Functional Status of the Children with Cerebral PalsyAnd Their Mothers’ Psychological Status: A Cross-sectional Study

Objective:  The  aims  of  this  study  were  to  assess  the  demographic  characteristics  and functional status of children with cerebral palsy (CP) and to evaluate the psychological status of  their mothers. Materials and Methods: Demographic characteristics, CP type, Gross Motor Functional Classification System (GMFCS) levels, Functional Independence Measure for Children (WeeFIM) scores were recorded. Mothers were asked to fill Symptom Check List 90 Revised  (SCL  -90-R). Results: A  total of 101 patients were  included  in the study (%57,4% boys, %42,6% girls). Their mean age was 6,79±4,48 (1,5-18) years. Mothers’ mean age was 33,31±7,72 (20-53) years. The neurologic classification were as follows: diplegia 27,7%, tetraplegia 45,5%, hemiplegia 19,8%, dyskinetic or ataxic 6,9%. The GMFCS levels were as follows: level 1 11,9%, level 2 14,9%, level 3 17,8%, level 4 25.7%, level 5 29,7%. SCL-90-R outcomes were as follows: 38,6% somatization, 18,8% anxiety, 37,6% obsessive-compulsive, 36,6% depression, 32,7% interpersonal-sensitivity, 21,8% eating-sleeping disorder. We didn’t detect any significant correlation between the GMFCS levels of children and mothers’ physicological status. Childrens’  low WeeFIM scores  were  related  with  anxiety,  obsessive-compulsive,  depression,  interpersonalsensitivity, paranoid ideation and eating-sleeping disorder. (p=0,009, p=0,017, p=0,009, P=0,0001, p=0,021, p=0,001 respectively). The presence of chronic disease was related with somatization, anxiety and depression (p=0,001, p=0,024, p=0,008 respectively). The presence of pain was related with somatization (p=0,0001). Conclusion: Lower WeeFIM scores of children with CP and chronic disease and pain presence in their mothers were detected as the factors that negatively affect psychological status of mothers.


Introduction
Cerebral Palsy (CP) is a permanent impairment of motor function which develops as a result of a non-progressive lesion in the developing brain. Although the lesion is static, activity limitation may change with age. 1,2 Motor disorders are often associated with cognitive, communication, behavior and seizure disorders with secondary musculoskeletal problems. 1,2 Due to musculoskeletal and accompanying problems, functional independence of children with CP is adversely affected. 3 Therefore, these children need a constant caregiver in their daily life activities so mothers are naturally caregivers. 4 Caring for children with physical disabilities can be overwhelming usually bacause this role is full time as they depend on the caregiver for most of their daily living activities. 4,5 This situation brings with it many difficulties for the caregiver in daily life activities that negatively affects their psychological state. 6,7 Caring for a child with a chronic condition may be more stressful than caring for a child without a disability. 8,9 The aim of this study was to evaluate the relationship between the functional status of children with CP and the psychological status of their mothers.

Materials and Methods
This study was carried out at a tertiary hospital and 3 special education centers, after obtaining the approval of the hospital's ethics committee. It was performed by the principles stated in the Declaration of Helsinki. A total of 101 children who were previously diagnosed with CP and their mothers, who applied to our outpatient clinic and received physiotherapy in special education centers, participated in the study. Written informed consent were obtained from the mothers. Demographic data of patients and their families were recorded. The cases were classified according to Gross Motor Function Classification System (GMFCS) and CP types. Functional independence scores were recorded by evaluating the Pediatric Functional Independence Measure (WeeFIM). The mothers were given a symptom screening list (SCL90 R) form and asked to fill it out in a room where they could be alone. Inclusion criteria: All children aged between 1.5 and 18 years who were diagnosed with CP and their mothers were included. Exclusion criteria: Mothers being illiterate The Symptom Checklist 90R (SCL90R) was used to assess the psychiatric morbidity. The questionnaire consists of 90 items dealing with an individual's symptom distress in the previous three months. The rating is made on a Likert-type scale (0-not at all, 4-severe). The scale consists of 9 dimensions (somatization, obsessivenesscompulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism). In addition to these results this scale also offers Global Severity Index (GSI) which was used as indicator of the current level or the depth of the disorder. 10 Gross Motor Function Classification System (GMFCS) was used to classify functional level compatible with age of individuals with CP. Children with cerebral palsy are the least dependent on level 1 and the most dependent on level 5 in motor functions. 11 The Functional Independence Measure for Children (WeeFIM) was used for the functional independence assessment of children. The WeeFIM consists of 18 items in 6 domains: self-care, sphincter control, transfers, mobility, communication, and social cognition. Scoring is done between 1 (fully dependent) and 7 (fully independent) points. The lowest possible score is 18 and the highest score is 126. 12 Statistical analyses were performed using IBM SPSS Statistics version 25 (SPSS Inc., Chicago, IL, USA). Categorical data were presented as numbers and percentages, while continuous data were reported as means ± SD. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to examine the normal distribution, data were normally distributed so means for continuous variables were compared using independent t-tests. Pearson correlation was used to find the correlation between SCL-90R and WeeFIM, GMFCS, child age, mother age. The results were evaluated bilaterally at 95% confidence interval, significance level at p <0.05 and p < 0.01.

Discussion
We examined the effects of the functional status of children with CP on the psychological status of their mothers. Among mothers 43,6% of them had somatization (pains in the chest or heart region, headaches, stomach-related disorders…), 39,6% had depression, and 31,7% had additional scale (eating, sleep disorders).
Half of our CP patients had a level of 4-5 according to GMFCS, and their average WeeFIM score was low. We found that lower WeeFIM scores were associated with anxiety, obsession, depression, interpersonal sensitivity, paranoid thinking, phobic anxiety and additional scale in the mother. It was determined that the GMFCS levels did not affect the psychological state of the mothers except interpersonel sensitivity.
Mobarek et al. found that 41.8% of mothers of children with CP were at risk for psychiatric disease. 13 In another study significant psychopathology was found in 90% of mothers 14 Depression, anxiety, somatization and obsessivecompulsive disorders were the most detected problems. 14,15 It was found that depression and anxiety were higher in mothers of children with CP when compared with healthy children's mothers. 16,17 The depression levels of the mothers were positively correlated with the child's GMFCS score and negatively correlated with the WeeFIM score of child with CP. 16 We also found that low WeeFIM scores negatively affected the psychological state of the mother. Similar to our findings, GMFCS levels of CP children were not found to be associated with depression, anxiety and stress in mothers. [17][18][19] There are also studies that found that children's GMFCS levels were correlated with mothers' physical and mental health. 6,20 Not only the functional status of the child but behavioral problems due to inability of being independent in daily living activities, sleep problems, and incontinence can cause stress in mothers. 13,21,22 In a study the child's behavioral problems were found as the single most influential factor on the mother's psychological state. 23 Families of children with disabilities have to cope with greater financial stress, deterioration of family relationships, and reduced social activity outside the family. 20,22 Mother's work outside the home affected their mental health in a good way. 22 Since almost all of the mothers were housewives in our study, we could not evaluate the effect of working outside on their psychological state. In a study examining the mothers of children with hemophilia, 83% of the mothers stated that they thought the disease limited their lives and affected their mental states. 24 Ozturk et al. found that mothers showed their strains by somatizing. 24 Primary caregivers of children with CP had more psychological and physical symptoms and the burden of caregiving increases stress and this manifests itself in different chronic conditions. 25 There was a strong relationship between comorbid factors and parental stress. 18 Unsatisfying parental health status was associated with intensity of anxiety and depression in the parents of children with CP. 26 We found that the presence of chronic disease in mothers was associated with somatization, anxiety, depression, psychosis, paranoid thought, phobic anxiety, additional score and general symptom elevation. Having children with CP deteriorated musculoskeletal health. 19 Among caregivers of CP children it was found that aproximately 65% of them had pain complaints. 19,27 Children with CP are unable to manage themselves and they are dependent on their mothers, and the mothers experience more difficulties. Lifting and carrying the child can cause more physical strain and pain to the mother. 19,27,28 It was found that the incidence of musculo-skeletal pain increased as the child's functional level deteriorated. 28,29 We found that the presence of pain was 67,3% in mothers and this was associated with somatization. The limitations of the present study are its crosssectional nature and lack of healthy control group. Despite these shortcomings, we would like to draw attention to the psychological state of mothers. They may experience stressrelated health problems, and this can impact the mother's relationship with the child and can be detrimental to the child's development and wellbeing. 30 Mothers with disabled children need psychosocial support more than other mothers. Therefore phsyologic status of these mothers should be closely monitored, emotional sharing should be ensured and when needed psychological support should be provided. 31 Conclusion Lower WeeFIM scores of children with CP andchronic disease and pain presence in their mothers were detected as the factors that negatively affect psychological status of mothers.Reducing caregiving burden of the mothers' and increasing psychosocial supports may help improve the mother's physical and mental health. Conflict of interest:The authors declare that they have no confict of interest. This article is produced from Esma Demirhan's specialty thesis in Medicine.