History Taking in Children with Cerebral Palsy
A comprehensive history for a child with cerebral palsy must systematically identify risk factors across the preconception, prenatal, perinatal, and postneonatal periods, document the emergence and evolution of motor dysfunction, and distinguish between two critical diagnostic pathways based on when concerns first arose 1.
Risk Factor Assessment by Timeline
Preconception and Pregnancy History
Document the following high-risk indicators that account for 80-90% of CP cases 1:
Preconception risks:
- History of stillbirths or miscarriages
- Low socioeconomic status
- Assisted reproduction
- Abnormal genetic copy number variations
Pregnancy risks:
- Genetic abnormalities or birth defects
- Multiple gestation
- Male sex
- Maternal thyroid disease or preeclampsia
- Maternal infection during pregnancy
- Intrauterine growth restriction (IUGR)
- Prematurity
- Substance abuse
Perinatal and Neonatal History
Identify "newborn-detectable risks" that enable early screening before 5 months' corrected age 1:
- Prematurity
- Atypical intrauterine growth
- Encephalopathy
- Genetic abnormalities
- Neonatal seizures
Two Critical Diagnostic Pathways
The history must determine which pathway applies, as this dictates timing and tools for diagnosis 1:
Pathway 1: Newborn-Detectable Risks (Before 5 Months)
Half of all CP cases have identifiable high-risk indicators in the newborn period. These children warrant immediate investigation with General Movements assessment, HINE, and MRI before 5 months' corrected age.
Pathway 2: Infant-Detectable Risks (After 5 Months)
The other half have apparently uneventful pregnancies and deliveries. Parent-identified concerns or professional observations of delayed motor milestones trigger investigation 1:
- Not sitting by 9 months
- Hand asymmetry
- Head lag
- Inability to grasp or reach for toys at appropriate age
- Any observable motor dysfunction
Motor Development History
Document the quality and timing of motor milestone achievement, not just whether milestones were met 1:
- Quality of movement (reduced or neurologically abnormal)
- Early observable hand asymmetry
- Head control and head lag
- Sitting ability
- Grasping and reaching patterns
- Any regression or plateau in motor skills
Critical Caveat for Milder Presentations
In unilateral CP, children often master early rudimentary skills (smiling, swallowing, head control), and asymmetries only become observable when attempting complex motor skills like grasping 1. Specifically ask about one-handed completion of tasks or asymmetric movement patterns.
Associated Conditions Screening History
Because associated deficits are common, the history must screen for 2:
- Seizures or epileptic features
- Vision problems
- Hearing impairment
- Speech and language delays
- Feeding difficulties or oral-motor dysfunction
- Cognitive concerns
Functional Impact Assessment
Document activity limitations and participation restrictions:
- Self-care abilities
- Communication methods
- Social participation
- Family concerns and goals
Neuroimaging History
If prior imaging exists, document findings predictive of CP 1:
- White matter injury (56%): cystic periventricular leukomalacia, periventricular hemorrhagic infarctions
- Gray matter lesions (18%): basal ganglia/thalamus lesions, watershed injury, multicystic encephalomalacia, stroke
- Brain maldevelopments (9%): lissencephaly, pachygyria, cortical dysplasia, polymicrogyria, schizencephaly
Coagulation History for Hemiplegic CP
For children with hemiplegic CP, specifically inquire about family history of thrombotic disorders or stroke, as cerebral infarction incidence is high in this population 2. This warrants consideration of coagulation disorder testing.
Common Pitfalls to Avoid
Don't dismiss normal standardized motor scores in isolation. A child with hemiplegia may score normally by completing assessments one-handed, or a child with diplegia may have normal upper limb scores masking abnormal lower limb function 1.
Don't wait for "classic" spasticity. Motor types emerge and change during the first 2 years, and early signs may be subtle quality-of-movement abnormalities rather than frank hypertonia 1.
Don't assume uneventful pregnancy/delivery rules out CP. Half of all CP cases have no identifiable newborn risk factors 1.
Documentation Framework
The history should enable assignment of either:
- Definitive CP diagnosis (when motor dysfunction plus neuroimaging abnormalities and/or clinical history create congruent findings)
- High risk of CP (interim diagnosis requiring motor dysfunction PLUS at least one of: abnormal neuroimaging OR clinical history indicating CP risk) 1
This structured approach ensures early identification, appropriate diagnostic pathway selection, and timely referral for CP-specific early intervention to optimize neuroplasticity and functional outcomes 1.