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Cited by 106Cerebral Palsy and Movement DisordersFamily and Disability Support ResearchChild and Adolescent Psychosocial and Emotional Development

Mental Health Disorders and Physical Risk Factors in Children with Cerebral Palsy: A Cross-Sectional Study

Open access
Whitney, Daniel G, Warschausky, Seth A, Peterson, Mark D·2019·Developmental Medicine & Child Neurology
DOI 10.1111/dmcn.14083PMC PMC6450728
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Abstract

AIM: To examine the prevalence of mental health disorders among children with and without cerebral palsy (CP), and to examine how physical risk factors in children with CP might mitigate any elevated risk of mental health disorders in this population. METHOD: Children from 6 years to 17 years of age with (n=111) and without (n=29 909) CP from the 2016 National Survey of Children's Health were included in this cross-sectional study. Mental health disorders included depression, anxiety, behavior/conduct problems, and attention deficit disorder/attention-deficit/hyperactivity disorder (ADHD). Physical risk factors included physical activity (number of active days ≥60min), sleep duration, and pain. RESULTS: Adjusting for sociodemographics, children with CP had higher odds of mental health disorders (odds ratio [OR]=2.7-7.1, p<0.05) except for attention deficit disorder/ADHD (OR=2.5; 95% confidence interval [CI]=0.9-7.1). Further adjusting for physical factors, the odds of depression were no longer increased (i.e. attenuated) in children with CP (OR=1.0; 95% CI=0.3-3.3); however, the odds of anxiety (OR=3.8; 95% CI=1.9-7.8) and behavior/conduct problems (OR=3.8; 95% CI=1.3-11.1) remained elevated. Assessed individually, low physical activity and pain attenuated the odds of depression in children with CP (OR=1.9; 95% CI=0.7-5.3; OR=1.4; 95% CI=0.6-3.8 respectively). INTERPRETATION: Children with CP have an elevated prevalence of mental health disorders even after accounting for physical risk factors. Low physical activity and pain partially accounts for the association between CP and depression. WHAT THIS PAPER ADDS: Children with cerebral palsy (CP) have an elevated risk of developing mental health disorders. Physical factors do not fully account for higher mental health disorder prevalence. Physical activity partially accounts for the relationship between CP and depression. Pain partially accounts for the relationship between CP and depression.

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Crossref · 10.1111/dmcn.14083

Cites

28 of 28 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 17 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    When pain was added to the socio-demographic model, the odds of depression in children with cerebral palsy were no longer significantly increased (OR=1.4, 95% CI 0.6-3.8).

    “When pain was added to Model 2, the odds of depression were no longer significantly increased in children with CP, suggesting that pain accounts for the association between CP and depression.”
    • Also stated in: § RESULTS · plain
      “Assessed individually, low physical activity and pain attenuated the odds of depression in children with CP (OR=1.9; 95% CI=0.7–5.3; OR=1.4; 95% CI=0.6, 3.8 respectively).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.
  • Findingown data

    Children with cerebral palsy had a higher prevalence of pain compared to controls.

    “Children with CP also had a higher prevalence of pain compared to controls.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.
  • Findingown data

    In the full model, the odds of anxiety in children with cerebral palsy remained significantly elevated (OR=3.8, 95% CI 1.9-7.8).

    “however, the odds of anxiety (OR=3.8; 95% CI=1.9–7.8) and behavior/conduct problems (OR=3.8; 95% CI=1.3–11.1) remained elevated.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.
  • Findingown data

    In the full model, the odds of multimorbidity in children with cerebral palsy were no longer significantly increased.

    “the odds of depression and multimorbidity were no longer significantly increased for children with CP.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.
  • Findingown data

    In the full model, the odds of behavior/conduct problems in children with cerebral palsy remained significantly elevated (OR=3.8, 95% CI 1.3-11.1).

    “however, the odds of anxiety (OR=3.8; 95% CI=1.9–7.8) and behavior/conduct problems (OR=3.8; 95% CI=1.3–11.1) remained elevated.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.
  • May combine two claims. 16
  • The quote only partly states this claim. 3
  • Classified as probably not a substantial claim. 6

  • May combine two claims.

    Findingown data

    When sleep duration was added to the socio-demographic model, the odds of depression, anxiety, behavior/conduct problems, and multimorbidity remained significantly increased in children with cerebral palsy.

    “When sleep duration was added to Model 2, the odds of depression, anxiety, behavior/conduct problems, and multimorbidity remained significantly increased in children with CP.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • The quote only partly states this claim.

    Findingown data

    When physical activity was added to the socio-demographic model, the odds of depression in children with cerebral palsy were no longer significantly increased (OR=1.9, 95% CI 0.7-5.3).

    “When physical activity was added to Model 2, the odds of depression were no longer significantly increased in children with CP.”
    • Also stated in: § RESULTS · plain
      “Assessed individually, low physical activity and pain attenuated the odds of depression in children with CP (OR=1.9; 95% CI=0.7–5.3; OR=1.4; 95% CI=0.6, 3.8 respectively).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • The quote only partly states this claim.

    Findingown data

    In the full model that adjusted for socio-demographics plus physical activity, sleep duration, and pain, the odds of depression in children with cerebral palsy were no longer significantly increased (OR=1.0, 95% CI 0.3-3.3).

    “Further adjusting for physical factors, the odds of depression were no longer increased (i.e. attenuated) in children with CP (OR=1.0; 95% CI=0.3–3.3)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims.

    Findingown data

    When physical activity was added to the socio-demographic model, the odds of anxiety and multimorbidity in children with cerebral palsy remained significantly increased but were reduced.

    “The odds of anxiety, behavior/conduct problems, and multimorbidity remained significantly increased in children with CP; however, the odds of anxiety and multimorbidity were reduced, suggesting that physical activity accounts for some of the association between CP and these mental health disorders.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims.

    Findingown data

    When pain was added to the socio-demographic model, the odds of anxiety, behavior/conduct problems, and multimorbidity in children with cerebral palsy remained significantly increased but were reduced.

    “The odds of anxiety, behavior/conduct problems, and multimorbidity remained significantly increased in children with CP; however, these odds were reduced, suggesting that pain accounts for some of the association between CP and these mental health disorders.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    After adjustment for socio-demographic variables, children with cerebral palsy had significantly higher odds of depression, anxiety, behavior/conduct problems, and multimorbidity than children without cerebral palsy.

    “After adjusting for socio-demographic variables (Model 2), the odds of all mental health disorders and multimorbidity remained significantly increased in children with CP, except for attention deficit disorder/ADHD.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.

  • May combine two claims.

    Findingown data

    Children with cerebral palsy had higher prevalence and unadjusted odds of all examined mental health disorders and multimorbidity compared to controls.

    “Children with CP had higher prevalence and unadjusted odds of all mental health disorders examined in the present study and multimorbidity compared to controls.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.

  • May combine two claims.

    Findingown data

    Children with cerebral palsy had a higher prevalence of 0 days of physical activity and a lower prevalence of 4-7 days of physical activity compared to controls.

    “children with CP had a higher prevalence of 0 days of physical activity and a lower prevalence of 4 days to 7 days of physical activity compared to controls.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims.

    Study design and conductreasoning

    The analyses accounted for the complex survey design by including sampling strata and primary sampling units and used weighted estimates to address oversampling, nonresponse, and population distribution.

    “We therefore accounted for sampling strata and the primary sampling unit to obtain correct variance estimation, and weighted estimates to account for oversampling, survey nonresponse, and distribution of target population.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Pain attenuated the cerebral palsy-depression association and accounted for a portion of the cerebral palsy-anxiety, cerebral palsy-behavior/conduct problems, and cerebral palsy-multimorbidity associations.

    “Pain attenuated the CP-depression association and accounted for a portion of the CP-anxiety, CP-behavior/conduct problems, and CP-multimorbidity associations.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims.

    Interpretationown data

    The combination of physical activity, sleep duration, and pain accounts for the cerebral palsy-depression association but only partially accounts for the cerebral palsy-anxiety and cerebral palsy-behavior/conduct problems associations.

    “This suggests that the combination of these three modifiable risk factors accounts for the CP-depression association, but only partially accounts for the CP-anxiety and CP-behavior/conduct problems associations.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Missing data for variables in the logistic regression models were included in analyses and represented less than 4% for children with cerebral palsy and controls.

    “Individuals that had missing data for any variables in the logistic regression models were included in analyses, which represented less than 4 percent for CP and controls.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The United States Census Bureau's nonresponse bias analysis for the 2016 NSCH concluded there was no strong or consistent evidence of nonresponse bias.

    “The United States Census Bureau conducted a nonresponse bias analysis for the 2016 NSCH.14 Although response was higher in geographical locations where income was higher, they concluded that there is no strong or consistent evidence of nonresponse bias.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14]

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    There were no group differences in age, sex, household poverty status, or sleep duration between children with cerebral palsy and controls.

    “There were no group differences in age, sex, household poverty status, or sleep duration.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.

  • May combine two claims.

    Premisecitation

    Children with cerebral palsy have more sleep disturbances than typically developing children, and these disturbances are associated with behavioral issues and quality of life.

    “Children with CP also have more issues with sleep disturbances than typically developing children, which is associated with behavioral issues and quality of life.8,9”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source

      Not checked in the free run.

    • cites [9] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Cerebral palsy is the most common physical disability of childhood.

    “Cerebral palsy (CP) is the most common physical disability of childhood3”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Physical activity attenuated the cerebral palsy-depression association, accounted for a portion of the cerebral palsy-anxiety and cerebral palsy-multimorbidity associations, and did not contribute to the cerebral palsy-behavior/conduct problems association.

    “Physical activity attenuated the CP-depression association, accounted for a portion of the CP-anxiety and CP-multimorbidity associations, and did not contribute to the CP-behavior/conduct problems association.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

  • May combine two claims.

    Premisecitation

    Pain is associated with mental health disorders in children with cerebral palsy but not in adults with cerebral palsy.

    “Further, pain is associated with mental health disorders in children,11 but not adults,10 with CP.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] source

      Not checked in the free run.

    • cites [10] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The weighted prevalence of cerebral palsy in children aged 2-17 years was 2.8 per 1000, consistent with previous estimates.

    “This resulted in a CP prevalence of 2.8 per 1000, which is consistent with a previous study that found CP prevalence estimates of 2.6 and 2.9 in two nationally representative surveys in the USA from 2011 to 2013.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] source

      Not checked in the free run.

    • Rests on an assumption: Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A considerable proportion of the global burden of disease is associated with disability.

    “Importantly, a considerable proportion of the overall global burden of disease is associated with disability.2”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the general population, low physical activity, sleep disorders, and pain increase the risk of developing mental health disorders.

    “In the general population, physical risk factors, such as low levels of physical activity,4 sleep disorders,5 and pain,6 increase the risk of developing mental health disorders.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [4] source

      Not checked in the free run.

    • cites [5] source

      Not checked in the free run.

    • cites [6] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Mental health disorders account for a substantial portion of the global burden of disease.

    “Mental health disorders account for a substantial portion of the overall global burden of disease.1”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] source

      Not checked in the free run.

22 of 22

  • The paper relies on this without support.

    Cerebral palsy is a lifelong condition.

    “These 24 individuals were excluded from the study because CP is a lifelong condition, so the placement of these individuals in the second response may have been because of an original misdiagnosis.”

  • The paper relies on this without support.

    Parent or guardian report of a doctor's diagnosis is a valid measure of cerebral palsy and of mental health disorders in children.

    “Children were considered to have a mental health disorder if the respondent reported a positive diagnosis of depression, anxiety, behavioral/conduct problems, or attention deficit disorder or attention-deficit/hyperactivity disorder (ADHD) to the following survey prompt, ‘Has a doctor or other healthcare provider EVER told you that this child has [specified condition]’.”
    “Respondents were asked, ‘Has a doctor or other healthcare provider EVER told you that this child has cerebral palsy?’”

  • The paper relies on this without support.

    The National Survey of Children's Health measures of physical activity, sleep duration, and pain are valid indicators of these risk factors.

    “Physical activity was determined by the number of days that the child exercised, played a sport, or participated in physical activity for at least 60 minutes.”
    “A dichotomous variable for pain (presence or absence) was determined if the child had ‘FREQUENT or CHRONIC difficulty’ with ‘repeated or chronic physical pain, including headaches or other back or body pain.’”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Whitney et al. reported that the odds of ADHD were no longer increased after controlling for sociodemographic variables.

    “However, when compared to controls, Whitney et al. [11] reported that that the odds of ADHD were no longer increased after controlling for sociodemographic variables”

    From The Mental Health of Children with Cerebral Palsy: A Review of the Last Five Years of Research (2025) · cites this paper as [11]

    The Results and Discussion report that, compared with controls, the odds of attention deficit disorder/ADHD in children with cerebral palsy were no longer significantly increased after adjustment for sociodemographic variables. The citing sentence omits “significantly”: the adjusted odds ratio remained above 1 (2.5), but its 95% confidence interval included 1 (0.9–7.1). (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Whitney et al. reported a prevalence of ADHD of 19.5% in children with cerebral palsy.

    “Whitney et al. [25] and Whitney et al. [11] reporting a prevalence of 19.5%”

    From The Mental Health of Children with Cerebral Palsy: A Review of the Last Five Years of Research (2025) · cites this paper as [11]

    The Results section, under “Mental health disorder profiles in children with CP” (page unavailable), says the study assessed ADHD prevalence and found it higher in children with cerebral palsy than in controls. It refers to Table II for the prevalence figures, but the passages available from our copy do not give an ADHD prevalence of 19.5%; searches for “19.5” and the Table II ADHD figure did not find it. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Individuals with CP often experience significant pain and lower health-related quality of life compared to the general population.

    “Findings indicated that individuals with CP often experience significant pain and lower health-related quality of life compared to the general population.”

    From The Mental Health of Children with Cerebral Palsy: A Review of the Last Five Years of Research (2025) · cites this paper as [11]

    The Results report more pain among children with CP than among controls, and the Discussion says pain is related to lower quality of life in children with CP. The paper does not establish that people with CP have lower health-related quality of life than the general population; its study findings concern children, not individuals of all ages. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Behavioral problems occurred in 27.3% of a sample of children with CP.

    “Whitney et al. [25] and Whitney et al. [11] reported behavioral problems occurring in 27.3% of their sample.”

    From The Mental Health of Children with Cerebral Palsy: A Review of the Last Five Years of Research (2025) · cites this paper as [11]

    The Results section ('Mental health disorder profiles in children with CP'; page unavailable) reports a higher prevalence of mental health disorders, including behavior/conduct problems, among children with CP. It directs readers to Table II for prevalence figures, but the available passages do not state 27.3%, so the specific percentage cannot be verified from our copy. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • After accounting for sociodemographic variables, the odds of mental health disorders in children with cerebral palsy remained significant except for ADHD, with reported odds ratios between 2.7 and 7.1 for included disorders.

    “After accounting for sociodemographic variables, the odds of mental health disorders in children with CP remained significant (except for ADHD), with reported odds ratios between 2.7 and 7.1 for included disorders [11].”

    From The Mental Health of Children with Cerebral Palsy: A Review of the Last Five Years of Research (2025) · cites this paper as [11]

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Authors
Whitney, D. G., Warschausky, S. A., & Peterson, M. D.
Affiliations
University of Michigan (US)
Corresponding author
Whitney, Daniel G
ORCID
Venue
Developmental Medicine & Child Neurology
Publisher
Wiley
Published
2018-10-26
Volume
61
Issue
5
Pages
579-585
ISSN
  • 0012-1622 (ISSN-L)
  • 1469-8749
DOI
10.1111/dmcn.14083
PMC
PMC6450728
OpenAlex
W2898551097
Cited by
106
References
28
Citations by year
2026: 13 · 2025: 18 · 2024: 11 · 2023: 13 · 2022: 9 · 2021: 12 · 2020: 16 · 2019: 13
FWCI
8.07
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Developmental Medicine & Child Neurology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Deep Blue (University of Michigan) (submittedVersion)
Funders
  • National Institute on Disability, Independent Living, and Rehabilitation Research (90AR5020‐0200, 90IF0102‐01)
  • National Institutes of Health (1KO1 HD074706, 5 UL1 TR002240‐05)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Cerebral Palsy and Movement Disorders
  • Social Sciences › Psychology › Clinical Psychology › Family and Disability Support Research
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
cerebral palsy, mental illness, depression, anxiety, conduct problems, attention deficit hyperactivity disorder, attention deficit disorder, physical activity, sleep duration, pain, children, physical risk factors, prevalence
MeSH terms
Adolescent, Age Factors, Mental Disorders, Cerebral Palsy, Child, Cross-Sectional Studies, Female, Humans, Male, Pain, Predictive Value of Tests, Risk Factors, Sleep, Exercise, Outcome Assessment, Health Care

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