A half century ago electronic fetal monitoring was rushed into clinical use with the promise that the secrets of fetal heart rate decelerations had been discovered and that the newly discovered knowledge would prevent cerebral palsy with just in time cesarean sections preventing babies from experiencing asphyxia, which was thought to be the primary cause of cerebral palsy. In the years since electronic fetal monitoring’s debut, it has been discovered that asphyxia is a rare cause of (...) cerebral palsy. At the same time electronic fetal monitoring use increased to 85% of all labors, the C-section rate increased to 33% without an attributable decrease in the rate of cerebral palsy. What went wrong with electronic fetal monitoring? The answer lies in a new analysis of the physiologic theories concerning fetal heart rate decelerations, demonstrating that the earlier electronic fetal monitoring theories were wrong. This revelation is only the latest evidence that electronic fetal monitoring use today... (shrink)

_Aims:_ The aim of the present study was to examine how executive functions are assessed in children and adolescents with Cerebral Palsy. _Method:_ A systematic literature review was conducted using four bibliographic databases (WebScience, Scopus, PubMed, and Psycinfo), and only studies that evaluated at least one executive function were selected. Both the research and reporting of results were based on Cochrane's recommendations and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. _Results:_ The instrument most frequently used (...) was the D-KEFS. All studies point to the existence of impairments in the executive functions among children and adolescents with Cerebral Palsy with an impact on several cognitive and life domains. _Interpretation:_ There is a need to further systematize the research protocols to study the executive functions and their assessment in the intervention context. Findings of this review presented a diversity of tests (e.g., D-KEFS) or tasks (e.g., The inhibitory ability task) used with children with Cerebral Palsy. However, no information was given about adaptations performed to the test/task to meet Cerebral Palsy's specificities. Future research could consider including this information, which is key both to researchers and practitioners. The results of this study have important implications and suggestions for future avenues and guidelines for research and practice. (shrink)

Individuals with cerebral palsy (CP) have deficits in processing of somatosensory and proprioceptive information. To compensate for these deficits, they tend to rely on vision over proprioception in single plane upper and lower limb movements and in standing. It is not known whether this also applies to walking, an activity where the threat to balance is higher. Through this study, we used visual perturbations to understand how individuals with and without CP integrate visual input for walking balance control. (...) Additionally, we probed the balance mechanisms driving the responses to the visual perturbations. More specifically, we investigated differences in the use of ankle roll response i.e., the use of ankle inversion, and the foot placement response, i.e., stepping in the direction of perceived fall. Thirty-four participants (17 CP, 17 age-and sex-matched typically developing controls or TD) were recruited. Participants walked on a self-paced treadmill in a virtual reality environment. Intermittently, the virtual scene was rotated in the frontal plane to induce the sensation of a sideways fall. Our results showed that compared to their TD peers, the overall body sway in response to the visual perturbations was magnified and delayed in CP group, implying that they were more affected by changes in visual cues and relied more so on visual information for walking balance control. Also, the CP group showed a lack of ankle response, through a significantly reduced ankle inversion on the affected side compared to the TD group. The CP group showed a higher foot placement response compared to the TD group immediately following the visual perturbations. Thus, individuals with CP showed a dominant proximal foot placement strategy and diminished ankle roll response, suggestive of a reliance on proximal over distal control of walking balance in individuals with CP. (shrink)

Taking children with Cerebral Palsy (CP) as an example, the article seeks an understanding of children with disabilities that connects neuropsychological theories of neural development with the situated cognition perspective and the child as an active participant in its social practices. The early brain lesion of CP is reconceptualised as a neurobiological constraint that exists in the relations between the neural, cognitive and social levels. Through a multi-method study of two children with CP, it is analysed how neurobiological (...) constraints arise, evolve and sometimes are resolved through local matches between the child and its social practices. The result is discussed as support of a developmental science approach that includes processes at the social practice level along with knowledge of biological processes. (shrink)

From a cultural-historical perspective, the impairments of a child with a condition like cerebral palsy have biological origins, but the disability evolves from the mismatch between the child and his/her social conditions for development. One example of this dialectical production of disability can be seen in the challenge of the 21st-century welfare state: How to provide economically feasible health and educational services anchored in evidence-based methods and practices. Standardized social service pathways for children with CP illustrates an attempt (...) to address this challenge and moderate the mismatch by acting in the intersection between impairment and society. The aim of the article is to analyze challenges in the practice of connecting research and practice-based knowledge with societal practices in order to diminish the disability of the child. A multidisciplinary group assembled by the Danish National Board of Social Services engaged in a practice of developing a guideline for a social service pathway. Agendas and minutes from their series of meetings provide insight in how the work evolved through conflictual discussions. Rather than a neutral transformation of knowledge into practice, the practice revealed itself as a value-laden process in which the needs of the child and family were at times decentred and the focus shifted to how social services could be realised in complex, structured social practices. While the group managed to overcome several conflicts and agree of a social service pathway, a socio-economic analysis was unable to argue for the comprehensive social service pathway as an economic sound choice for municipal decision-makers. The conflict between the welfare ideology and economic feasibility remains unresolved and can be expected to limit the extent that impairments can be remedied and the mismatch decreased. Overcoming or diminishing the mismatch might never become economic worthwhile. As the political pendulum oscillates between welfare and economic concerns, the experience of disability will likewise diminish or expand. (shrink)

Despite external environmental changes in walking, such as manipulating gait speed, previous studies have shown that the underlying muscle synergy structures (synergy weights or vectors) rarely vary. The purpose of this study is to examine if external environmental changes to the walking task influence muscle synergies in children with cerebral palsy (CP) and/or typical development (TD). To identify muscle synergies, we extracted muscle synergies from eight children with CP and eight age-matched TD in three treadmill walking conditions, e.g., (...) baseline (adjusted to individual comfortable walking speed), variable speed (VS), or restricted foot width (RW). Then, we grouped similar muscle synergies using k-mean clustering and discriminant analyses from all datasets of individual synergy structures. Proportion tests exhibited six clusters of muscle synergies predominantly arising from children with CP and four clusters from children with TD. Also, the proportion of muscle synergies was significantly different in four of the CP-preferred clusters across conditions. Specifically, the proportion of the baseline condition was significantly different from VS and RW conditions in one and two clusters, respectively. The proportion was significantly different between VS and RW conditions in four clusters. Cadence and step lengths differed across conditions but not groups which makes the group differences in proportion even more notable. In contrast, step width, while significantly lower in CP, did not differ across conditions. Our findings demonstrate that muscle synergies in children with CP are more sensitive to changes in the external walking environment than in typically developing children. (shrink)

Spasticity and muscle weakness is common in children with cerebral palsy (CP). Spasticity can be treated with Botulinum Neurotoxin-A (BoNT-A), but this drug has also been reported to induce muscle weakness. Our purpose was to describe the effect on muscle strength in the lower extremities after BoNT-A injections in children with cerebral palsy. A secondary aim was to relate the effect of BoNT-A to gait pattern and range of motion. Twenty children with spastic cerebral (...) class='Hi'>palsy were included in the study, eight girls and 12 boys (mean age 7.7 years). All were able to walk without support, but with increased muscle tone interfering with motor function and gait pattern. Sixteen children had unilateral spastic CP and four bilateral spastic CP. Twenty-four legs received injections with BoNT-A in the plantar flexor muscles. The children were tested before treatment, around six weeks after at the peak effect of BoNT-A, and at six months after treatment, with measurement of muscle strength, gait analysis and range of motion. There were no differences in muscle strength in plantar flexors of treated legs at peak effect compared to baseline. Six months after treatment, there was still no change in untreated plantar flexor muscles, but an increasing trend in plantar flexor strength in legs treated with BoNT-A. Parents reported positive effects in all children, graded as: small in three children, moderate in eight, and large in nine children. The gait analysis showed a small improvement in knee extension at initial contact, and there was a small increase in passive range of motion for ankle dorsiflexion. Two children had a period with transient weakness and pain. We found that voluntary force production in plantar flexor muscles did not decrease after BoNT-A, instead there was a trend to increased muscle strength at follow-up. The increase may be explained as an effect of the blocking of involuntary nerve impulses, leading to an opportunity to using and training the muscles with voluntary control. Adequate muscle strength is important for maintaining the ability to walk and knowledge of how a treatment affects muscle strength is useful when selecting interventions. (shrink)

Intrinsic gait variability, i.e., fluctuations in the regularity of gait patterns between repetitive cycles, is inherent to the sensorimotor system and influenced by factors such as age and pathology. Increased GV is associated with gait impairments in individuals with cerebral palsy and has been mainly studied based on spatiotemporal parameters. The present study aimed to describe kinematic GV in young people with CP and its associations with clinical impairments [i.e., passive range of motion, muscle weakness, reduced selective motor (...) control, and spasticity]. This retrospective study included 177 participants with CP representing 289 clinical gait analyses [n = 172 for unilateral CP vs. 117 for bilateral CP ]. As variability metrics, Root Mean Square Deviation for nine lower-limb kinematic parameters and Gait Standard Deviation – as composite score of the kinematic parameters – were computed for the affected and most affected side, respectively, as defined by clinical scores. GaitSD was then computed for the non/less-affected side for between leg comparisons. Uni- and multivariate linear regressions were subsequently performed on GaitSD of the affected/most affected side with all clinical impairments as independent variables. Highest RMSD were found in the transverse plane, for distal joints in the sagittal plane and for foot progression. GaitSD was not different between uCP and bCP but higher in the non-affected vs. affected side in uCP. GaitSD was associated with age, gait deviation index, muscle weakness, selectivity, and pROM. After adjustment for age and GDI, GaitSD remained associated with muscle weakness and selectivity. Kinematic GV can be expressed as global indicator of variability in young people with CP given the strong correlation of RMSD for lower-limb kinematic parameters. In terms of asymmetry, increased variability of the non-affected vs. affected side may indicate contralateral compensation mechanisms in uCP. Notably muscle weakness and selectivity – but not spasticity – were associated with GaitSD. Further studies need to explore the clinical relevance of kinematic GV in CP to support the interpretation of clinical gait analyses and therapeutic decision-making. (shrink)

IntroductionThere is a need to maintain rehabilitation activities and motivate movement and physical activity during quarantine in individuals with Cerebral Palsy.ObjectiveThis paper sets out to evaluate the feasibility and potential benefits of using computer serious game in a non-immersive virtual reality implemented and evaluated completely remotely in participants with CP for Home-Based Telerehabilitation during the quarantine period for COVID-19.MethodsUsing a cross-sectional design, a total of 44 individuals participated in this study between March and June 2020, 22 of which (...) had CP and 22 typically developing individuals, matched by age and sex to the individuals with CP. Participants practiced a coincident timing game1 and we measured movement performance and physical activity intensity using the rating of perceived exertion Borg scale.ResultsAll participants were able to engage with the VR therapy remotely, reported enjoying sessions, and improved performance in some practice moments. The most important result in this cross-sectional study was the significant increasing in rating of perceived exertion in both groups during practice and with CP presenting a higher rating of perceived exertion.ConclusionChildren with CP enjoyed participating, were able to perform at the same level as their peers on certain activities and increased both their performance and physical activity intensity when using the game, supporting the use of serious games for this group for home therapy and interactive games.Clinical Trials Registrationhttps://Clinicaltrials.gov, NCT04402034. Registered on May 20, 2020. (shrink)

Conflicts of interest. None to report Healthcare is a context where individuals with disability confront important ethical and social challenges. Adolescents and young adults with cerebral palsy (CP) seem to face additional challenges but we have little insight into their perspectives. This qualitative study aimed to identify and better understand such challenges. We interviewed 14 participants with CP aged 18 to 25. Participants described a range of challenges experienced when using health services, including: lack of long-term follow-up, shortcomings (...) in physical access to infrastructures, and situations of injustice. Challenges specific to medical consultations were reported (e.g., rude attitudes, belittlement, inadequate communication, lack of consideration). We discuss and explain further that: (1) the ethical principle of respect for persons needs to be concretely specified to improve current practices; (2) respect for autonomy calls for further direct empowerment of individuals with CP and, (3) gaps in dedicated healthcare resources for CP and the long-term needs associated should be addressed. (shrink)

In this systematic review, we collected and analyzed literature works comparing self-reported fatigue and objectively-measured fatigue in individuals with cerebral palsy and in age-matched typically developing/typically developed controls. The search was conducted on four electronic databases/platforms using the key words “cerebral palsy” combined with “fatig*,” where the asterisk was used as a wildcard. As a critical appraisal tool, the Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies was used. A total of 22 studies passed the (...) critical appraisal rating and were included in both narrative and quantitative analyses. The overall evidence quality of the findings was considered very good. Data of objectively-measured fatigue in performing maximal fatiguing tasks indicated lower fatigue levels in participants with CP, possibly due to their pathological inability to recruit highly fatigable muscle fibers. Highly trained individuals with CP and TD controls performing maximal fatiguing tasks seem to be an exception to this, as they exhibited similar levels of fatigue. In submaximal fatiguing tasks, including daily physical activities, either objectively-measured or self-reported fatigue was higher in participants with CP than in TD controls, indicating a lower ability for development of neurophysiological compensation for fatigue among participants with CP. Further studies on fatigue are needed to gain an insight into the multifold mechanisms of fatigue in individuals with CP. Understanding fatigue mechanisms could help in setting up strategies for effective intervention programs, with benefits in healthcare and improved quality of life of individuals with CP.Systematic Review Registration: [PROSPERO 2019], identifier [CRD42019143524]. (shrink)

BackgroundBilateral cerebral palsy is the most common type of CP in children and is often accompanied by different degrees of communication impairment. Several studies have attempted to identify children at high risk for communication impairment. However, most prediction factors are qualitative and subjective and may be influenced by rater bias. Individualized objective diagnostic and/or prediction methods are still lacking, and an effective method is urgently needed to guide clinical diagnosis and treatment. The aim of this study is to (...) develop and validate an objective, individual-based model for the prediction of communication impairment in children with BCP by the time they enter school.MethodsA multicenter prospective cohort study will be conducted in four Chinese hospitals. A total of 178 children with BCP will undergo advanced brain magnetic resonance imaging at baseline. At school entry, communication performance will be assessed by a communication function classification system. Three-quarters of children with BCP will be allocated as a training cohort, whereas the remaining children will be allocated as a test cohort. Multivariate lesion- and connectome-based approaches, which have shown good predictive ability of language performance in stroke patients, will be applied to extract features from MR images for each child with BCP. Multiple machine learning models using extracted features to predict communication impairment for each child with BCP will be constructed using data from the training cohort and externally validated using data from the test cohort. Prediction accuracy across models in the test cohort will be statistically compared.DiscussionThe findings of the study may lead to the development of several translational tools that can individually predict communication impairment in children newly diagnosed with BCP to ensure that these children receive early, targeted therapeutic intervention before they begin school.Trial registrationThe study has been registered with the Chinese Clinical Trial Registry. (shrink)

Impaired hand proprioception can lead to difficulties in performing fine motor tasks, thereby affecting activities of daily living. The majority of children with unilateral cerebral palsy experience proprioceptive deficits, but accurately quantifying these deficits is challenging due to the lack of sensitive measurement methods. Robot-assisted assessments provide a promising alternative, however, there is a need for solutions that specifically target children and their needs. We propose two novel robotics-based assessments to sensitively evaluate active and passive position sense of (...) the index finger metacarpophalangeal joint in children. We then investigate test-retest reliability and discriminant validity of these assessments in uCP and typically developing children, and further use the robotic platform to gain first insights into fundamentals of hand proprioception. Both robotic assessments were performed in two sessions with 1-h break in between. In the passive position sense assessment, participant's finger is passively moved by the robot to a randomly selected position, and she/he needs to indicate the perceived finger position on a tablet screen located directly above the hand, so that the vision of the hand is blocked. Active position sense is assessed by asking participants to accurately move their finger to a target position shown on the tablet screen, without visual feedback of the finger position. Ten children with uCP and 10 age-matched TDC were recruited in this study. Test-retest reliability in both populations was good >0.79). Proprioceptive error was larger for children with uCP than TDC, indicating discriminant validity. The active position sense was more accurate than passive, and the scores were not correlated, underlining the need for targeted assessments to comprehensively evaluate proprioception. There was a significant effect of age on passive position sense in TDC but not uCP, possibly linked to disturbed development of proprioceptive acuity in uCP. Overall, the proposed robot-assisted assessments are reliable, valid and a promising alternative to commonly used clinical methods, which could help gain a better understanding of proprioceptive impairments in uCP, facilitating the design of novel therapies. (shrink)

BackgroundThe interpretation of clinical gait data in children with cerebral palsy (CP) is time-consuming, requires extensive expertise and often lacks transparency. Here we aimed to develop a set of look-up tables to support this process, linking typical gait features as present in CP to their potential underlying impairments.MethodsWe developed an initial core set of gait features and their potential underlying impairments based on biomechanical reasoning, literature and clinical experience. This core set was further specified through a Delphi process (...) in a multidisciplinary group of experts in gait analysis of children with CP and evaluated on 20 patient cases. The likelihood of the listed gait feature–impairment relationships was scored by the expert panel on a five-point scale.ResultsThe final core set included 120 relevant gait feature–impairment relations including likelihood scores. This set was presented in the form of look-up tables in both directions, i.e., sorted by gait features with potential underlying impairment, and sorted by impairments with potential related gait features. The average likelihood score for the relations was 3.5 ± 0.6 (range 2.1–4.6).ConclusionThe developed set of look-up tables linking gait features and impairments, can assist gait analysts and clinicians in standardized biomechanical reasoning, to support treatment decision-making for gait impairments in children with CP. (shrink)

Purpose:Human navigation skills are essential for everyday life and rely on several cognitive abilities, among which visual-spatial competences that are impaired in subjects with cerebral palsy. In this work, we proposed navigation tasks in immersive virtual reality to 15 children with CP and 13 typically developing peers in order to assess the individual navigation strategies and their modifiability in a situation resembling real life.Methods:We developed and adapted to IVR an application based on a 5-way maze in a playground (...) that was to be navigated to find a reward. The learning process, navigation strategies, and adaptation to changes were compared between participants with CP and their TD peers and correlated with visual-spatial abilities and cognitive competences.Results:Most participants with CP needed more attempts than TD participants to become proficient in navigation. Furthermore, the learning phase was correlated to visual-spatial memory but not with cognitive competences. Interestingly, navigation skills were comparable between groups after stabilization. While TD participants mainly relied on allocentric strategies based on environmental cues, egocentric strategies based on body motion prevailed in participants with CP. Furthermore, participants with CP had more difficulties in modifying their navigation strategies, caused by difficulties in executive processes beyond the visual-perceptual impairment, with an inefficient shift between implicit and explicit competences.Conclusions:The navigation abilities in participants with CP seem to be different from their TD peers in terms of learning and adaptation to new conditions; this could deeply affect their everyday life and ultimately participation and inclusion. A regular assessing and focused rehabilitative plans could help to better navigate the environment and affect self-perception. (shrink)

The study reported in this paper utilised a qualitative approach to investigate the everyday lives of two children with cerebral palsy, as experienced by their carers. Analysis of the data collected through in-depth interviews with the girls’ teachers, mothers and therapists was informed by the reflective lifeworld research approach of Dahlberg et al.. The broader theme identified, negotiating motor in/capabilities, comprised the constituent sub-themes identity and difference, and living motor in/capabilities in a disabling/enabling environment. The phenomenological approach employed (...) revealed that, as experienced by their carers, the two girls, both of whom have quite profound forms of motor impairment, flourish by utilising their bodily and psychosocial resources towards experiencing enhanced autonomy and a sense of mastery. Overall, their respective carers served as resources for each of the girls, providing them with enabling social and physical environments that promote their optimal functioning. Theory-driven intervention efforts to promote social participation and well-being in children with cerebral palsy who have severe motor impairments would benefit from taking into account the nuances and complexities inherent in the everyday experiences of these children. (shrink)

BackgroundCerebral Visual Impairment is a very common finding in children affected by Cerebral Palsy. In this paper we studied the characteristics of CVI of a large group of children with CP and CVI, describing their neurovisual profiles according to three different age subgroups.MethodsWe enrolled 180 subjects with CP and CVI for the study. We carried out a demographic and clinical data collection, neurological examination, developmental or cognitive assessment, and a video-recorded visual function assessment including an evaluation of ophthalmological (...) characteristics, oculomotor functions, and basic visual functions. In school-aged children, we also performed an evaluation of their cognitive-visual profiles.ResultsThere were signs of CVI in all the three subgroups. Subgroup 1 and subgroup 2 were different for fixation, visual acuity and contrast sensitivity, being more frequently impaired in younger children. Comparing subgroup 2 with subgroup 3, the older children presented more frequently myopia while the younger ones esotropia and alteration in smooth pursuit and saccades. Furthermore, fixation, smooth pursuit, visual acuity, contrast sensitivity and visual filed were more frequently impaired in younger children compared to the older ones. Multiple correspondence analysis confirmed the different neurovisual profiles according to age: younger children with CP showed more signs of CVI compared to the older ones. 34 out of 68 children belonging to subgroup 3 underwent the cognitive visual evaluation; an impairment of cognitive visual skills was detected in 21 subjects.ConclusionYounger children with CP showed more signs of CVI compared to the older ones, likely for the physiological maturation of visual system and mechanisms of neuroplasticity. In this direction, we suggest an early neurovisual evaluation to detect any weak visual functions. (shrink)

BackgroundDisorders in different levels of body representation are present in hemiplegic cerebral palsy. However, it remains unclear whether the body image develops from aspects of body schema and body structural description, and how this occurs in children with HCP.Objective and methodsIn a cross-sectional study, we investigated 53 children with HCP and 204 typically developing control children to qualitatively evaluate whether and how body schema and body structural description affect the development of children’s body image and whether this development (...) is delayed through HCP. Graph analysis was used to create a lexical-semantic map of body representation from data of a semantic word fluency task.ResultsResults indicated a similar qualitative pattern of influences of sensorimotor and visuospatial experiences on lexical-semantic knowledge of body parts, with a delayed developmental course in children with HCP compared to TD children.ConclusionThese findings suggest that children’s body image seemed to be influenced by body schema and body structural descriptions as indicated by poorer lexical-semantic knowledge of body parts in children with HCP due to missing physical experiences of the affected body parts. This might imply that “body talk” may beneficially complement physical therapy for children with HCP to promote body image development. (shrink)

Hemiparetic stroke in adulthood often results in the grouped movement pattern of the upper extremity flexion synergy thought to arise from an increased reliance on cortico-reticulospinal pathways due to a loss of lateral corticospinal projections. It is well-established that the flexion synergy induces reaching constraints in individuals with adult-onset hemiplegia. The expression of the flexion synergy in individuals with brain injuries onset earlier in the lifespan is currently unknown. An early unilateral brain injury occurring prior to six months post full-term (...) may preserve corticospinal projections which can be used for independent joint control and thus minimizing the expression of the flexion synergy. This study uses kinematics of a ballistic reaching task to evaluate the expression of the flexion synergy in individuals with pediatric-onset hemiplegia (PH) ages six to seventeen years. Fifteen individuals with brain injuries before birth (n = 8) and around full-term (n = 7) and nine age-matched controls with no known neurological impairment completed a set of reaches in an admittance controlled robotic device. Descending drive, and the possible expression of the upper extremity flexion snergy, was modulated by increasing shoulder abduction loading. Individuals with early PH achieved lower peak velocities when reaching with the paretic arm compared to controls however no differences in reaching distance were found between groups. Relative maintenance in reaching seen in individuals with early brain injuries highlights minimal expression of the flexion synergy. We interpret this conservation of independent control of the paretic shoulder and elbow as the use of more direct corticospinal projections instead of indirect cortico-reticulospinal pathways used in individuals with adult-onset hemiplegia. (shrink)

This paper draws upon Deleuze and Guattari's ideas to suggest a different kind of reading of a narrative of a mother of a child with severe disability, and thus a different kind of ethical response to them. This reading gives readers the possibility of opening up experiences of parents and children with disability, rather than compartmentalising such stories. The reader becomes, is transformed, through reading these narratives and through engaging with the intensities which are recognised in the text, asking the (...) question ‘Does it work for me?’ This is what Gilles Deleuze calls ‘reading with love’. (shrink)

Brain-computer interfaces (BCIs) have been successfully used by adults, but little information is available on BCI use by children, especially children with severe multiple impairments who may need technology to facilitate communication. Here we discuss the challenges of using non-invasive BCI with children, especially children who do not have another established method of communication with unfamiliar partners. Strategies to manage these challenges require consideration of multiple factors related to accessibility, cognition, and participation. These factors include decisions regarding where (home, clinic, (...) or lab) participation will take place, the number of sessions involved, and the degree of participation necessary for success. A strategic approach to addressing the unique challenges inherent in BCI use by children with disabilities will increase the potential for successful BCI calibration and adoption of BCI as a valuable access method for children with the most significant impairments in movement and communication. (shrink)