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: [email protected]

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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