunctionwasalsoclassifiedbasedonthemethodologyoftheSurveillanceofCerebralPalsyinEurope(SCPE)group(Beckung,Hagberg,Uldall,&Cans,2008),focusingonwalkingability(unaidedwalking,walkingwithaids,orunabletowalk)as an indicator of general motor skills. In assigning walking ability, children classified using the GMFCS were collapsed intoone of the three categories: Levels I or II were classified as ‘‘walks independently’’; Level III, ‘‘walks with handheld mobilitydevice’’; and Levels IV or V, ‘‘limited or no walking ability.’’ Some children had sufficient information to assign a level of walkingability,but notaGMFCS level;forthesechildren,walkingability wasindependentlyassigned.Inafeasibility study,exact agreement among reviewers was 75% for the GMFCS and 94% using the three-level walking ability classification(Benedict et al., 2011).  2.5. Definitions of co-occurring developmental disabilities 2.5.1. Epilepsy Childrenolderthan1monthwereidentifiedashavingepilepsyifanevaluation(s)byaqualifiedprofessionaldocumentedadiagnosisofepilepsyoranepilepsysyndrome,oradescriptionoftwoormoreunprovoked,nonfebrileseizures,morethan24h apart (Commission on Epidemiology and Prognosis & International League Against Epilepsy, 1993).  2.5.2. Autism spectrum disorder  Children were classified as having an autism spectrum disorder (ASD) if evaluation records documented behaviorsconsistent with the  Diagnostic and Statistical Manual, Fourth Edition, Text Revision  (DSM-IV-TR) (American PsychiatricAssociation, 2000) criteria for autistic disorder; pervasive developmental disorder, not otherwise specified; or Aspergerdisorder. The methods for collecting data from evaluation records, clinician review and case classification are described indetail elsewhere (Yeargin-Allsopp et al., 2008). ASD case determination was done independently of CP by a team of ASDclinician reviewers.  2.6. Data analysis Periodprevalenceestimateswerecalculatedusingasthedenominatorthenumberof8-year-oldchildrenresidingineachsurveillanceareaaccordingtotheNationalCenterforHealthStatistics(NCHS)Vintage2007PostcensalPopulationEstimatesfromJuly1,2006(NationalCenterforHealthStatistics,2008).Theseestimatesdifferentiatebyage,genderandraceforeachUScountyonanannualbasis.Poissonapproximationtothebinomialdistributionwasusedtocalculate95%CI(Selvin,1996).Prevalence results are reported per 1000, 8-year-old children. The race or ethnicity, or both, of each child was determinedfrom information in the data source records or, if missing, from maternal race and ethnicity information on the child’s birthcertificate.Prevalenceestimateswerecomparedacrossthefoursitestoidentifyinter-sitevariability.A  p -valueof  < 0.05wasconsidered significant. R.S. Kirby et al./Research in Developmental Disabilities 32 (2011) 462–469 464  Qualitycontrolofbothabstractorsandclinicianreviewerswasconductedatmultiplestagesofthecaseidentificationanddetermination processes (Van Naarden Braun et al., 2007). Sensitivity analyses conducted to evaluate the effect on CPprevalence of records that could not be located demonstrated that the effect of missing records was minimal: 3.2% inWisconsin and Missouri, 3.4% in Alabama, and 5.9% in Georgia. 3. Results For 2006, the average prevalence of CP among 8-year-old children across the four surveillance sites was 3.3 (95%CI, 3.1–3.7) per 1000 (Table 2). Prevalence estimates varied significantly across sites, ranging from 2.9 (Wisconsin) to 3.8(Georgia)per1000,8-yearolds(  p < 0.02).Withinsites,theboy-to-girlratioexceededunityinthreeofthefoursites,rangingfrom 0.9 to 1.6 (Table 2). The median age at the most recent qualifying CP evaluation was 87.5 months (mean=79 months).TheproportionofchildrenwithCPage36monthsorgreateratthemostrecentevaluationwas92%;thisrangedfrom91%to93%acrossthefoursites;correspondingproportionsat48monthsorgreaterwere87%overallwitharangeacrosssitesfrom83% to 90%. The proportion of CP children with postneonatally acquired CP across all sites was 7.4%, ranging from 4.8% to11.3%.The distribution of the population by race and ethnicity varied across sites; overall, approximately 58% of the childrenwere White non-Hispanic (White-NH), 29% were Black or African-American non-Hispanic (Black-NH), and 9% were of Hispanic ethnicity, regardless of race (Table 1). In Alabama and Missouri, the prevalence of CP was slightly higher amongBlack-NH children than among White-NH children and similar across these two racial and ethnic groups for Georgia andWisconsin (Table 2). CP prevalence varied little between Hispanic, White-NH and Black-NH children in Georgia; the otherthree siteshad lower prevalence estimates for Hispanic children. The overall prevalence of CP among Hispanic children (2.2per1000,8-yearolds;95%CI,1.5–3.1)wassignificantlylowerthanamongWhite-NHchildren(3.2per1000;95%CI,2.8–3.6,  p < 0.01); when compared with the prevalence among Black-NH children (3.7 per 1000; 95% CI, 3.2–4.4,  p < 0.054) thisdifference approached statistical significance.Although ADDM Network methods do not rely solely on a CP diagnosis to determine case status, across all sites theaverage proportion of children with a documented diagnosis of CP by a qualified professional or an  InternationalClassification of Diseases, Ninth Revision ,  Clinical Modification  (World Health Organization, 2000) CP diagnostic code notedin their source files at age 8 or younger was approximately 97%, ranging from 94% in Wisconsin to 99% in Alabama.Clinician reviewers wereableto assign CP subtype for more than 90% ofchildrenwith CP.The proportion of children witha spastic CP subtype was similar across sites: 81% in Georgia, Missouri, and Wisconsin, and 82% in Alabama (Table 3).Although there was slight variation in the distribution at each site, bilateral spastic CP was more common than unilateralspasticCP(60–80%versus20–41%,respectively)(Table3).TheproportionofchildrenwithnonspasticCPsubtypesrangedfrom 2% to 8%.Across all sites, approximately 8% of children with CP had a co-occurring ASD and 35% had epilepsy (Table 4). While theproportion ofchildren with a co-occurring ASD varied from 3%to 12% across the four study sites, these differences were notstatistically significant (  p > 0.05). The proportion of children with CP who had co-occurring epilepsy was similar across allsites (34–36%).Acrossallsites,63.9%( n =304)ofchildrenwithCPwereassignedaGMFCSlevel(Table4);38.1%werefunctioningatLevelI,16.4% atLevelII,13.2% atLevelIII, 15.2%atLevel IV, and17.1%atLevel V. Amongchildrenwithunilateralspastic CP,90.7%were classified at GMFCS Levels I or II, with most (70.7%) at Level I. Among children with bilateral spastic CP, 43.5% were  Table 2 Demographic characteristics of cerebral palsy prevalence estimates by site, Autism and Developmental Disabilities Monitoring Network, 2006 (per 1000,8-year-old children).Alabama Georgia Missouri Wisconsin All sitesTotal number of CP cases 117 178 84 97 476Total of 8-year-olds in surveillance area a 35,126 46,621 26,533 34,058 142,338Total prevalence b (95% CI) 3.3 (2.8–4.0) 3.8 (3.3–4.4) 3.2 (2.6–3.9) 2.9 (2.3–3.5) 3.3 (3.1–3.7)Sex-specific prevalence (95% CI)Boy 3.2 (2.5–4.2) 4.1 (3.4–5.0) 3.6 (2.7–4.7) 3.5 (2.7–4.5) 3.6 (3.2–4.1)Girl 3.4 (2.7–4.4) 3.5 (2.8–4.4) 2.8 (2.0–3.8) 2.2 (1.6–3.0) 3.0 (2.7–3.5)Boy:girl ratio 0.9:1 1.2:1 1.3:1 1.6:1 1.2:1Race/ethnicity-specific prevalence (95% CI)White, non-Hispanic 3.1 (2.5–3.9) 3.8 (3.0–4.8) 2.8 (2.1–3.7) 3.0 (2.4–3.8) 3.2 (2.8–3.6)Black or African American, non-Hispanic 4.3 (3.2–5.9) 3.9 (3.1–4.8) 3.4 (2.3–5.2) 2.8 (1.7–4.4) 3.7 (3.2–4.4)Hispanic 1.2 (0.3–5.0) 3.3 (2.2–5.2) 1.3 (0.2–9.1) 1.0 (0.4–2.6) 2.2 (1.5–3.1)American Indian/Alaska native, non-Hispanic – – – 5.5 (0.8–39.2) 1.8 (0.3–12.6)Asian/Pacific-Islander, non-Hispanic – 2.6 (1.2–5.4) 1.3 (0.2–9.2) 3.3 (1.2–8.8) 2.4 (1.4–4.2)CP, cerebral palsy; CI, confidence interval. Prevalence is reported per 1000 8-year children. a Denominator data were obtained from National Center on Health Statistics’ bridged-race postcensal population estimates for 2006. b Allchildrenareincludedinthetotalregardless ofraceor ethnicity,as wellaschildrenforwhomrace orethnicityisunknown.Becauseofthelackofanappropriate denominator, multiracial or other race or ethnicity categories are not presented. R.S. Kirby et al./Research in Developmental Disabilities 32 (2011) 462–469  465  classified at GMFCS Levels I or II and 40.3% at Levels IV or V, with most at either Level I (29.0%) or Level V (24.2%). Amongchildren with nonspastic CP, the largest proportion was classified at Level I (42.9%).Acrossthesites,amongchildrenwithCPwhohaddataonwalkingability( n =359),approximately56%wereclassifiedasable to walk independently (Table 4). Over 90% with unilateral spastic CP were categorized as able to walk independently,comparedwith45%ofchildrenwithbilateralspasticCP.Overall,33%ofchildrenwithCPwerecategorizedashavinglimitedor no walking ability. Although only 3.8% with unilateral spastic CP were classified with limited or no walking ability, theproportion among children with bilateral spastic CP was considerably higher (41%). The pattern of walking ability forchildren with nonspastic CP was similar to that of children with unilateral spastic CP. In Georgia, Missouri, and Wisconsin,the majority of children with CP with sufficient data on walking ability were categorized as walking independently (58%,61%,and60%,respectively).InAlabama,walkingabilitywasmoreevenlydistributedbetweenwalkingindependently(47%)and limited or no walking ability (43%). Overall and within each site, children were categorized least frequently as walkingwith handheld mobility devices.WalkingabilityamongchildrenwithCPwhohadco-occurringASD,epilepsy,orboth,isshowninFig.1.Theproportionof children with co-occurring epilepsy increased from 27% among children who walked independently to 70.1% among thosewithlimitedtonowalkingability.ThepatternamongchildrenwithCPandaco-occurringASDwasintheoppositedirection.As walking ability decreased, the proportion of children with a co-occurring ASD also declined, from 12.9% among childrenwho walked independently to 3.4% among those with limited or no walking ability (  p < 0.005).  Table 4 Co-occurring developmental disabilities and gross motor function among 8-year-old children with cerebral palsy by subtype, Autism and DevelopmentalDisabilities Monitoring Network, 2006.Total Spastic Nonspastic a Other b n  (%) All spastic c Unilateral d Bilateral e n  (%)  n  (%) n  (%)  n  (%)  n  (%)Total 476 387 110 275 27 62Co-occurring ASD 39 (8.2) 24 (6.2) 7 (6.4) 17 (6.2) 4 (14.8) 11 (17.7)Co-occurring epilepsy 166 (34.9) 135 (34.9) 28 (25.5) 107 (38.9) 11 (40.7) 20 (32.3)GMFCS levelGMFCS data available 304 (63.9) 251 (64.9) 65 (59.1) 186 (67.6) 21 (77.8) 32 (51.6)I 116 (38.1) 100 (39.8) 46 (70.7) 54 (29.0) 9 (42.9) 7 (21.9)II 50 (16.4) 40 (15.9) 13 (20.0) 27 (14.5) 3 (14.3) 7 (21.9)III 40 (13.2) 33 (13.1) 3 (4.6) 30 (16.1) 2 (9.5) 5 (15.6)IV 46 (15.1) 33 (13.1) 3 (4.6) 30 (16.1) 4 (19.0) 9 (28.1)V 52 (17.1) 45 (17.9) 0 (–) 45 (24.2) 3 (14.3) 4 (12.5)Walking abilityWalking ability data available 359 (75.4) 298 (77.0) 78 (70.9) 219 (79.6) 23 (85.1) 38 (61.2)Walks independently 202 (56.3) 172 (57.7) 72 (92.3) 99 (45.2) 13 (56.5) 17 (44.7)Walks with handheld mobility device 40 (11.1) 33 (11.1) 3 (3.8) 30 (13.7) 2 (8.7) 5 (13.2)Limited or no walking 117 (32.6) 93 (31.2) 3 (3.8) 90 (41.1) 8 (34.8) 16 (42.1)ASD – autism spectrum disorder; GMFCS – Gross Motor Functioning Classification System. a Includes ataxic, hypotonic, dyskinetic, and dyskinetic–ataxic. b Includes spastic–ataxic, spastic–dyskinetic, and cerebral palsy not otherwise specified (CP NOS). c Includes spastic NOS; two children had spastic NOS subtype and were not able to be classified as having bilateral or unilateral spastic CP. d Includes spastic monoplegia and spastic hemiplegia. e Includes spastic diplegia, spastic quadriplegia, and spastic triplegia.  Table 3 Cerebral palsy subtypes by site, Autism and Developmental Disabilities Monitoring Network, 2006.Alabama Georgia Missouri Wisconsin All sites n  (%)  n  (%)  n  (%)  n  (%)  n  (%)Total 117 178 84 97 476Spastic a 96 (82.1) 144 (80.9) 68 (81.0) 79 (81.4) 387 (81.3)Unilateral b 31 (32.6) 28 (19.6) 19 (27.9) 32 (40.5) 110 (28.6)Bilateral c 64 (67.4) 115 (80.4) 49 (72.1) 47 (59.5) 275 (71.4)Nonspastic d 8 (6.8) 14 (7.9) 2 (2.4) 4 (4.1) 28 (5.9)Other e 13 (11.1) 20 (16.7) 14 (16.7) 14 (14.4) 61 (12.8) a Includes spastic not otherwise specified (NOS). b Includes spastic monoplegia and spastic hemiplegia. c Includes spastic diplegia, spastic quadriplegia, and spastic triplegia. d Includes dyskinetic, ataxic, hypotonic, and dyskinetic–ataxic. e Includes spastic–ataxic, spastic–dyskinetic, and cerebral palsy NOS. R.S. Kirby et al./Research in Developmental Disabilities 32 (2011) 462–469 466
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