critique
OR I G I N A L A R T I C L E
Exploring quality of life of children with cerebral palsy and intellectual disability: What are the important domains of life?
E. Davis1 | D. Reddihough2,3 | N. Murphy4 | A. Epstein4 | S. M. Reid2,3 | A. Whitehouse4 |
K. Williams2,3 | H. Leonard4 | J. Downs4,5
1The Jack Brockhoff Child Health and
Wellbeing Program, Melbourne School of
Population and Global Health, The University
of Melbourne, Melbourne, VIC, Australia
2Developmental Disability and Rehabilitation
Research, Murdoch Children’s Research Institute, University of Melbourne, Melbourne,
VIC, Australia
3Department of Paediatrics, University of
Melbourne, Melbourne, VIC, Australia
4Telethon Kids Institute, The University of
Western Australia, Perth, WA, Australia
5School of Physiotherapy and Exercise
Science, Curtin University, Perth, WA,
Australia
Correspondence
Jenny Downs, Telethon Kids Institute,
University of Western Australia, PO Box 855,
West Perth, WA 6872, Australia.
Email: jenny.downs@telethonkids.org.au
Funding information
Early Career Fellowship, Grant/Award Num-
ber: 1072442; Senior Research Fellowship
from the National Health and Medical
Research Council, Grant/Award Number:
1117105 and 1077966; National Health and
Medical Research Council, Grant/Award
Number: 1103745; Victorian Government’s Operational Infrastructure Support Program;
Victorian Department of Health and Human
Services
Abstract
Background: Although it is estimated that half of all children with cerebral palsy also have
comorbid intellectual disability, the domains of quality of life (QOL) important for these children
are not well understood. The aim of this study was to identify important domains of QOL for
these children and adolescents.
Methods: Due to the children’s communication impairments, qualitative semi‐structured
interviews were conducted with 18 parents. The children (9 males) had a median age of 12 (range
7 to 17) years at interview and nearly two thirds were classified as Gross Motor Function
Classification System IV or V. A grounded theory approach was used to identify domains of QOL.
Results: The 11 domains identified as important to QOL were physical health, body comfort,
behaviour and emotion, communication, predictability and routine, movement and physical
activity, nature and outdoors, variety of activity, independence and autonomy, social
connectedness, and access to services.
Conclusions: The domains of QOL that emerged from this study will be useful for
professionals who support children with cerebral palsy and their families. They will also be
important for developing a QOL instrument essential for informing the development of
interventions and their monitoring and evaluation.
KEYWORDS
adolescents, cerebral palsy, children, intellectual disability, quality of life
1 | INTRODUCTION
With a prevalence of approximately 2 per 1,000 births (Reid et al.,
2016), cerebral palsy (CP) is the most common physical disability in
childhood and is considered to be a permanent disorder of movement
and posture (Rosenbaum, Paneth, Leviton, Goldstein, & Bax, 2007).
Many areas of the lives of children with CP, including physical,
social and emotional well‐being, and participation, may be impacted
by their disability (Colver, Fairhurst, & Pharoah, 2014). Consequently,
there is need for substantial support, especially as approximately
half of these children also have an intellectual disability (ID) (Reid
et al., 2016).
Quality of life (QOL) is broadly defined as “the individual’s
perceptions of their position in life in the context of the culture and
value systems in which they live, and in relation to their goals,
expectations, and concerns” (World Health Organization, 1993).
Assessment of QOL is increasingly used as a mechanism to gain
insight into a child’s life, to identify areas of life that are positive or
challenging and to inform and evaluate interventions. The International
Classification of Functioning, Disability and Health provides a frame-
work for conceptualizing different aspects of life affected by disability
(World Health Organization, 2001). These have been worded more
contemporaneously as the F‐words (Fitness, Function, Family, Friends,
and Fun), which together build towards the child’s future (Rosenbaum
Received: 1 May 2017 Revised: 7 July 2017 Accepted: 10 July 2017
DOI: 10.1111/cch.12501
854 © 2017 John Wiley & Sons Ltd Child Care Health Dev. 2017;43:854–860.wileyonlinelibrary.com/journal/cch
& Gorter, 2011). The adult literature regards QOL as an attribute of
the reporter and therefore self‐report is critical to an accurate
appraisal. In the paediatric literature, child self‐report is also recognized
as important (Bjornson & Mclaughlin, 2001; Davis et al., 2007).
However, despite technological advances, for some children with
marked communication difficulties or ID, parent‐proxy reporting may
be the only option given a child’s inability to communicate verbally or
their reduced capacity to understand and respond to questionnaires
or provide narrative during interviews.
Increasing interest in measuring the QOL of children with CP has
resulted in the development of five CP specific instruments over the
last 10 years. These instruments vary in their purpose, origin,
domains, opportunity for self‐report, item wording, their length and
psychometric properties (Waters et al., 2009), as well as their
applicability for children with comorbid ID. Specifically, the Cerebral
Palsy Quality of Life Questionnaires (CP QOL‐Child and CP
QOL‐Teen) focus on well‐being rather than functioning or limitations
and were developed based on qualitative interviews with children with
CP and their parents (Davis et al., 2009; Waters, Maher, Salmon,
Reddihough, & Boyd, 2005). In contrast, the Pediatric Quality of Life
Inventory (PedsQL)‐CP Module was based on a combination of
previous scales, with contributions from parents and health
professionals, and items focus on functioning (Varni et al., 2006). The
Caregiver Priorities and Child Health Index of Life with Disabilities
(CPCHILD) does not measure QOL but was designed to assess
caregiver priorities in domains of personal care; positioning, transfer,
and mobility; communication and social interaction; comfort, emotions,
and behaviour; and health (Narayanan et al., 2006). The DISABKIDS‐CP
Module was developed to include the perspectives of children and
parents; however, the items are negatively worded and may threaten
self‐esteem (e.g., “Do people think you are not as clever as you are”;
Baars, Atherton Ci Fau ‐ Koopman, Koopman Hm Fau ‐ Bullinger,
Bullinger M Fau ‐ Power, & Power, 2005).
It must be recognized that these instruments were all developed
over 10 years ago, and it is questioned whether the domains of QOL
remain the same. In that time, there have been social changes as well
as changes to disability and health care that could impact expectations
and outcomes and in turn influence our understanding and perceptions
of QOL. In addition, an understanding of the QOL domains that are
important for children with CP and ID has not been developed
previously. The qualitative study that informed the development of
the CP QOL‐Child used data from 28 families of children across
different levels of functioning (Waters et al., 2005), but the number with
ID was unknown. A later qualitative study investigated the applicability
of the CPQOLmeasures for children in theUK, andmost of the children
had no or mild ID (22/28; Parkinson, Rice, & Young, 2011). Overall,
there are limited data on the important areas of QOL for children with
CP and ID. There has, however, been no investigation of the areas of life
that contribute to QOL specifically for children with CP and ID. In our
experience, some parents report that completing the CP QOL‐Child,
which is designed to be used for all children with CP, is challenging
because they are not aware how their child feels about a particular area
of their life, such as whether they feel accepted in their community.
QOL instruments developed for children with ID could be useful
for children with CP and ID, but instruments measuring the QOL of
children with ID are few. The parent/carer report of the Quality of
Life‐Profound Multiple Disabilities was developed for use with
children and adults with the greatest support needs (Petry, Maes, &
Vlaskamp, 2009). A new QOL instrument, KidsLife, has been
developed but is based on a predefined model of eight domains that
have been shown to be important for adults rather than children
(Gomez et al., 2016). We do not know whether the domains of QOL
that are important for adults with ID differ from children with ID, but
in the general population, QOL instruments for children include
different domains to those for adults.
We have previously identified domains of QOL important to
children with Rett (Epstein et al., 2016) and Down (Murphy et al.,
2017) syndromes by coding parent‐reported observations that
indicated the child’s pleasure, satisfaction, or challenge with different
aspects of their life. More information is needed about the areas of life
that are important for children with CP who also have ID. Given
communication limitations, parent‐proxy reports based on ratings of
what they believe their child’s perceptions to be rather than their
own perceptions, are the best available way of gathering this
information (Davis et al., 2007). In the absence of any research
specifically focused on children with CP and ID, the aim of this study
was to identify the domains of QOL important for children with CP
and ID. Due to the children’s communication impairments, this
preliminary study utilizes parent‐proxy reports of their children’s QOL.
2 | METHODS
2.1 | Participants
Eligible participants were identified from the Victorian Cerebral Palsy
Register, a population‐based registry established to collect data on
individuals with CP born or living in Victoria, Australia, from 1970
onwards (Reid et al., 2016). Recruitment was purposive for sex, age,
health issues, and area of residence to optimise variability within the
sample. Of 373 families who were provided information by email about
the study by registry staff, 18 responded that they were interested in
being contacted by the researchers and all then agreed to participate.
The 18 children (9 males) had a median age of 12 (range 7–17) years
at the time of interview. Nearly two thirds of children were classified
as Gross Motor Function Classification System (Palisano et al., 1997)
Level IV or V and more than three quarters were non‐verbal. Routinely
collected information on the registry indicated that each of the
children had ID and experienced at least one comorbid medical
condition (e.g., epilepsy). Half of the parents reported that their child
had behavioural problems (e.g., hitting or biting; Table 1).
Key messages
• Children with CP and ID face unique issues beyond
those captured in current CP specific QOL instruments.
• The domains ‘predictability and routines’ and
‘opportunity to enjoy nature and the outdoors’ are not
traditionally included in QOL instruments for children.
DAVIS ET AL. 855
2.2 | Procedure
Qualitative research was undertaken using a grounded theory
approach, allowing the domains of QOL to evolve naturally through
constant assessment and contrasting of different themes as captured
in the interview transcripts (Strauss & Corbin, 1990). Semi‐structured
stem and leaf telephone interviews were conducted by two
researchers with psychology training (NM and AE), using our
previously described methods (Epstein et al., 2016; Murphy et al.,
2017). Of note, the additional leaf questions captured observable
behaviours that more clearly illustrated aspects of life quality by asking
parents to provide specific examples that supported their proxy report
(e.g., “How do you know this?”).
Recordings were transcribed and given to parents to provide them
with the opportunity to edit or add information, and 77% (14/18) of
families provided feedback. Coding data during the data collection
period confirmed that new themes were not emerging and that
thematic saturation was achieved after the participation of 18 parents.
A Consumer Reference Group meeting was held with four parents who
participated in the study interviews to review the domains and further
inform interpretation of the findings. Ethics approval for this study was
provided by the Human Research Ethics Committee at the University
of Western Australia, Western Australia (RA/4/1/6931), and parents
provided informed consent to participate in this study.
2.3 | Analyses
The interview transcripts were read and reread, and data describing
observable behaviours were coded by NM using NVivo (10th Ed,
QSE International Pty Ltd, Burlington, MA). Similar segments of
interview data were compiled and coded into themes until no new
themes or “domains” were identified. Four researchers (ED, NM, AE,
and JD) reviewed and interpreted the categorization and labelling of
the domains with joint discussion until a consensus was achieved.
Domains were then compared with those in five parent‐report QOL
measures designed for CP, including the CP QOL Child and
Teen (Davis et al., 2009; Waters et al., 2005), PedsQL v3 CP (Varni
et al., 2006), CPCHILD (Narayanan et al., 2006), and DISABKIDS‐CP
(Baars et al., 2005).
3 | RESULTS
3.1 | QOL domains
Eleven domains were identified as important to QOL in children with
CP and ID, and sample quotes are shown in Figure 1. Parents in the
Consumer Reference Group discussed the 11 domains in the light of
their experiences and concurred with data coding.
3.2 | Function
“Communication” referred to verbal or non‐verbal expressions. This
domain included the child’s ease or difficulty in making choices and
conveying feelings or sharing details of their own experiences. Parents
discussed their child’s ability to communicate feelings in a variety of
ways if they were not able to use language or how they showed frus-
tration when unable to verbalize or express their needs. Some parents
commented that their child showed pleasure in simply being with
others and listening to their conversations.
“Predictability and routine” referred to feeling comfortable with
known patterns of activity, familiar people and recognizable
environments. Some parents described how their child felt more
relaxed when routines were followed. Others indicated their child
was happy for changes in their environment or routines, provided a
clear explanation was given in advance.
“Movement and physical activity” referred to opportunities to be
mobile and active. For example, walking, being active in water, and
participating in physical activities such as horseback riding.
3.3 | Fitness
“Behaviour and emotion” referred to behaviours and associated
emotional states. Observable behaviours included variations in body
language that indicated emotional well‐being and willingness to
cooperate. Parents described their children as smiling and being
TABLE 1 Characteristics of children with cerebral palsy (n = 18)
Number (%)
Age
Middle childhood (6 to 11 years) 8 (44.4)
Adolescence (12 to 18 years) 10 (55.6)
Sex
Female 9 (50.0)
Male 9 (50.0)
Location of residence
Urban 11 (61.1)
Rural 7 (38.9)
Gross Motor Functioning Classification System (GMFCS)
Level II 5 (27.8)
Level III 2 (11.1)
Level IV 5 (27.8)
Level V 6 (33.3)
Intellectual impairment
Severe impairment 5 (27.8)
Mild to moderate impairment 3 (16.6)
Unknown severity 10 (55.6)
Speech impairment
Some impairment 4 (22.2)
Non‐verbal 14 (77.8)
Parent reported behaviour problemsa 9 (50.0)
Medical comorbidities
Hearing impairment 8 (44.4)
Vision impairment 8 (44.4)
Epilepsy 7 (38.9)
Gastrostomy 7 (38.9)
Lower limb musculoskeletal problems necessitating orthopaedic surgery
7 (38.9)
Diagnosis of scoliosis 3 (16.6)
aThese included hitting, biting, throwing objects, and threatening behaviours.
856 DAVIS ET AL.
interested in the environment and activities, or in contrast, being
distressed and frustrated with moodiness, anxiety, aggression, and
poor impulse control.
“Body comfort” referred to comfort or discomfort experienced
because of the child’s physical condition or sensory needs and could
include sensory stimulation such as the enjoyment of listening to
conversations or alternatively physical pain or discomfort.
“Physical health” referred to bodily health and wellness. This
domain included energy levels and fatigue, nutrition, fitness, illnesses,
co‐morbidities, and poor saliva control. Surgical and other medical
procedures were sometimes associated with improvements in a
child’s life, or alternatively, with setbacks in learning or community
engagement.
3.4 | Fun
“Nature and outdoors” referred to opportunities to be outside, to enjoy
nature, gardening, or spending time with pets, farm animals, or visiting
the zoo.
“Variety of activity” referred to participation in different home‐
based and community endeavors. This domain included activities such
as listening to music, watchingTV, playing sport, being a part of a cheer
squad, or attending special events such as theatre and concerts.
“Independence and autonomy” referred to developing skills that
provided opportunities for the child to control their own actions and
aspects of their environment. Elements related to the child’s choice
and personal preferences, mastery and achievement, and developmen-
tal maturity. Several parents gave examples of children expressing
pleasure when mastering new activities that ranged from self‐care to
domestic tasks and when making persistent effort to improve strength
and physical capability.
3.5 | Family/friends
“Social connectedness and relationships” referred to interactions
within social settings. This domain included elements such as social
inclusion and acceptance, shared enjoyment and anticipation,
expressions of love and affection, empathy and other behaviours that
reflected social maturity. Children’s sensitivity to how others
responded to them, involvement in shared activities, excitement when
sharing news, and playful interactions were also described.
“Access to services” referred to experiences with support services
and included elements such as service accessibility and provision of
necessary financial assistance. Parents discussed the importance of
the right match between the services offered and their child’s needs,
professional sensibility, being provided with appropriate equipment,
and access to facilities.
3.6 | Comparison of domains with those in comparative measures
Concept mapping of our data against the five existing QOL measures
indicated that some of the domains within the comparative measures
also emerged as domains in our dataset (e.g., physical health, behaviour
and emotion, body comfort, and communication; Table 2). CP
QOL‐Child and CP QOL‐Teen included the most domains in common
with ours and DISABKIDS‐CP the least. None of the measures
included all the currently identified domains, and the domains
FIGURE 1 Domains of quality of life important for children with cerebral palsy and intellectual disability, shown alongside the F‐words (Rosenbaum & Gorter, 2011) [Colour figure can be viewed at wileyonlinelibrary.com]
DAVIS ET AL. 857
“predictability and routine” and “nature and the outdoors” were not
included in any of the measures (Table 2). It is also acknowledged that
the items within the domains for these existing tools may be very
different or not applicable for children with CP and ID. For example,
our finding that communication included detail such as expressing
happiness when being understood was not articulated in the
comparison measures.
4 | DISCUSSION
The 11 QOL domains identified as important for children with CP and
ID aligned with concepts described in the International Classification
of Functioning, Disability and Health model of disability (World Health
Organization, 2001) and their associated F‐words (Fitness, Function,
Family, Friends, and Fun; Rosenbaum & Gorter, 2011) as illustrated in
Figure 1. The domains that emerged from our qualitative data could be
viewed as essential life domains necessary for professionals to
consider when counselling and supporting these children and their
families. It is interesting that 10 years after the existing questionnaires
were developed, the domains observed by parents as important remain
similar. Previously identified domains were also observed, but there
were some important differences.
Difficulties in functioning may have impacted on the child’s QOL.
Many of the children had substantial difficulties with communication
and relied on their communication partners to be sensitive to subtle
changes in their vocalisations or gestures. Communication devices
such as tablets, computers or phone applications, head switches, and
other equipment provided a framework to enable choice‐making for
exchanging feelings of love and affection and for some sharing of news
and events. The children displayed a sense of accomplishment with
access to physical activities and independent achievement of tasks,
such as indicating toileting needs or by opening their mouth during
teeth cleaning. Many of the children thrived on their day to day
routines and would become upset if unexpected changes occurred.
The value of routines was consistent with our findings for Rett
(Epstein et al., 2016) and Down syndromes (Murphy et al., 2017) and
not previously reported in other QOL measures (Solans et al., 2008)
including those for CP (Baars et al., 2005, Davis et al., 2009, Narayanan
et al., 2006, Varni et al., 2006). The presence of childhood routines
affects well‐being in the general population (Sytsma, Kelley, & Wymer,
2001) and was also observed to be supportive of functioning in our
sample with CP.
The domains related to fitness concerned physical and behavioural
well‐being. Children with more severe motor impairment are more
frequently affected by poor health including the presence of pain
(Colver et al., 2014) and co‐morbidities such as epilepsy and
respiratory illnesses, which were also associated with more hospital
admissions compared to children with less severe CP (Meehan et al.,
2017). Mental health problems can also affect individuals with CP
(Parkes et al., 2008) with some studies suggesting poorer mental
well‐being in those with comorbid ID (Parkes et al., 2008). Parents
reported that when children were healthy and happy, they were more
likely to be involved in social or other activities. Conversely, a
distressed or irritable child sometimes engaged in tantrums or other
injurious behaviours detrimental to QOL.
Aspects of fun included the child’s involvement in a variety of
recreational activities (e.g., horse riding) as well as independent
pastimes (e.g., listening to music). Children’s participation in a range
of activities was less common in those who were more severely
affected, yet these activities remained an important source of pleasure,
helping to build confidence and enhancing skills (Majnemer et al.,
2008). As is being increasingly recognized in the general population
(Bratman, Hamilton, & Daily, 2012), participation in the natural
environment was associated with enjoyment and relief of stress. This
domain has not been articulated in other QOL measures (Baars et al.,
2005; Davis et al., 2009; Narayanan et al., 2006; Solans et al., 2008;
Varni et al., 2006) but was observed in our qualitative studies on Rett
(Epstein et al., 2016) and Down syndromes (Murphy et al., 2017).
The domain of “social connectedness and relationships” focuses
on the child’s interactions with family and friends. The importance of
social relationships and inclusion in activities observed by the parents
has been previously documented (Colver et al., 2014; King et al.,
2006). Family and friends played an important role in the lives of our
sample of children with CP and ID, and the quality of social
relationships was critical to building a sense of personal worth and
TABLE 2 Quality of life domains from the current cerebral palsy dataset and their presence in the five comparative measures
Domains for children with CP and ID CP QOL‐Child CP QOL‐Teen PedsQL‐CP CPCHILD DISABKIDS‐CP
Physical health X X X X
Behaviour and emotion X X X X
Body comfort X X X X
Communication X X X X X
Movement and physical activity X X X X X
Predictability and routine
Independence and autonomy X X
Social connectedness and relationships X X X X
Variety of activity X X X
Nature and outdoors
Access to services X X
Note. CPCHILD = Caregiver Priorities and Child Health Index of Life with Disabilities; CP QOL = Cerebral Palsy Quality of Life; PedsQL = Pediatric Quality of Life Inventory.
858 DAVIS ET AL.
well‐being. Important elements that have not been previously
identified included excitement when sharing news with others and
being present and involved during mealtime conversations. New
technologies and applications (e.g., video chatting with friends) helped
make social connections available, which facilitated children’s
engagement with their peers. Access to services, such as timely
replacement of equipment, may mean the difference between comfort
or discomfort for some children or engagement in rewarding pastimes
using communication, educational, and recreational aids.
A suite of QOL measures has been developed for CP, but their
domains do not fully correspond to those identified in our study,
possibly because their development methods did not focus on ID.
Our domains most closely mapped to CP QOL‐Child (Waters et al.,
2005). This is not surprising because the CP QOL‐Child was also
developed using qualitative methods with a focus on well‐being rather
than on limitations (Baars et al., 2005), function (Baars et al., 2005;
Varni et al., 2006), or parent priorities (Baars et al., 2005), which may
not align with the concept of QOL (World Health Organization,
1993). However, it must be acknowledged that the items within the
domains may need to be quite different if the child has comorbid ID.
For example, the CP QOL‐Child assesses emotional well‐being through
how the child feels about themselves and their opportunities, although
the current study suggests suitable items for a new measure would
need to take into account behaviours such as frequency of smiling
and those that indicate frustration, problems with impulse control,
and aggression. Furthermore, the CP QOL‐Child omits potentially
important domains of “predictability and routine” and “nature and
outdoors.” In contrast, the domains identified in our study were
remarkably consistent with those identified for children with Rett
(Epstein et al., 2016) and Down syndromes (Murphy et al., 2017). ID
in children appeared to be associated with commonalities for QOL that
are not restricted to a specific diagnosis. Similar to our study with
Down syndrome (Murphy et al., 2017), we did not observe differences
in the domains reported for children or adolescents.
We relied on parent report given the pronounced communication
difficulties that many of the children experienced because we did not
want these children to be excluded from QOL investigations.
However, we recognize that this is associated with limitations because
QOL is an experiential concept and parents and children do not always
agree as to the composition of a child or young person’s QOL (Davis
et al., 2007). Some parents described ongoing observations of their
child to piece together combinations of words, gestures, and emotional
tone to determine what was satisfying or challenging for their child. To
overcome this potential limitation, our interview schedule included
probing questions eliciting what was observed by parents, and it was
only the reported observations that were coded, not expressed
personal views or values of the parents. Although recruited from a
population‐based database to capture variability in child experiences,
most children had severe disability and we may not have captured all
relevant domains for those with CP and milder ID. It would also be
important to replicate our methodology in other settings to check that
our domains are replicable.
Through the observations of parents, our study revealed the chil-
dren’s reactions to life’s challenges and rewards. It reinforced
the need for attention to concepts such as adequate and timely
responses to physical and emotional needs, building and maintaining
communication skills with social and community involvement, and
the need to aim for best possible levels of independence. Novel
themes in relation to “predictable routines” and “opportunity for time
in the natural environment” emerged and could indicate useful ways
that day to day QOL could be increased. The current CP measures
do not address the unique aspects of QOL for children with CP and
ID, and an important task is to translate these findings into a measure
that can quantify QOL for this group. Another challenge is to develop
methods that can directly capture the points of view of the children
with milder ID and gain insights into their views on important domains
of QOL. Guided by the diversity of communication strategies that the
children used, this might be possible with creative use of media and
technology along with skilled delivery of tailored approaches to
communicate with each child. The ultimate goal would be to capture
their reactions to experiences and situations that have been raised
within each of these domains.
ACKNOWLEDGEMENTS
The authors would like to thank all the families who participate in the
VictorianCerebral Palsy Registry andwho shared their thoughts and time
with us. The Victorian Cerebral Palsy Register receives funding from the
Victorian Department of Health and Human Services and from the
Victorian Government’s Operational Infrastructure Support Program for
support for register staff. This study is currently funded by the National
Health andMedical Research Council (#1103745). AW and HL are each
supported by a Senior Research Fellowship from the National Health
and Medical Research Council (#1077966, #1117105 respectively)
and SR is supported by an Early Career Fellowship from the National
Health and Medical Research Council (#1072442). The funders of this
research have had no roles in the study design, data collection, data
analysis, manuscript preparation, and/or publication decisions.
ORCID
J. Downs http://orcid.org/0000-0001-7358-9037
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How to cite this article: Davis E, Reddihough D, Murphy N,
et al. Exploring quality of life of children with cerebral palsy
and intellectual disability: What are the important domains of
life?. Child Care Health Dev. 2017;43:854–860. https://doi.
org/10.1111/cch.12501
860 DAVIS ET AL.
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