General movements detect early signs of hemiplegia in term infants with neonatal cerebral infarction

Background. Studies have reported that infants with hemiplegia of congenital origin may have a period between birth and up to 12 months when clinical signs of hemiplegia are not evident. The aim of this study was to establish whether the assessment of general movements (GMs) may help in the earlier detection of signs of hemiplegia. Subjects and Methods. Eleven infants with cerebral infarction on brain MRI, and eleven normal controls were enrolled in the study. Quality of GMs was assessed from videotapes between 3 and 6 weeks and between 9 and 16 weeks. Neurological outcome was evaluated at least at two years. Results. Seven of the 11 infants had an assessment performed between 3 and 6 weeks: abnormal GMs were observed in all the infants who developed hemiplegia, but one child had abnormal GMs and a normal outcome. All 11 infants had a scorable assessment between 9 and 16 weeks. In all a specific type of GMs, fidgety movements (FMs), were predictive of neurological outcome. The presence of early asymmetries at both 3 - 6 and 9 - 16 weeks was also significantly associated with later signs of hemiplegia. Conclusions. The assessment of GMs after the neonatal period appears to be very useful in the early identification of hemiplegia in infants with cerebral infarction. Whilst the prediction of hemiplegia should be possible from early neonatal MRI brain scans, this facility is not always available. Observation of GMs is a bedside clinical approach that allows confirmation of early prediction from MRI, early rehabilitation if needed and reassurance that neurological outcome will be good where that is appropriate.     

Transient structural MRI patterns correlate with the motor functions in preterm infants

AimTo explore the relationships between transient structural brain patterns on MRI at preterm and at term-equivalent age (TEA) as a predictor of general movements (GMs) and motor development at 1-year corrected age (CA) in very preterm infants.MethodsIn this prospective study, 30 very preterm infants (median = 28wks; 16 males) had structural magnetic resonance imaging (MRI) at preterm (median = 31wks + 6d) and at TEA (median = 40wks) and neuromotor assessments. The quality of GMs was assessed by Prechtl’s general movements assessment and a detailed analysis of the motor repertoire was performed by calculating a motor optimality score (MOS), both at term age and at 3 months post-term. Motor development at 1-year CA was evaluated with the Infant Motor Profile (IMP). Associations between qualitative MRI findings and neuromotor scores were investigated.ResultsAbnormal GMs and low motor performance at 1-year CA were associated with the poor visibility of transient structural pattern, that is with sagittal strata.InterpretationTransient structural MRI pattern, sagittal strata, at preterm age is related to the quality of GMs and later motor development in preterm infants. This transient fetal brain compartment may be considered as a component of neurobiological basis for early neuromotor behavior, as expressed by GMs.     

Putative neural substrate of normal and abnormal general movements

During the last decade it has become clear that the assessment of the quality of general movements (GMs) in foetus and young infant is a sensitive tool to evaluate the integrity of the young nervous system. GMs are movements in which all parts of the body participate. The hallmark of typical GMs is movement complexity and variation; in abnormal GMs movement complexity and variation is reduced or absent. Abnormal GMs may predict developmental outcome. Prediction on the basis of longitudinal series of GM assessments is best. Second best is prediction on the basis of an assessment at ‘fidgety’ GM age, i.e. at 2–4 months post-term. Definitely abnormal GMs at ‘fidgety’ age are related to cerebral palsy, mildly abnormal GMs to minor neurological dysfunction at school age. In the present paper the hypothesis is advanced that GM complexity and variation are brought about by the transiently present cortical subplate and that abnormal GMs are the result of damage or dysfunction of the subplate and its efferent motor connections in the periventricular white matter.     

General movements in early infancy predict neuromotor development at 9 to 12 years of age

Assessment of the quality of general movements (GMs) in early infancy is a powerful instrument to predict cerebral palsy (CP). The aim of the present study is to explore the value of GM assessment in predicting minor neurological dysfunction (MND) at 9 to 12 years of age. Two groups of infants were studied prospectively: 28 low-risk full-term infants (11 females, 17 males) and 24 high-risk infants, mostly born preterm (<37 weeks; 11 females, 13 males). In each group the quality of GMs (normal or abnormal) was assessed during two developmental periods: the age at which 'writhing' GMs occur (36 weeks' postmenstrual age to 7 weeks' postterm) and the age at which 'fidgety' GMs occur (8 to 17 weeks' postterm). Eight of 24 high-risk infants were diagnosed as having CP at 4 to 9 years of age. The remaining 44 children were followed-up at 9 to 12 years. In children without CP, quality of GMs at 'fidgety age' was related to neurological condition (normal, simple MND, complex MND) at follow-up (rho=0.46, p<0.01). Abnormal GMs at 'fidgety-GM age' showed a specific relationship to the development of coordination problems (chi2=6.1, p=0.01) and fine manipulative disability (Fisher, p<0.05) at 9 to 12 years. This finding supports the notion that the quality of GMs may provide information on the integrity of complex supraspinal circuitries.     

Assessment of general movements at routine medical examination of one-month-old infants

On routine medical examination of one-month-old infants, general movements (GMs) were video-recorded for about 5 minutes of 252 infants born at Kyoto City Hospital or other hospitals, including the infants discharged from the NICU. Their ages ranged from 39 postmenstrual to 8 post-term weeks. One of the experimenters assessed 181 infants among 252 available for assessment of their GMs twice at intervals of more than one month without being informed about their clinical histories. The subjects included 19 low-birthweight infants, and their average age was 3.5 post-term weeks. The assessment was carried out in comparison to the "gold standard" GMs depicted in a demonstration video produced by the GMs Trust. The Kappa value for intra-observer concordance was 0.85. Twenty (11.0%) out of the 181 infants were judged abnormal because of their poor repertoire of GMs in both the first and second assessment. Neither cramped synchronized GMs nor chaotic ones were observed. Meanwhile, 155 (85.6%) out of the 181 infants were found to be normal. The incidence of abnormal GMs was significantly higher among infants with history of asphyxia and/or respiratory distress than among low-risk infants. There of the experimenters independently assessed GMs of 50 infants among 181 which had been video-recorded between June and September 1998. The inter-observer concordance was higher among the low-birth weight infants than among full-term ones. In conclusion, qualitative assessment of GMs by an experienced observer at routine medical examination of one-month old infants is a useful method for the follow-up of high-risk infants.     

Early neurological signs in preterm infants with unilateral intraparenchymal echodensity

The aim of the study was to document the early developmental course of neurological signs in a group of preterm infants at risk for hemiplegia due to unilateral intraparenchymal echodensity (UIPE). Sixteen preterm infants with UIPE and sixteen controls were given serial neurological examinations, according to the protocols currently adopted in the different NICUs of the project. Moreover, the quality assessment of their general movements (GMs) was assessed subsequently from videotapes, from birth until around four months postterm. At two years, 12 of the UIPE infants showed hemiplegia and one suffered from asymmetrical diplegia. The findings of the traditional neurological examination were abnormal for the large majority of the UIPE infants, although normal findings were also recorded in some cases, especially during the preterm period. Asymmetries were found after term age in nine UIPE and in two control infants. From the first observation onwards, all infants with UIPE showed bilaterally abnormal GMs and in those with unfavourable outcome fidgety movements (FMs) were absent. At the FMs period (9-16 weeks postterm), all infants with subsequent hemiplegia showed asymmetry of distal segmental movements which were reduced or absent on the side contralateral to the lesion. CONCLUSIONS: Unilateral brain lesions induce clear neurological signs and abnormal GMs in particular, although these abnormalities are not initially asymmetrical. A reduction of segmental movements on one side of the body during the third month postterm is highly predictive of hemiplegia.     

Clinical significance of general movements

Human fetuses and young infants have a repertoire of distinct patterns of spontaneous movements. A set of these movement patterns are known as general movements (GMs), which were defined by Prechtl as gross movements involving the whole body, and lasting from a few seconds to several minutes, or longer. GMs are characterized by the variable sequence of arm, leg, neck and trunk movements which begin gradually, wax and wane in intensity, force and speed, and end gradually. Extension and flexion movements of the arms and legs are mostly complex and variable because of superimposed rotations and frequent, slight changes in direction, which make the movements fluent and elegant. Initially GMs are complex, and then differentiate into single movements. GMs show no change during the fetal period, but change in early infancy into writhing, fidgety, oscillating, saccadic and swipes & swaps. Hadders-Algra indicated that on EMG, burst duration of phasic activity shortens, burst amplitude attenuates and tonic background decreases with development. In contrast to normal GMs that are smaller and monotonous in trajectory, abnormal GMs include poor repertoire of GMs, cramped-synchronized GMs, chaotic GMs, absent fidgety, and abnormal fidgety, that are periodic and monotonous, showing no developmental change. For example, a normal twin showed elliptic or round trajectory of GMs that became smaller with age, whereas the other with periventricular leukomalacia and cerebral palsy had periodic and rectilinear trajectory showing no developmental change. GMs, especially fidgety, correlate with neurological prognosis of infants. Einspieler reported that GMs' sensitivity and specificity for neurological prognosis of high risk infants are 96% and 95%, respectively. Clinical significance of GMs 1. includes non-invasive, secure and easy observation, 2. high coincidence between trained observers, 3. high reliability 78-98%, mean 90% and, 4. correlation of abnormal GMs with the presence and degree of brain damage.     

Quality of general movements in infancy is related to neurological dysfunction, ADHD, and aggressive behaviour

The quality of general movements (GMs) was assessed repeatedly during the first postnatal months in a mixed group of 52 children at either low or high risk for neurodevelopmental disorders. In addition, all children were reexamined at 4 to 9 years. The follow-up assessment consisted of a neurological examination and an evaluation of behaviour by means of parental questionnaires. The quality of GMs changed frequently, to stabilize in the final phase. The final GM phase is that of the so-called fidgety GMs which occurs between 2 and 4 months postterm. The quality of the fidgety GMs predicted outcome very well. Definitely abnormal GMs were associated with a high risk for the development of cerebral palsy, whereas mildly abnormal GMs were associated with the development of minor neurological dysfunction, attention-deficit-hyperactivity disorder, and aggressive behaviour.     

Assessment of general movements: towards a better understanding of a sensitive method to evaluate brain function in young infants

The consistent presence of an abnormal quality of general movements (GMs) during the first postnatal months points to a high risk for the development of a neurological disability. To elucidate the significance of abnormal GMs during a single assessment, a classification system for abnormal GMs was developed. To this end six term and ten preterm infants with abnormal GMs were studied longitudinally with video and electromyographic (EMG) recordings till 59 weeks postmenstrual age (PMA). Two basic categories of abnormal GMs were distinguished: (1) mildly abnormal GMs (two types), which lacked fluency while conserving pattern complexity, and (2) definitely abnormal GMs (four types), which lacked fluency and complexity altogether. GM type before 39 weeks PMA correlated with findings on neonatal ultrasound brain scans. GM quality after 47 weeks PMA was strongly related to neurodevelopmental outcome at IK years of age, suggesting that the absence of the age-specific 'fidgety' character of GMs could be a herald of disability.     

Abnormal general movements in girls with Rett disorder: the first four months of life

An apparently normal early development was one of the initial criteria for classical Rett syndrome. However, several investigators considered Rett syndrome to be a developmental disorder manifesting very soon after birth. Videos of 14 infants with Rett disorder were carefully assessed for their spontaneous movements, in particular general movements (GMs), during the first 4 months of life. A detailed analysis clearly demonstrated that none of the infants had normal GMs. However, a specific abnormal GM pattern could not be detected for Rett disorder. The abnormal GMs described here, and their individual developmental trajectories are different from the abnormal GMs described in infants with acquired brain lesion. Our study is the first to apply specific standardised measures of early spontaneous movements to infants with Rett syndrome, proving conclusively that the disorder is manifest within the first weeks of life.     

Upper limb movements and outcome in intrauterine-growth-retarded infants at 2 years

This study aims to examine the usefulness of spontaneous upper limb movements (ULM) as an early marker for predicting neurodevelopmental outcome in infants with intrauterine-growth retardation (IUGR). The assessment of general movements (GMs) during the first 20 weeks is an accepted method for early detection of brain dysfunction. During this period, spontaneous upper limb movements were examined in 32 infants with IUGR and 32 appropriate-for-gestational-age-matched controls. ULM (arms, forearms and hands) were scored as optimal or suboptimal by sequential videotape recordings in the writhing (term-2 weeks: score 0-5); early fidgety (9-11 weeks: score 0-6); and late fidgety (14-16 weeks: score 0-6) periods, and correlated with neurodevelopmental score at 2 years of age. The mean ULM score was lower in the IUGR infants than the controls (p<0.05) and in the IUGR group was lower in the infants with abnormal outcome (p<0.05). Significant correlations were found between ULM and 2-year neurodevelopmental scores in the IUGR group. The ULM during late-fidgety period was most predictive for 2-year neurodevelopmental score. No difference was found in the mean ULM score between the pre-term and term IUGR infants. We conclude that ULM score can serve as an early predictor for neurodevelopmental outcome at 2 years of age in infants with IUGR.     

Ocular motor disturbances in autism spectrum disorders: Systematic review and comprehensive meta-analysis

There has been considerable focus placed on how individuals with autism spectrum disorder (ASD) visually perceive and attend to social information, such as facial expressions or social gaze. The role of eye movements is inextricable from visual perception, however this aspect is often overlooked. We performed a series of meta-analyses based on data from 28 studies of eye movements in ASD to determine whether there is evidence for ocular motor dysfunction in ASD. Tasks assessed included visually-guided saccade tasks, gap/overlap, anti-saccade, pursuit tasks and ocular fixation. These analyses revealed evidence for ocular motor dysfunction in ASD, specifically relating to saccade dysmetria, difficulty inhibiting saccades and impaired tracking of moving targets. However there was no evidence for deficits relating to initiating eye movements, or engaging and disengaging from simple visual targets. Characterizing ocular motor abnormalities in ASD may provide insight into the functional integrity of brain networks in ASD across development, and assist our understanding of visual and social attention in ASD.     

Specific postural support promotes variation in motor behaviour of infants with minor neurological dysfunction

This study evaluated the effect of specific postural support on motor behaviour of infants with and without minor neurological dysfunction (MND). The following questions were addressed: (1) Does application of supportive pillows affect the time during which the infant exhibits general movements (GMs) or specific movements? We defined specific movements as movements of specific parts of the body that occur in a specific, recognizable way. (2) Does application of pillows improve the quality of GMs or the repertoire of specific movements? (3) Is a pillow effect affected by neurological condition? Forty healthy, term infants (16 males, 24 females; mean age 3.04m [SD 1.24mo], range 1–5mo) participated in the study. Twenty were neurologically normal and 20 had MND. Spontaneous motor behaviour in a supine position was video‐recorded for 180 seconds in four conditions applied in random order: support by a pillow in (1) the shoulder region, (2) the pelvic region, (3) the shoulder and pelvic region, or (4) no pillow support. Two independent assessors evaluated the quality of GMs. The other movement parameters were assessed with a computer program. Duration of movements was determined and a variation index, consisting of the number of different specific movements in a condition, was calculated. The presence of pillows did not affect the time spent in GMs, specific movements, or GM quality in either group. In neurologically normal infants the shoulder pillow with or without pelvic pillow induced an increase in the variation index (p >0.01), whereas in the infants with MND, all pillow conditions resulted in a substantial increase of the movement repertoire (p >0.001). Our results demonstrate that specific postural support promotes variation in motor behaviour of young infants. This is particularly true for infants with MND.     

Video-based screening for children with suspected autism spectrum disorder – experience during the COVID-19 pandemic in India

BackgroundAssessments for children with autism spectrum disorder (ASD) must adapt to the current COVID-19 pandemic through innovation in screening and assessment strategies using technology. To our knowledge there are no such studies reported from India. We aimed to study the predictive ability of video-based screening tool with definitive diagnosis in children with ASD.MethodThirty-nine children were screened independently by two examiners with a video-based screening tool to start intervention followed by an in-person evaluation by clinical DSM-5 diagnosis three months later.ResultSimilar to studies from developed countries, videos assessments showed a 94.87% correlation with the final diagnosis. Interobserver video agreement had a kappa correlation of 0.803, which was classified as substantial agreement.ConclusionVideo-based evaluations may be used as an interim assessment to initiate early intervention in children with ASD in resource-limited setups in the current pandemic situation. Large, well-designed prospective studies are required to confirm our results.     

Language Assessment and Development in Toddlers with Autism Spectrum Disorders

One of the primary diagnostic criteria for the diagnosis of autism spectrum disorders (ASD) is the presence of a language delay or impairment. Children with ASD are now being identified at significantly younger ages, and prior research has consistently found that early language skills in this population are heterogeneous and an important predictor for later outcome. The goal of this study was to systematically investigate language in toddlers with ASD and to identify early correlates of receptive and expressive language in this population. The study included 164 toddlers with ASD between the ages of 18 and 33 months who were evaluated on several cognitive, language and behavioral measures. Results suggested good agreement among different measures of early language, including direct assessment and parent report measures. Significant concurrent predictors of receptive language included gestures, non-verbal cognitive ability and response to joint attention. For expressive language, the most significant predictors were non-verbal cognitive ability, gestures and imitation. These findings have important implications for intervention programs targeting this population.     

Sleep study on patients with severe brain damage--polysomnographical examination

Polysomnograms were obtained for five severely brain damaged patients, and phasic sleep parameters-body movements (BMs) and rapid eye movements (REMs)-were examined. CT scanning of their brains demonstrated large low density areas in the bilateral hemispheres. In the three patients with flat EEG, sleep could only be classified into two stages; one with REMs[R(+)] and one without REMs[R(-)]. In the other two patients, stage R(-) was further classified into two stages according to the EEG findings. Gross movements (GMs) showed a synchronous pattern in all the patients. GMs and low angle REMs decreased in number while twitch movements and high angle REMs showed almost the same incidences as in normal controls. Localized movements showed marked variations among the patients. It was suggested that, except for normal uncoordinated asymmetrical GMs, BMs did not necessarily require higher brain structures for their generation.     

What Do Repetitive and Stereotyped Movements Mean for Infant Siblings of Children with Autism Spectrum Disorders?

Repetitive and stereotyped movements (RSMs) in infancy are associated with later diagnoses of autism spectrum disorder (ASD), yet this relationship has not been fully explored in high-risk populations. The current study investigated how RSMs involving object and body use are related to diagnostic outcomes in infant siblings of children with ASD (Sibs-ASD) and typically developing children (Sibs-TD). The rate and number of different types of RSMs were measured at an average of 15 months with follow-up diagnostic evaluations approximately 18 months later. While Sibs-ASD displayed higher rates of RSMs relative to Sibs-TD, rates did not differ according to diagnostic outcome in Sibs-ASD. However preliminary evidence suggests that qualitative differences in RSM type warrant further investigation as early diagnostic markers.     

Comorbid psychopathology factor structure on the Baby and Infant Screen for Children with aUtIsm Traits-Part 2 (BISCUIT-Part 2)

Autism Spectrum Disorders (ASD) is a topic receiving great attention from researchers and clinicians in the field. However, many of these studies focus on children or adults, with research on infants and toddlers evincing ASD being virtually non-existent. Even more scant is information pertaining to the assessment of symptoms of comorbid psychopathology in this young population. Nonetheless, it is essential to identify comorbid conditions in addition to the symptoms associated with the core features of ASD. Building on the effectiveness of early intervention with children with ASD, comprehensive evaluations and individualized treatment goals are necessary and may enhance treatment efficacy. The Baby and Infant Screen for Children with aUtIsm Traits-Part 2 (BISCUIT-Part 2) is a new assessment, specifically designed to examine symptoms of psychopathology in infants and toddlers with ASD. The purpose of this study was twofold. First, the factor structure of the BISCUIT-Part 2 was established. Second, group differences in the endorsement of symptoms of psychopathology were examined between infants and toddlers with and without ASD.     

Early language milestones predict later language,but not autism symptoms in higher functioning children with autism spectrum disorders

Language ability is a known predictor of outcome in children with autism but plays a more controversial role for higher functioning children with autism spectrum disorders (ASD). We studied the relationship between early language milestones and later structural language, adaptive functioning and autism symptoms in a sample of 76 children (mean age = 9.1 years) with an ASD, using two different language milestones: first phrase by 24 or 36 months. After controlling for age and nonverbal abilities, retrospectively reported early language milestones were predictive of later structural language abilities, measured by a sentence repetition task, and adaptive communication skills, but not autism symptoms or adaptive social skills. Acquisition of phrase speech by 24 months was sensitive to language and communication impairments in our ASD group, the majority (84%) of which had already acquired phrase speech by 36 months of age. Early available and easily collectable milestone data may be a useful marker of later language performance even in higher functioning, verbal children on the autism spectrum. When a detailed assessment of language is not possible, data on early milestones may be useful for identifying children at-risk in clinical settings and for language phenotyping in the laboratory.     

La motricité spontanée du nouveau-né comme outil diagnostique et son rôle dans la prise en charge précoce

The neurological assessment of the newborn infant is fundamental to early diagnosis and prognosis, intensive monitoring, and treatment programs. The clinician can take advantage of a wide range of protocols, the majority of which are based on muscular tone and reflexes, but active and spontaneous behavior is increasingly taken into account, proceeding from the seminal work done by Prechtl, Brazelton and other authors in the seventies and eighties. Prechtl's method on the assessment of General Movements (GMs) is a standardized protocol for the recording, observation and qualitative judgement of spontaneous motor activity, suitable for the preterm as well as the full-term newborn infant from the preterm period up to 24 weeks of post-term age. The method has a very high predictive value for the major disorders of motor development, in particular cerebral palsy, with both sensitivity and specificity above 90%. But GMs are also predictive for minor neurological, cognitive and relational disorders. Recently, tight and specific relationships have been shown between GMs quality and structural anomalies found on neonatal neuroimaging. The importance of GMs in clinical practice is not restricted to evaluation: this is an approach that teaches us to observe without excessive manipulation, to respect age-specific functional competences, to pay attention to spontaneous activity as a potential repertoire, from which the most effective patterns can be selected, reinforced and adapted.