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The Role of Anxiety in Children with Cerebral Palsy
with Spasticity and Movement Disorders:
A Brief Case Series
Laura L. Owens, MD1,2 Stephanie Chopko, PhD1 Maura McManus, MD1,2
1 Nemours/AI
Introduction
•Multiple children seen in the Nemours/AIDHC multidisciplinary
cerebral palsy (CP) spasticity clinic have been found to have
extremely difficult to control spasticity or dystonia.
•Many of these children also met DSM-IV-TR/DSM5 criteria for
diagnosis of anxiety, triggering the question of the relationship
between the two processes.
•Particular areas of the brain, including the basal ganglia, are more
susceptible to hypoxic, ischemic or metabolic insult and are related
to both movement , cognitive function and mood control.
•This extrapyramidal modulator is involved with higher-order
cognitive aspects of motor control as well as the planning and
execution of complex motor strategies, influencing the increase or
decrease of motor output.
•We hypothesize that improved control of anxiety will result in
improved function with decreased tone and excess movement.
Methods
•Patients with both difficult to manage spasticity or dystonia along
with components of anxiety identified at clinic visits.
•Patients and families interested in participating had at least 1
outpatient psychology visit for either individual and/or family
therapy and were followed up with future office visits.
•Patients continued with appropriate medical management,
including titration of oral and intrathecal spasticity medications and
agents for movement disorders (ie Sinemet).
•Changes in mood and tone were based on both patient and family
report and clinician evaluation at subsequent visits as documented
in the chart.
Contact Information: Laura Owens, MD
[email protected], 302-651-5600
Nemours/AIDHC Dept. of Rehabilitation Medicine,
1600 Rockland Rd. Wilmington DE, 19806
duPont Hospital for Children, Wilmington, DE
2Thomas Jefferson University, Kimmel College of Medicine, Philadelphia, PA
Brief Case Synopses
•17 year-old male with history of spastic quadriplegic CP, treated with intrathecal baclofen,
intellectual disabilities and history of anxiety and depression. He was noted to have increased
tone, often triggered by anxiety, along with a “startle” reflex, especially when discussing
difficult issues such as a recent death in the family. The patient received several sessions of
psychotherapy along with a low-dose SSRI. He and family noted an improvement in tone along
with better overall functioning.
•15 year-old female with quadriplegic CP with spasticity and dystonia, treated with intrathecal
baclofen , cognitively intact with dysarthric speech. Mental health history included anxiety,
emotional volatility, verbal aggression and agitation with family stressors and limited
community resources. The patient was seen for worsening anxiety, triggering increased tone,
often with dramatic movements of her arms and legs. She was seen for two visits with limited
improvement and referred to community practitioner closer to her home for on-going care.
•22 year-old female with spastic quadriplegic CP, treated with intrathecal baclofen, and history
of anxiety and depression. She was initially referred due to symptoms of worsened anxiety and
depression, which coincided with on-going pain symptoms, resulting in inability to continue at
college independently. The patient had minimal improvement with short-term intervention (e.g.,
deep breathing/imagery before a medical procedure) however these gains were not able to be
maintained without on-going treatment. It is unclear to what degree these symptoms were being
worked on via the community provider, as she has since sought treatment closer to home.
•13 year-old male with quadriplegic CP mixed-movement disorder (dystonia and athetoid
movements), treated with intrathecal baclofen, as well as intellectual disabilities and limited
speech. The patient presented with concerns of anxiety with physical manifestations (sweating,
shaking, increased movements and startle). He was seen by psychology and had limited
improvement with behavioral interventions but did show marked reduction in these episodes
with initiation of an SSRI.
Nemours is an internationally recognized children’s health system that owns and operates the Nemours/Alfred I. duPont Hospital for
Children in Wilmington, DE, along with major pediatric specialty clinics in Delaware, Florida, Pennsylvania, and New Jersey. In October,
2012, it opened the full-service Nemours Children’s Hospital in Orlando, Florida. To learn more about Nemours, visit www.Nemours.org.
Discussion
•The addition of psychology support in the CP program has
brought to light a significant number of teenagers with
anxiety disorders in addition to motor deficits of cerebral
palsy. We have noted over a dozen children with this dual
diagnosis.
•In some cases onset or worsening of underlying anxiety
appears to be linked to worsening of spasticity or movement
disorder which is often refractory to available medical
management.
•Addition of mental health support with individual and/or
family therapy along with judicious use of medications may
improve both mood and physical functioning.
Conclusions
•The exploration of anxiety disorders in children with CP is
ripe for study, most notably in regards to the link between
anxiety and worsening of spasticity and dystonia.
•We look forward to continuing to further pursue this link,
enriching the knowledge of anxiety disorders in CP and their
link to patient function. Our plans include a formalized
approach to instituting psychology support and further
surveillance of outcomes using quality of life, anxiety, and
spasticity measures in this population.
•Further research looking at the relationship of anxiety and
spasticity vs movement disorders, the cognitive level of
patient function, and/or the impact of structured psychology
interventions and medications will be helpful in the future
treatment of these patients.
References
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2. Leisman, Gerry, and Robert Melillo, Frederick R. Carrick. “Clinical Motor and Cognitive Neurobehavioral Relationships in the Basal
Ganglia”. Basal Ganglia – An Integragive View. Ed. Fernando A. Barrios and Clemens Bauer. 2003. Available from:
http://www.intechopen.com/books/basal-ganglia-an-integrative-view/clinical-motor-and-cognitive-neurobehavioral-relationships-in-thebasal-ganglia
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