REFERENCES

1. Soo B, Howard J, Boyd RN, et al. Hip displacement in cere-

bral palsy. J Bone Joint Surg Am 2006; 88: 121–9.

2. Wynter M, Gibson N, Kentish M, Love SC, Thomason

P, Graham HK. Consensus Statement on Hip Surveillance

for Children with Cerebral Palsy:. Australian Standards of

Care 2008. http://www.ausacpdm.org.au/professionals/hip-

surveillance (accessed 12 September 2011).

3. Robin J, Graham HK, Baker R, et al. A classification system

for hip disease in cerebral palsy. Dev Med Child Neurol 2009;

51: 183–92.

4. Presedo A, Oh CW, Dabney KW, Miller F. Soft-tissue

releases to treat spastic hip subluxation in children with cere-

bral palsy. J Bone Joint Surg Am 2005; 87: 832–41.

5. Gose S, Sakai T, Shibata T, Akiyama K, Yoshikawa H,

Sugamoto K. Verification of the Robin and Graham classifica-

tion system for hipdisease in cerebralpalsy usingthree-dimen-

sional computed tomography. Dev Med Child Neurol 2011;

53: 1107–12. DOI: 10.1111/j.1469-8749.2011.04130.x.

6. Brunner R, Picard C, Robb J. Morphology of the acetabulum

in hip dislocations caused by cerebral palsy. J Pediatr Orthop

B 1997; 6: 207–11.

7. Brunner R, Robb JE. Inaccuracy of the migration percentage

and center-edge angle in predicting femoral head displace-

ment in cerebral palsy. J Pediatr Orthop B 1996; 5: 239–41.

A tool kit for measuring functioning in children with neurodisability:calibrating activitiesMICHAEL E MSALLThe University of Chicago, Joseph P Kennedy Jr Intellectual and DevelopmentalDisabilities Research Center, Chicago, IL, USA.

doi: 10.1111/j.1469-8749.2011.04133.x

This commentary is on the original article by Haley et al. on pages1100–1106 of this issue.

A critical need for children with disabilities is to be as inde-pendent as possible in daily activities.1 A challenge forhealth and community professionals is to describe children’sperformance in self-care, mobility, social cognition, andjudgment over time. Advances in the statistical analyses of abroad spectrum of items from valid questionnaires allowsfor the possibility of profiling the impact of a child’s dis-ability in body structure or physiology.2 A limitation to thisapproach has been the difficulty of having several differentquestions over many daily tasks for the various age groups.It is in this context that the study by Haley et al.3 should beexamined.

What was done? Building on their experiences with thePediatric Evaluation of Disability Inventory (PEDI), an itembank of 76 self-care (eat, groom, chores, operating electronicdevices), 105 mobility (roll, sit, walk, run, carry, transfer, nego-tiate stairs, terrains, public transportation), 64 social ⁄ cognition(communication, peer interaction, play, attention, problem-solving), and 53 responsibility (organizing and planning, tak-ing care of daily needs, health management, sleeping safely)tasks were analyzed.4 Computer-generated algorithms usingitem response theory were able to generate a core number ofquestions to describe a child’s current strengths and challengesin these domains of activities.

Who was studied? A representative sample of 2205 Eng-lish-speaking parents of children without developmentaldelay or special health care needs were recruited through anInternet survey organization (YouGovPolimetrix). Thecohort was representative of sex, race, and socioeconomicstatus of children residing in the United States, and included

100 children at each age level from the first year of lifethrough age 21. In addition, 617 children with a physical,cognitive, or behavioral disability from the same survey net-work and 86 children with neurodevelopmental disabilitiesfollowed in clinical programs for children with special healthcare needs were recruited. The children with disabilityincluded children with cerebral palsy, traumatic brain injury,and neurosensory impairments as well as those with a widevariety of communication, learning, attention, developmen-tal, and behavioral challenges.

What was found? The new computer-adaptive PEDI tests(PEDI-CAT) allows children and young people between thefirst year of life and 21 years to be surveyed with a focusednumber of items to describe their performance along a contin-uum in daily activities of functioning.

The test was taken by the parents of children with or with-out a disability and involved 15 items, and 10 to 15 minutesof interview time. Assessments could take place over the Inter-net through existing opt-in survey panels or through computertablets in clinical sites.

The accuracy of both the 10-item and 15-item PEDI-CATwas proven by the high correlation coefficients using scoresfrom real world data. Accuracy was highest for performance inthe midrange.

This study demonstrates the value of the computer-adaptivetest as a tool to develop appropriate items across a spectrum ofindividual functional performance in mobility, self-care, socialcognition, and judgment tasks.

What are the implications? The advantage of using a largeitem bank that has previously been validated in children withdevelopmental and acquired disability is that item responsetheory can be applied, so that children’s ability in functionalskills already mastered can lead to a more focused interviewon skills that are the immediate next steps in the child’s reper-toire. For example, if a child walks indoors to criterion specifi-cations, one does not need to ask if they roll or crawl.Similarly, if one communicates basic needs in short sentences,one does not have to query if they are able to speak in single

Commentaries 1073

words. Using this approach, 15-item PEDI-CATs can provideaccurate assessments and will be a valuable addition to mea-suring outcomes in functioning in epidemiological, clinical,and rehabilitation studies.

What are the next steps? There is a great deal of interestamong individuals with disability, their families, and healthprofessionals to optimize and maintain function. Crucial tothis undertaking is to have a tool kit for measuring functioningin order to evaluate which combination of medical and reha-bilitation interventions work for which individuals and inwhich context, and how to promote enablement in activitiesthat allow for participation in social roles. Haley et al.5 havehelped in evaluating our current efforts by giving clinicians,

researchers, and families of children with neurodisabilitya multidimensional toolbox. Our next task is to apply thesemeasures to more systematically examine how current inter-ventions are impacting positively or negatively on children’sfunctioning and how these measures capture responsiveness tochange over time.

ACKNOWLEDGEMENTSSupported in part by NIH ⁄ NICHD Grant P30 HD054275 Joseph P

Kennedy Jr Intellectual and Developmental Disabilities Research

Center, and HRSA-DHHS T73 MC11047 Leadership Education in

Neurodevelopmental and Related Disorders Training Program

(LEND).

REFERENCES

1. Msall ME, Park JJ. Neurodevelopmental management strate-

gies for children with cerebral palsy: optimizing function,

promoting participation, and supporting families. Clin Obstet

Gynecol 2008; 51: 800–15.

2. Cella D, Gershon R, Lai J, Choi S. The future of outcomes

measurement: item banking, tailored short-forms, and

computerized adaptive assessment. Qual Life Res 2007; 16

(Suppl. 1): 133–43.

3. Haley SM, Coster W, Dumas HM, et al. Accuracy and

precision of the Pediatric Evaluation of Disability Inventory

computer-adaptive tests (PEDI-CAT). Dev Med Child Neurol

2011; 53: 1100–06. DOI: 10.1111/j.1469-

8749.2011.04107.x.

4. Dumas H, Fragala-Pinkham M, Haley S, et al. Item bank

development for a revised Pediatric Evaluation of Disability

Inventory (PEDI). Phys Occup Ther Pediatr 2010; 30: 168–84.

5. Haley S, Coster W. PEDI-CAT: Development, Standardiza-

tion and Administration Manual. Boston, MA: CRECare,

LLC, 2010.

Influence of cerebellar malformations on cerebral volume: does itmatter?ANDREA PORETTIDivision of Pediatric Radiology, Russell H. Morgan Department of Radiology andRadiological Science, The Johns Hopkins School of Medicine, Baltimore, MD, USA.

doi: 10.1111/j.1469-8749.2011.04100.x

This commentary is on the original article by Bolduc et al. on pages1128–1134 of this issue.

The cerebellum is not only important for motor functions,but also affects a wide range of cognitive tasks includingexecutive functions, spatial perception, language and speech,and affective functions. This was highlighted by Schmahmannand Sherman1 in their description and conceptualization ofthe cerebellar cognitive affective syndrome (CCAS). Sincethen, the impact of the cerebellum on cognitive functions hasbeen increasingly shown in cerebellar malformations.2 Eventhough the pattern of cognitive impairment in cerebellar mal-formations is less specific than in acquired focal cerebellarlesions, it is still reminiscent of the CCAS.

The anatomical basis of the cerebellar role in higher cogni-tive functions is the existence of cerebro-cerebellar connec-tions (cortico-ponto-cerebellar and cerebello-thalamo-corticalloops) that link the cerebellum with associative regions in theprefrontal, posterior parietal, superior temporal polymodalregions, and dorsal parastriate cortices as well as with the limbic ⁄paralimbic regions.

The interaction between cerebellum and cerebrum mayaffect the anatomical structures involved in terms of volume.

In preterm infants, unilateral cerebral parenchymal brain inju-ries have been shown to result in subsequent impairment inthe contralateral cerebellar volume and, conversely, primaryunilateral cerebellar injuries were reported to be associatedwith impaired contralateral cerebral brain volume at term.3

Bolduc et al.4 demonstrate that cerebellar volumetricimpairment is associated with altered growth in specific cere-bral regions and attribute this to cerebellar malformations.5

Although the small number of children included and theheterogeneous cohort of patients may be limitations ofthe study (in terms of different cerebellar malformations), theauthors demonstrated significantly reduced volume in thedeep grey matter nuclei, inferior occipital grey matter, andsubgenual and midtemporal white matter. The developingcerebrum, therefore, appears to require an intact cerebellumto achieve its normal structure and volume as the result of atrophic transynaptic effect. The authors hypothesize that theassociated regional reductions in cerebral volumes may repre-sent a possible mechanism underlying developmental disabili-ties and cognitive impairment in children with cerebellarmalformations.

The interaction between cerebellum and cerebrum, how-ever, is not limited only to a trophic transsynaptic effect, butmay also lead to a cerebral cortical functional impairment. Theposterior fossa syndrome is a particularly acute form of theCCAS characterized by cerebellar dysfunction, oromotorapraxia, emotional lability, and mutism in patients after infra-tentorial injury. This syndrome is a good example of function-

1074 Developmental Medicine & Child Neurology 2011, 53: 1071–1076