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Original Article • Dement. neuropsychol. 11 (3) • Jul-Sep 2017 • https://doi.org/10.1590/1980-57642016dn11-030011 copy

Mini-mental state exam for children (MMC) in children with hemiplegic cerebral palsy

MINI-EXAME DO ESTADO MENTAL PARA CRIANÇAS (MMC) NA PARALISIA CEREBRAL

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Cognitive impairment is frequent in cerebral palsy (CP) and there is a lack of multiprofessional screening instruments.

OBJECTIVE:

The aim of this study was to investigate the utility of the Mini-Mental State Examination for Children (MMC), an adapted version of the Mini-Mental State Examination, in screening for cognitive impairments in children with CP.

METHODS:

We assessed 397 Brazilian children, 310 with typical development and 87 with CP (hemiplegic and quadriplegic forms), aged 5-16 years. Association between the MMC and general intelligence was assessed by the Colored Progressive Matrices instrument.

RESULTS:

Psychometric indexes for the MMC were adequate. ROC analyses revealed effective diagnostic accuracy in all ages assessed. Cut-off values are reported. Major difficulties on the MMC were observed in children with CP, particularly individuals with the quadriplegic form. Moreover, the MMC showed moderate correlation with the intelligence test, and was reliable in discriminating, among clinical cases, those with poorer cognitive abilities.

CONCLUSION:

The MMC could be useful as a multiprofessional screening instrument for cognitive impairment in children with hemiplegic CP. Results of the MMC in quadriplegic CP children should be interpreted with caution. Diagnosis should be confirmed by further psychological testing.

Key words:
cerebral palsy; Mini-Mental State Exam; screening; cognitive impairment

Age (years)	General sample				Subsample
Age (years)	Control (n=310)	Hemiplegia (n=67)	Quadriplegia (n=20)		Control (n=64)	Hemiplegia (n=49)
5-6	16	10	5		13	8
7	40	9	0		14	6
8	40	10	0		6	8
9	55	12	1		11	11
10	65	13	3		14	11
11	37	6	2		6	5
12	36	1	2
13	15	3	3
14-15-16	6	3	4

Sample		AUC	95% CI		Cut-off (z score)	Specificity	Sensitivity	ppv	npv
Sample		AUC	Lower	Upper	Cut-off (z score)	Specificity	Sensitivity	ppv	npv
a) Complete sample	MMC: Clinical vs Control	0.919	0.888	0.951	–1.10	0.82	0.87	0.94	0.65
	MMC: Hemiplegia vs Control	0.896	0.856	0.936	–0.91	0.81	0.84	0.95	0.52
	MMC: Quadriplegia vs Control	0.993	0.981	0.999	–3.79	0.95	0.99	0.99	0.90
b) Subsample	MMC: Hemiplegia vs Control	0.916	0.862	0.969	–0.87	0.81	0.89	0.86	0.85
b) Subsample	CPM: Hemiplegia vs Control	0.884	0.824	0.943	0.62	0.84	0.78	0.86	0.74

MMC Score	General	Control	Hemiplegia	Quadriplegia
0	0.00	0.00	0.01	0.80
1	0.04	0.00	0.03	0.85
2	0.04	0.00	0.03	0.85
3	0.04	0.00	0.03	0.85
4	0.04	0.00	0.03	0.85
5	0.04	0.00	0.03	0.85
6	0.04	0.00	0.03	0.85
7	0.05	0.00	0.03	0.85
8	0.05	0.00	0.04	0.85
9	0.05	0.00	0.04	0.85
10	0.05	0.00	0.04	0.85
11	0.05	0.00	0.04	0.85
12	0.05	0.00	0.04	0.90
13	0.05	0.00	0.07	0.90
14	0.06	0.00	0.07	0.90
15	0.06	0.00	0.09	0.90
16	0.07	0.00	0.12	0.90
17	0.07	0.01	0.21	0.90
18	0.08	0.01	0.21	0.90
19	0.09	0.01	0.24	0.90
20	0.10	0.01	0.27	0.95
21	0.10	0.02	0.30	1.00
22	0.12	0.02	0.33	1.00
23	0.14	0.03	0.42	1.00
24	0.15	0.03	0.45	1.00
25	0.17	0.05	0.51	1.00
26	0.19	0.06	0.55	1.00
27	0.23	0.10	0.60	1.00
28	0.26	0.13	0.63	–
29	0.27	0.14	0.67	–
30	0.34	0.20	0.79	–
31	0.38	0.24	0.82	–
32	0.44	0.31	0.87	–
33	0.51	0.40	0.91	–
34	0.63	0.54	0.97	–
35	0.78	0.72	0.99	–
36	0.91	0.89	1.00	–
37	1.00	1.00	–	–

Age	Control				Clinical			AUC	95% CI		Cut-off score
Age	n	mean	sd		N	mean	sd	AUC	Lower	Upper	Cut-off score
5-6	16	26.94	3.02		15	12.73	9.85	96.88	92.05	100	24
7	40	29.80	4.36		9	19.89	8.48	89.17	78.19	100	25
8	40	33.80	2.72		10	24.90	5.74	95.25	89.88	100	31
9	55	33.16	3.47		13	25.08	6.76	86.85	76.36	97.35	32
10	65	34.83	2.07		16	24.38	12.53	90.48	80.77	100	33
11	37	34.30	2.27		8	21.25	13.32	95.78	90.29	100	32
12	36	34.61	2.43		3	11.33	19.63	91.20	73.36	100	35
13	15	33.80	2.46		6	15.67	15.63	86.11	66.90	100	30
14-15-16	6	31.83	3.92		7	14.57	11.47	95.24	84.13	100	30

Function	Tests	Score
Orientation	Name, surname, age, sex	0-1-2-3-4
	Name of parents, state, city, place	0-1-2-3-4
	Age, month, day of month, day of week	0-1-2-3-4
Object naming	Pen, watch, glasses	0-1-2-3
Digit span – forward	5 -3	0-1-2-3-4
	4-7-2
	5-9-3-1
	2-7-5-9-4
Digit span – backward	3-6	0-1-2-3
	2-9-5
	4-1-9-7
Recall	Pen, watch, glasses	0-1-2-3
Naming body parts	Naming body part indicated by the examiner: hand, foot, knee, nose, ear	0-1-2-3-4-5
Command	"Take the paper in your right hand, fold it in half, and put it on the floor" ("Pegue o papel com a mão, dobre-o ao meio e coloque-o no chão")	0-1-2-3
Verbal string repetition	"'No ifs, ands, or buts." ("Nem aqui, nem lá, nem acolá")	0-1
Reading	"Read this and do what it says" ("Close your eyes")	0-1
Writing	"Write your name"	0-1
Constructional praxis	"Copy the drawings. Do it as best you can" (Vertical line at age 3 years, cross at age 4 years, circle at age 5 years, square at age 6 years and diamond at age 7 years)	0-1
	Maximum total score	37

Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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