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The Cerebral Palsy Diagnosis Checklist

A diagnosis of cerebral palsy will come only after several evaluations, observations and tests are performed. The Cerebral Palsy Diagnosis Checklist allows parents to document test results, appointment outcomes, and formal diagnosis on one easy-to-use form. It is likely parents will share these details with school officials, other health care providers, therapists and caregivers in the months and years ahead. The checklist can be easily stored in a child’s home medical records for easy retrieval.


About diagnosis

With cerebral palsy, every child’s condition is unique. Some may have a mild form, others severe. The impairment may involve one limb, two, three or all four. The child may have paresis or paralysis. The cause of impairment is due to one of four classifications of brain damage, which should be accurately relayed to those charged with a child’s care.

Obtaining a cerebral palsy diagnosis is often a lengthy process. Usually, a child’s development is observed over time. The child’s primary health care provider, often a pediatrician, looks for signs of impairment during well-baby check-ups. A parent notices symptoms that may indicate concern, such as delayed developmental milestones. Tests may be ordered and medical specialists consulted.

During this process, the child’s parent or legal guardian is provided with observations, test results and diagnosis. A cerebral palsy diagnosis can be overwhelming as a parent begins to realize his or her child has a physical impairment that cannot be cured, but can be managed. Often, parents retain only a portion of information initially presented by doctors and other medical practitioners. Questions arise later, yet many parents do not know what questions will provide answers and help fully define the child’s condition.

As the child grows, parents will meet with school administrators, physical therapists, adaptive equipment specialists, home care providers, and more. In initial consults, the parent will be asked the cause, type, and form of cerebral palsy their child has. Some medical specialists find it helpful to know the extent, location, and severity of the child’s impairment.

The industry may use various common medical terms to define various aspects of the child’s impairment., Although health care providers will likely confirm diagnosis with the child’s primary care physician before formally treating the child, a parent may nonetheless benefit from a sheet cataloging this information for such interactions.

The Diagnosis Checklist is designed by MyChild™ to provide a parent with better understanding and an easy-to-use checklist to document a child’s condition as provided by health care providers. Over the course of the child’s lifetime, it is likely parent will need to provide this information to many individuals caring for the child. The information can be easily stored in the child’s home medical records. Consult with a physician to check off all conditions that apply.

Types and Forms

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Basic Information

Basic Information


____________________ Child’s Name

____________________ Mother’s Name

____________________ Father’s Name

____________________ Primary Care Physician

____________________ Birth Date

____________________ Birth Weight

____________________ Birth Height

____________________ Week’s Gestation

____________________ APGAR Score

____________________ Blood Type

Types and Forms

Cause of Cerebral Palsy Checklist

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Hypoxic-Ischemic Encephalopathy, or HIE – Lack of oxygen to the brain or asphyxia

Intracranial Hemorrhage, or IVH – Brain Hemorrhage

Periventricular Leukomalacia, or PVL – Damage to white matter tissue in the brain

Cerebral Dysgenesis – Brain malformation, abnormal brain development

Other ____________________

None

Types and Forms

When Brain Damage Occurred Checklist

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Acquired Cerebral Palsy – The child did not have cerebral palsy at the time of birth. Cerebral palsy was acquired after birth, but before brain was fully developed.

Congenital Cerebral Palsy – The child was born with the condition. Brain damage occurred during pregnancy, at birth, or immediately after birth.

Genetic Predisposition to Cerebral Palsy – Cerebral palsy is not considered to be hereditary, but hereditary conditions predisposed the child to cerebral palsy.

No Cerebral Palsy – The brain damage occured after the brain has fully developed causing impairment similar to cerebral palsy, but is clinically identified by the actual cause.

Not Determined – Timing of brain damage has not yet been determined.

Types and Forms

Severity Level Checklist

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Mild – cerebral palsy means a child can move without assistance. Their daily activities are not limited.

Moderate – Moderate cerebral palsy means a child will need braces, medications, and adaptive technology to accomplish daily activities.

Severe – Severe cerebral palsy means a child will require a wheelchair and will have significant challenges in accomplishing daily activities.

Other ____________________

None

Types and Forms

Topographical Distribution Checklist

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Extent:

Paresis means weakened

Plegia means paralyzed

Prefix:

Monoplegia/Monoparesis means that only one limb is affected. It’s thought that this may be a form of hemiplegia/hemiparesis where one limb is significantly impaired.

Diplegia/Diparesis usually indicates that the legs are affected more than the arms. Primarily lower body involvement.

Hemiplegia/Hemiparesis indicates that the arm and leg on one side of the body is affected.

Paraplegia/Paraparesis means the lower half of the body, including both legs, are affected.

Triplegia/Triparesis indicates that three limbs are affected. This could be both arms and a leg, or both legs and an arm. Or, it could refer to one upper and one lower extremity and the face.

Double Hemiplegia/Double Hemiparesis indicate that all four limbs are involved, but one side of the body is more affected than the other.

Tetraplegia/Tetraparesis indicates that all four limbs are involved, but three limbs are more affected than the fourth.

Quadriplegia/Quadriparesis means that all four limbs are involved.

Pentaplegia/Pentaparesis means that all four limbs are involved, with neck and head paralysis often accompanied by eating and breathing complications.

Other ____________________

None

Types and Forms

Motor Function Checklist

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Muscle Tone:

Hypertonia — increased muscle tone often resulting in very stiff limbs. Hypertonia is associated with spastic cerebral palsy

Hypotonia — decreased muscle tone often resulting in loose, floppy limbs. Hypotonia is associated with non-spastic cerebral palsy

Spasticity:

Spastic (Pyramidal) – Spasticity means increased muscle tone. Muscles continually contract making limbs stiff, rigid, and resistant to flexing or relaxing. Reflexes can be exaggerated and movements jerky and awkward.

Non-Spastic (Extrapyramidal) – Non-spastic cerebral palsy is decreased and/or fluctuating muscle tone. There are multiple forms, each characterized by particular impairments. One of the main characteristics of non-spastic cerebral palsy is involuntary movement. Movement can be slow or fast, often repetitive, and sometimes rhythmic.

Mixed – It is common for a case to involve both spastic and non-spastic cerebral palsy. When a child’s impairments fall into both categories, it is considered mixed cerebral palsy. The most common form of mixed cerebral palsy sees some limbs affected by spasticity and others by athetosis.

Non-Spastic Sub-Categories:

Ataxic – Ataxic cerebral palsy affects coordinated movements. Balance and posture are involved. Walking gait is often very wide, and possibly irregular. Control of eye movements and depth perception can be impaired. Often fine motor skills requiring coordination of the eyes and hands, such as writing, are made difficult.

Dyskinetic – Dyskinetic cerebral palsy is separated further into two different groups; athetoid and dystonic. Athetoid cerebral palsy includes the cases with involuntary movement, especially in the arms, legs, and hands. Dystonic cerebral palsy encompasses the cases that affect the trunk muscles more than the limbs, and results in fixed, twisted posture.

Athetosis — slow, writhing movements that are often repetitive, sinuous, and rhythmic.

Chorea — irregular movements that are not repetitive or rhythmic, and tend to be more jerky and shaky.

Choreoathetoid — a combination of chorea and athetosis, where the movements are irregular, but twisting and curving.

Dystonia — involuntary movements accompanied by an abnormal, sustained posture.

Ataxia — does not have to do with involuntary movements, but instead indicates impaired balance and coordination.

Other ____________________

None


Types and Forms

Gross Motor Function Classification System Checklist

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GMFCS Level I. Walks without limitations.

GMFCS Level II. Walks with limitations. Has limitations walking long distances and balancing. Not as able as Level I to run or jump. May require use of mobility devices when first learning to walk, usually prior to age 4. May rely on wheeled mobility equipment when outside of home for traveling long distances.

GMFCS Level III. Walks with adaptive equipment assistance. Requires hand-held mobility assistance to walk indoors, while utilizing wheeled mobility outdoors, in the community and at school. Can sit on own or with limited external support. Has some independence in standing transfers.

GMFCS Level IV. Self-mobility with use of powered mobility assistance. Usually supported when sitting. Limited self-mobility. Likely to be transported in manual wheelchair or powered mobility.

GMFCS Level V. Severe head and trunk control limitations. Requires extensive use of assisted technology and physical assistance. Transported in a manual wheelchair, unless self-mobility can be achieved by child learning to operate a powered wheelchair.

Other ____________________

None

Types and Forms

Orthopedic Impairment Assessment Checklist

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Muscle Tone
Movement Coordination and Control
Reflexes
Posture
Balance
Gross Motor Function
Fine Motor Function
Oral Motor Function
Other ____________________
None

Types and Forms

Associative Conditions and Co-Mitigating Factors Checklist

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Behavior
Cognition
Communication
Developmental Delay
Digestive Health
Dysphagia
Hearing
Mobility
Neurologic Health
Nutrition Health
Oral Health
Orthopedic Health
Respiratory Health
Seizure Control
Sensory
Skin Health
Socialization
Vision
Other ____________________
None


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Diagnosis

doctor checking infant's reflexes

American Academy of Pediatrics Issues Clinical Report Urging Early Diagnosis of Cerebral Palsy

For decades, physicians have been overly cautious in diagnosing cerebral palsy and other motor delays. But recently, the American Academy of Pediatrics stressed the importance of early diagnosis in a clinical report.
AAP urges doctors for early diagnosis »

Diagnosis

MRI for diagnosing cerebral palsy

Screens, Tests and Evaluations Used in Diagnosing Cerebral Palsy

Unfortunately, no single test or screen will definitively confirm cerebral palsy. In severe cases, or under specific circumstances, a child may be diagnosed shortly after birth. In the majority of cases, however, medical practitioners will most likely observe, screen, and test the child over the first one to five years of development and growth. During this time, doctors are able to rule out conditions, including cerebral palsy. This story provides information about reproductive health, screens, tests, and evaluations used during the process of diagnosis. Learn more.
Screens, Tests and Evaluations »

Diagnosis

a team of doctors and nurses with a boy during exam

12-Step Diagnosis Process

For parents of children being evaluated for developmental delay or for cerebral palsy, the diagnosis process can seem intimidating. Diagnosis, in most cases, takes time. Understanding the diagnosis process can be a source of comfort for parents anxious about the process. Learn more.
The 12-Step Diagnosis Process »

The Unexpected Journey

baby's hand holding parent's finger

Awaiting Diagnosis

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Cerebral Palsy Diagnosis

doctor checking infant's reflexes

The Importance of Early Diagnosis

Many people involved with the research and treatment of cerebral palsy believe the earlier a diagnosis is made, the better the child will fare. Early diagnosis allows the child to begin treatment before impairments have “set in.”

An infant’s brain, muscles, reflexes, and motor control continue to develop long after birth. For children with cerebral palsy, their brain injury prevents normal development. Eventually, muscles, coordination, and posture may become impaired. Beginning treatment early in infancy can yield some of the largest gains.

Because the young brain is developing (in a way, learning how to be a brain) treatment may help the child’s brain to adjust to the injury. The younger the brain, the more adaptable it may be, perhaps increasing the chance that the brain can “rewire” itself to mitigate the extent of the injury.

Motor control and reflexes are also still developing in babies. Spasticity becomes more apparent as the child grows. During infancy, the child may show no or little spasticity. As a result, the limbs are easier to move, possibly increasing the effectiveness of physical therapy both on the muscles and the brain.

Early diagnosis also enables parents to find benefits and funding for their children. A diagnosis increases the chances of qualifying for Early Intervention programs and receiving state and government aid.

Cerebral Palsy Diagnosis

baby sleeping peacefully

Reasons for Delayed Diagnosis

For all the benefits of early diagnosis, delayed diagnosis does occur – predominantly because the disorder is difficult to diagnose and doctors worry about the impact on parents. Receiving a diagnosis of cerebral palsy can be devastating, and doctors fear parents may withdraw and further hamper the child’s development.

Doctors do not want to deliver premature diagnoses. Where they may suspect cerebral palsy, doctors might keep the suspicions to themselves and talk to the parents about the symptoms. They may mention their suspicions, or just subtly prepare the parents for an eventual diagnosis.

Of course, the main reason to delay diagnosis is the difficulty of clearly identifying the disorder. Many possibilities exit, including the brain’s potential to compensate for the injury. Additionally, a number of other conditions may appear as cerebral palsy. Misdiagnosis is a danger of early diagnosis.

Cerebral Palsy Diagnosis

baby in NICU getting a backrub

Avoiding Misdiagnosis

Misdiagnosing any condition can be harmful to a child and can lead to inappropriate treatment such as unnecessary surgeries, medications, and expense.

Misdiagnosis can mean the condition was wrongly identified, altogether. Or, it can mean the condition was correctly identified, but the subtype was classified in error. Misdiagnosis could also entail wrongly identifying the underlying condition, the cause of the condition, the extent or severity of the condition, or complications of the condition.

For instance, the diagnosis of cerebral palsy may be correct, but the severity, extent or co-mitigating factors may have been improperly diagnosed. Not all specialists agree on the classification of the condition as provided and defined by another specialist.

Commonly diagnosed conditions are misdiagnosed less, while difficult-to-diagnose conditions are more commonly mistaken. Misdiagnosis can be the result of a doctor’s error, misread test results, incorrect laboratory readings, or overlooked alternatives.

It is recommended that parents avoid misdiagnosis by obtaining a second opinion, consulting with specialists, having medical tests thoroughly explained, and becoming educated on the child’s diagnosed condition.

If a child who has cerebral palsy is not diagnosed properly, the untreated impairment can result in more severe spasticity, abnormal posture, contractures and deformities. Other conditions can be mistaken for cerebral palsy.

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