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The objective of this study was to compare recovery time and duration of active rehabilitation following concussion between adolescents with and without attention-deficit/hyperactivity disorder (ADHD).A retrospective cohort study was conducted among adolescents presenting to a specialty concussion clinic. One-quarter of the eligible episodes of care were selected. The final sample included 540 adolescents (ages 13-17 years, median age 15 years; 49.8% girls), of which 65 (12.0%) had a pre-injury diagnosis of ADHD.ADHD was not associated with recovery time (ADHD: median = 49 days, IQR = 25-77; No ADHD: median = 47 days, IQR = 29-85) in univariate (Z = -0.45;Our findings support accumulating evidence that ADHD, in and of itself, is not a risk factor for longer recovery or worse outcomes following pediatric concussion.

To (1) determine the level of agreement between symptom provocation and performance-based tests of vestibulo-ocular reflex (VOR) function after pediatric mild traumatic brain injury (mTBI) and (2) describe the level of symptom provocation induced by a VOR task in individuals with and without cervical findings.Cross-sectional.This study was conducted at a tertiary care pediatric hospital.A total of 101 participants (N=101) aged 6-18 years within 3 weeks of mTBI diagnosis were included (54.5% female; mean age, 13.92±2.63 years; mean time since injury at assessment, 18.26±6.16 days).None.No outcomes demonstrated agreement with symptom provocation (κ=-0.15 to 0.14). Fair agreement demonstrated between clinician-observed VOR performance and HTT (κ=0.32), with little to no agreement demonstrated between other measures. Proportions reporting test-induced dizziness and headache were greater among individuals with cervical findings (29.1%-41.8%) than without (2.3%-6.8%).Findings support that symptom provocation and performance-based tests measure different constructs and thus have distinct roles when assessing VOR function. Findings suggest results from measures of symptom provocation may be influenced by coexisting cervical impairments, underlining the value of assessing for cervical injury after pediatric mTBI.

BACKGROUND Although postural impairments have long been reported following a concussion in the pediatric population, we still know very little about who is more at risk of presenting those balance problems and how the mechanism of injury (sport vs non-sport) could influence balance problems after concussions. The purpose of this study was to compare balance function in children having sustained a sport-related (SRC) or non-sport-related (NSRC) concussion, to that of children with an orthopedic injury (OI) and to non-injured (NI), over a one-year period. METHODS One-hundred and twelve participants were included in this study. Among them, 38 were concussed, with 27 having sustained a SRC; and 11 an NSRC, as well as 38 NI, and 36 OI. Balance function was evaluated at 2 weeks, 3 months, 6 months, and 12 months after a concussion, and at the same time intervals for the control groups. The balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOT2) and Timed Foam Test was used to measure postural instability. Concussion related symptoms were measured by the Post Concussion Symptom Scale (PCSS). RESULTS There was an improvement in tandem standing on the balance beam (P=.02) and in single-leg standing (SL) on foam surface (P=.02) for all groups over a year. At the 2nd week, NSRC had more postural instability than NI during SL on the balance beam when eyes were closed (P =.01), and performed significantly worse than SRC (P =.01) and NI (P =.01) during SL on the foam surface. NSRC also reported more symptoms than SRC on PCSS (P < 0.001). In the 3rd month, NSRC still had lower performance than SRC in SL on foam surface (P =.01). CONCLUSIONS Children sustaining a concussion outside of a sport seem to have higher levels of postural instability up to 3 months post-injury when compared to those injured in sport.

Objective The primary objective is to evaluate the feasibility (safety and acceptability) of implementing early active rehabilitation (AR) for concussion management in youth with symptoms persisting 2 weeks after injury. A secondary and exploratory objective was to estimate the potential efficacy of early AR compared with standard AR. We hypothesize that AR at 2-weeks postconcussion will be safe and acceptable to patients. Design Randomized clinical trial. Setting The Montreal Children's Hospital of the McGill University Health Center (MCH-MUHC), a tertiary care pediatric teaching hospital affiliated with McGill University in Montreal, Canada. Participants Twenty youth aged 9 to 17 years old with postconcussion symptoms for at least 2 weeks. Intervention Active rehabilitation (aerobic exercise, coordination drills, visualization, and education/reassurance) was administered by physiotherapists in-person, and then continued as a home program. Methods Twenty participants were randomized to either early AR (initiated 2 weeks after injury) or standard AR (initiated 4 weeks after injury). Results Two adverse events (one in each group) were identified through an online survey more than one-month postconcussion. Postconcussion symptoms decreased over time for both groups. Conclusions The results from this pilot study indicate that a full clinical trial estimating the efficacy of early AR (starting 2 weeks after injury) is feasible. Further study is needed to determine the superiority of this strategy over current treatment approaches.

Research Objectives Alterations to vestibulo-ocular reflex (VOR) function (1-3) and cervical spine injury (4-6) may contribute to dizziness reported following pediatric mild traumatic brain injury (mTBI). Moreover, dizziness has been correlated with a more negative prognosis. While various measures are used to assess VOR function, there is no consensus on what the optimal battery of tests may be. The influence of cervical injury on findings from these tests remains unclear. Objectives: i) to determine the level of agreement between symptom- and performance-based tests of VOR function in a pediatric mTBI sample; ii) to characterize the level of symptom provocation induced by VOR tests in individuals with and without cervical findings. Design Cross-sectional study. Setting Tertiary care pediatric hospital. Participants 101 participants (54.5% female), mean age 13.92 years (SD 2.63), completed a VOR assessment (mean time since injury 18.26 days (SD 6.16)). Interventions N/A. Main Outcome Measures Symptom provocation was measured by the Vestibular/ocular motor screening tool (VOMS). Performance was measured by VOMS VOR performance, the head thrust test (HTT), the computerized dynamic visual acuity test, and the video head impulse test. Cervical impairment was measured by the cervical flexion rotation test, range of motion test and self-reported neck pain. Results No outcomes demonstrated agreement with VOR symptom provocation (k=-0.15-0.14). Among performance-based measures, fair agreement was demonstrated between VOMS VOR performance and the clinical HTT (k=0.32), while little to no agreement was demonstrated between the remaining measures. VOR dizziness symptoms were reported in a greater proportion of individuals with cervical findings (41.1-41.8%) than without (2.3-6.8%). Conclusions The findings indicate i) that symptom-based VOR tests measure a different construct than performance-based tests, ii) the distinct role of each measure when assessing VOR function should be further understood, and iii) cervical injury may contribute to symptoms induced by tests of VOR function. Author(s) Disclosures The authors have no conflicts of interest to disclose. This study was funded by an ERA-Net NEURON JTC Cofund Program.

To compare the ability of clinical balance measures to detect differences between children recovered from a mild Traumatic Brain Injury (mTBI) and healthy controls.A cross-sectional study, with twenty-six children with mTBI and twenty-two age-matched controls was conducted. Balance was evaluated on three scales: Bruininks- Osteresky Test-second edition; Balance Error Scoring System and Community Balance and Mobility Scale, along with gait analysis of three paradigms (self-selected paced walking, obstacle crossing and tandem walking), under single and dual-task conditions, using GAITRite\scriptsize® walkway. Independent sample t-tests (α = 0.05) were used to identify group differences. Dual-Task Cost (DTC) was analyzed using repeated measures ANOVA and t-tests. Discriminant analysis predicted which balance measure best identified the groups.Children with mTBI performed worse on all balance scales (p0.05). Gait parameters were significantly better for the controls. There were no group differences on the motor and cognitive DTC. The Community Balance and Mobility Scale and gait parameters including velocity at obstacle crossing and parameters for tandem walking, best discriminated the groups.Clinical balance assessments may need to include static and dynamic measures, to capture possible performance difficulties. The inclusion of these measures will enhance clinical decision making and prevent premature return to physical activities in children with mTBI.

OBJECTIVE (1) To determine the impact of providing participants aged 8 to 17 years who are slow to recover after a concussion with a well-developed active rehabilitation intervention (ARI), compared with receiving standard care alone, on postconcussion symptoms (PCS) at 2 and 6 weeks after the initiation of ARI; and (2) to investigate functional recovery 6 weeks after initiation of ARI. DESIGN A multicenter prospective quasi-experimental control group design. SETTING Tertiary care pediatric trauma center and community health care providers. PARTICIPANTS Forty-nine youth were enrolled (experimental n = 36; control n = 13). PROCEDURES Participants were assessed on 3 different occasions: (1) initial visit (baseline); (2) 2 weeks; and (3) 6 weeks after enrollment. MAIN OUTCOME MEASURES Child- and parent-reported PCS were obtained by the PCS Inventory Scale (primary outcome). Secondary outcomes included: (1) mood and anxiety; (2) quality of life; (3) energy level; (4) coordination and balance; (5) neurocognition; (6) parental anxiety; and (7) satisfaction with intervention. RESULTS Both groups reported decrease of PCS over time (child: P = 0.01; parent: P = 0.03). Children in the experimental group presented higher quality of life (P = 0.04) and less anger (P = 0.02). A trend toward significance was observed for better tandem gait (P = 0.07) and for less general fatigue on self-reported PCS (P = 0.09) in the experimental group. CONCLUSIONS Active rehabilitation intervention does not affect the PCS beyond the usual management, but it increases their quality of life, decreases anger, and potentially increases energy level and balance.

OBJECTIVE To estimate the extent to which biologic sex contributes to the severity of postconcussion symptoms (PCSs) in concussed youth, who are slow to recover and who receive an active rehabilitation intervention (ARI) as part of their standard care. SETTING The concussion clinic of a pediatric trauma center in Canada. PARTICIPANTS A total of 355 youth with persistent PCS (188 girls and 167 boys) as per the following criteria: (1) diagnosed with a concussion (or mild traumatic brain injury) as per the 2004 World Health Organization definition; (2) aged 8 to 17 years (mean = 14.34, standard deviation [SD] = 2.22 years); (3) presenting with at least 1 PCS interfering with daily activities (mean total PCS score at initial assessment = 24.50, SD = 18.88); and (4) on ARI 4 weeks postinjury (mean = 30.46, SD = 3.74 days). DESIGN A retrospective analysis of a prospective cohort. MAIN MEASURES PCS severity, measured by the PCS Scale (PCSS) included in the Sports Concussion Assessment Tool-3, was the dependent variable. PCSs were assessed 3 times over a 4-week period. RESULTS Boys presented with significantly fewer symptoms than girls 4 weeks postinjury, at initiation of the ARI (PCSS total score mean: ♂ = 19.9, ♀ = 28.5, P < .001, confidence interval = -14.8 to -6.4), at 2 and 4 weeks of follow-up, but the rate of recovery was slightly faster for girls over the follow-up period. CONCLUSION Despite differences between the PCSS score reduction after 4 weeks of intervention, our results favored to a slightly faster recovery for girls over the follow-up period. Although our findings are not strong enough to suggest distinct sex-specific intervention, both boys and girls benefit from participating in an ARI.

The purpose of this study was to examine the effectiveness of an active rehabilitation intervention for adolescents who are slow-to-recover after a sport-related concussion. Ten adolescents (three girls and seven boys) seen at the Montreal Children's Hospital Concussion Clinic participated in this case series. Adolescents who were symptomatic more than 4 weeks after the injury were provided with an active rehabilitation intervention (M = 7.9 weeks following injury; range = 3.7 to 26.2 weeks). The rehabilitation program includes gradual, closely monitored light aerobic exercise, general coordination exercises, mental imagery, as well as reassurance, normalization of recovery, and stress/anxiety reduction strategies. The program continued until complete symptom resolution and readiness to begin stepwise return to activities. The primary outcome of the study was evolution of post-concussion symptoms. Secondary outcomes included mood, energy, balance, and cognition. After the intervention, post-concussion symptoms significantly decreased for the group of participants. They also had decreased fatigue and improved mood after 6 weeks of initiating the rehabilitation intervention. This case series shows that postconcussive symptoms and functioning in adolescents following sports-related concussion can be improved after participation in an active rehabilitation intervention. The introduction of graded light intensity exercise in the post-acute period following concussion is safe, feasible and appears to have a positive impact on adolescents' functioning.

To estimate the extent to which post-concussion symptoms were influenced by participation in an Active Rehabilitation (AR) program (aerobic exercise, coordination drills, visualization and education) for children and adolescents who are slow to recover from concussion. A secondary exploratory objective included examining the influence of sex on symptom evolution.Analysis of prospectively collected data was performed on 277 youth who initiated an AR program, between three and four weeks post-injury at a Concussion Clinic in a tertiary care paediatric teaching hospital.Post-concussion symptom scale (PCSS) from Sport Concussion Assessment Tool-3 (SCAT 3).Children and adolescents participating in an active rehabilitation program displayed improved post-concussion symptom severity at follow-up (median = 9.5) compared to pre-intervention (median = 18) (p.05). Patients demonstrated improved physical, cognitive, emotional and sleep-related post-concussion symptoms (p.05). Female sex was associated with an increased post-concussion symptom severity at follow-up.Youth experiencing persisting symptoms three to four weeks post-concussion demonstrated improved post-concussion symptoms scores (physical, cognitive, emotional and sleep related) with participation in an active rehabilitation program.

OBJECTIVE To estimate the time frame during which initiating an active rehabilitation intervention (aerobic exercise, balance, and sport specific skills) after concussion contributed to improvement in symptoms at follow-up in children and adolescents who are slow to recover (symptoms persisting beyond 2 weeks) from concussion. SETTING Concussion clinic at a tertiary care pediatric teaching hospital. PARTICIPANTS A total of 677 children and adolescents with concussion aged 7 to 18 years. DESIGN Case series of participants starting active rehabilitation less than 2, 2, 3, 4, 5, or 6 or more weeks postconcussion. MAIN MEASURE Symptom severity measured by the 22-item Post-Concussion Scale (PCS)-revised. RESULTS All patients experienced significant improvement of symptoms while participating in active rehabilitation, irrespective of the start time postonset. Patients initiating active rehabilitation at 2 (P < .001) or 3 (P = .039) weeks postinjury demonstrated lower symptom severity at follow-up than those starting at 6 weeks or later. Patients starting at 2 weeks had lower symptom severity than patients starting less than 2 (P = .02), 4 (P = .20), or 5 weeks postinjury (P = .04). Lastly, patients starting less than 2 and 6 weeks or more postinjury yielded equivalent outcomes. CONCLUSIONS The findings support the use of active rehabilitation in children and adolescents who are slow to recover from concussion. Participants starting active rehabilitation less than 2 weeks and up to 6 or more weeks postconcussion demonstrated significant symptom improvements, but improvement was observed in all groups, regardless of the time to start active rehabilitation.

We wished to determine the frequency of complementary and alternative health care (CAHC) use in preschool aged children with physical disabilities (PD) waiting for public rehabilitation services in the province of Quebec (Canada), to evaluate its effectiveness from the parents' perspective and to explore factors associated with its utilisation.Children with PD referred to rehabilitation centres from two Montreal hospitals were recruited. We evaluated the use of CAHC and its effectiveness from the parents' perspective in a cross-sectional manner, using descriptive statistics. We explored factors associated with utilisation, using logistic regression models.In this group of children with PD (n = 206, mean age: 2.6 years), 31 (15%) used CAHC and 15 (48.4%) of those tried more than one type. CAHC was considered at least moderately beneficial by parents in 53% of the cases. The use of CAHC was higher among children with low health-related quality of life (HRQOL) and children whose mothers were more educated and considered themselves as Canadian (p0.05).Although the use of CAHC by young children with PD was low, use of CAHC was higher among children with lower HRQOL and whose mothers were highly educated and Canadian. CAHC use should be evaluated by health providers to better educate parents of children with PD, which may help them to make the best decisions regarding their child's treatment while waiting for rehabilitation services.

To determine whether longer waiting times for rehabilitation were associated with deterioration in child functional status and/or quality of life.Parents of 124 children (mean age 45 months) with physical disabilities (e.g., cerebral palsy, global developmental delay, spina bifida) who were referred to pediatric rehabilitation centers were interviewed every three months, from referral until admission into the rehabilitation program. Information from parental interviews included socio-demographics, parental empowerment (Family Empowerment Scale), function (WeeFIM: Functional Independence Measure for Children), and quality of life (PedsQL). Data on date of referral, age, gender, and diagnosis were obtained from hospital databases.Half of the sample waited more than 9.1 months (95% confidence interval: 6.5-16.1) for admission to a public rehabilitation program. A total of 42% paid for some private services while waiting. Over the waiting period, there was statistically significant improvement in WeeFIM cognition and total scores but not in mobility scores. PedsQL psychosocial summary score declined over the waiting period (p.05).Longer wait times for rehabilitation were associated with declining psychosocial quality of life. Reducing waiting times for rehabilitation services may allow rehabilitation specialists to address psychosocial problems for these children.

Objective To estimate the extent to which gender contributes to severity of post-concussion symptoms (PCS) in youth with concussion, who are slow to recover and who receive an active rehabilitation intervention as part of their standard care. Design A retrospective analysis of a prospective cohort Setting Concussion Clinic of a Paediatric Trauma Centre in Canada. Participants 355 youth with persistent PCS (188 girls; 167 boys). All Concussion patients’ information is entered prospectively in a clinical database and participants were selected for this study if they met the following criteria: 1) aged 6 to 17 years (mean=14.34, SD=2.22 years); 2) presenting with at least one PCS interfering with daily activities (mean total PCS score at initial assessment=24.50, SD=18.88), and 3) beginning an active rehabilitation intervention 4 weeks post injury (mean=30.46, SD=3.74 days). Outcome measures Severity of post-concussion symptoms, measured by the PCS scale included in the SCAT3, was the dependent variable. PCS were assessed 3 times over a 4-week follow-up period. Main results Boys presented with significantly less symptoms than girls 4 weeks post-injury, when starting the active rehabilitation intervention (PCSS total score mean; m=19.9, f=28.5, p Conclusions Although there are gender differences in the levels of PCS 4-weeks post-injury, and while boys may recover earlier from persistent PCS, both boys and girls benefit from participating in an active rehabilitation intervention. Competing interests None.

To present an innovative approach to the management of children who are slow to recover after a sport-related concussion.The article describes the underlying principles and the development of specific interventions for a new rehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures.Development of the intervention was done using multiple perspectives including that of the literature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric and adolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. The intervention was implemented and evaluated with a sample of 16 children and adolescents.The presented cases suggest that involvement in controlled and closely monitored rehabilitation in the post-acute period may promote recovery in children and adolescents who present with atypical recovery following a concussion. All 16 of the children and adolescents who participated in the programme experienced a relatively rapid recovery and returned to their normal lifestyles and sport participation.A gradual, closely-supervised active rehabilitation programme in the post-acute period (i.e. after 1 month post-injury) appears promising to improve the care provided to children who are slow to recover.

Health services research regarding the needs, delivery and utilization of paediatric rehabilitation is an emerging field of interest, given the increase in infant survival and subsequent growing focus on childhood disabilities (Perrin 2002; Halfon et al. 2004; Msall et al. 1998; Majnemer et al. 2002; Limperopoulos et al. 2001). Childhood disability has a substantial impact on the healthcare system, as children who have restrictions in activities are high users of healthcare services, particularly rehabilitation (Newacheck and Halfon 1998). Early identification of children with physical and developmental disabilities is crucial to ensure that appropriate interventions are provided as soon as possible to allow children to develop their full potential, maximize their level of function and prevent further disabilities (L’Office des personnes handicapees du Quebec 1992; Michaud and Committee on Children with Disabilities 2004; Halfon et al. 2004; Majnemer 1998; Majnemer et al. 2002; Feldman et al. 2002; Simpson et al. 2003; American Academy of Pediatrics 1996). Conversely, barriers limiting accessibility to rehabilitation services (e.g., long waiting times) could significantly compromise a child’s functional and health status. In Quebec, services were reformed in the early 1990s to better meet the needs of families of children with disabilities. The intent was to implement comprehensive coordinated services within the community (Office des personnes handicapees du Quebec 1992; Regie regionale de la sante et des services sociaux de Montreal-Centre 1998; Ordre des physiotherapeutes du Quebec 1996). Paediatric outpatient rehabilitation services for children under 6 years of age were no longer provided at acute care paediatric hospitals; children requiring these services were referred to specialized paediatric rehabilitation centres. This situation created accessibility problems (Regie regionale de la sante et des services sociaux de Montreal-Centre 1998; Institut de readaptation en deficience physique de Quebec 2002). Problems with accessibility to paediatric rehabilitation services are not limited to Quebec residents (Fox et al. 1993; Majnemer et al. 2002; Feldman et al. 2002; Simpson et al. 2003). Some of the factors associated with accessibility to these services have been identified. Younger children typically receive rehabilitation services before older children (Majnemer et al. 2002; Bailey et al. 2004; Feldman et al. 2002; CanChild 2000). Very young children referred to rehabilitation are more likely to have an identifiable pathologic condition (e.g., genetic syndrome, seizure disorder) or risk condition such as prematurity. Older children are more likely to be referred for problems related to developmental delay (Bailey et al. 2004). Severity of the disability may be another factor influencing accessibility. For example, children may be denied access to rehabilitation services provided by Health Maintenance Organizations (HMOs) if the child cannot improve significantly over a short period of time, which is often the case for children with severe disabilities (Fox et al. 1993). In other cases, the more severe a physician perceives a child’s disability, the more likely it is that the child will be referred to physical therapy (Campbell et al. 1995). Diagnosis may also influence referral times to rehabilitation. Because paediatricians appear to be reluctant to refer children with developmental delays or less severe disabilities to early intervention services (Bailey et al. 2004), it is unclear whether severity enhances or impedes access to rehabilitation. Socio-economic status (SES) may also influence access to rehabilitation. Parental knowledge of child development has been linked with higher parental educational level (McCune et al. 1984), implying that those who are knowledgeable may recognize problems earlier, perhaps leading to earlier rehabilitation. In addition, it is well established that lower family SES has been associated with higher incidence and severity of disability in children (Simpson et al. 2003; Msall et al. 1998; Perrin 2002). Two studies have explored service delivery (by measuring waiting times or service utilization patterns) for paediatric rehabilitation services in Montreal. These studies used a cross-sectional design and were limited to only one of two paediatric tertiary care hospitals (Feldman et al. 2002; Majnemer et al. 2002). Feldman et al. (2002) included school-aged children using resources allocated by the school system as opposed to rehabilitation centre, while the study by Majnemer et al. (2002) included children with pervasive developmental delay (autistic spectrum disorders) receiving services at centres specialized in treating intellectual disability. Neither study measured disability in a consistent or standardized fashion. The current study was designed to address some of the limitations of previous studies. We followed a prospective cohort of preschool-age children with physical disabilities recruited from both tertiary care paediatric hospitals in Montreal and measured their performance with a well-accepted functional measure. The objectives of this study were to describe waiting time to receive physical therapy (PT) or occupational therapy (OT) services at rehabilitation centres for preschool-aged children with physical disabilities, and to examine the factors associated with waiting time, including the child’s age and the diagnosis and severity of the physical disability. We hypothesized that access time to rehabilitation was longer for younger children within specific diagnostic groups and for those with more severe disabilities.

Objectives: To determine the association between functional status, measured by the WeeFIM and health-related quality of life (HRQL), measured by the PedsQL4.0 for children with physical disabilities. To explore child, parent and service-related factors associated with each of these measures. Patients: Parents of 115 children (2–5 years) with physical disabilities who were referred to occupational (OT) or physical therapy (PT). Mean age of the children was 3 years 7 months (±10 months), 79 were boys and 67 were diagnosed with global developmental delay. Results: Children had more difficulties with self-care tasks and cognitive abilities, as compared to mobility activities on the WeeFIM. The correlation between total WeeFIM and total PedsQL4.0 was r = 0.39. WeeFIM mobility and self-care quotients were each fairly correlated with PedsQL-Physical Health Summary Score (r s = 0.29 and r s = 0.28 respectively). There was no significant association between WeeFIM cognition quotient and each of PedsQL scores (r s = 0.03–0.05). The receipt of PT services was highly associated (p

Objective To describe when and by whom concern is first expressed for children referred to rehabilitation because of neuromotor problems. Study Design and Setting We conducted a survey of parents of 92 children (aged 0-6 years) who were on the waiting list for physical or occupational therapy services at rehabilitation centers in Montreal, Quebec. We compared age of child at initial concern with who first expressed concern for children who were considered at risk due to their perinatal history of prematurity and those who were not born prematurely but were later diagnosed as having neuromotor problems. Intervention Parents were interviewed regarding their child’s medical history and utilization of health care services. Results Parents were concerned later than physicians were regarding their child’s development (mean difference, 8.2 months; 95% confidence interval [CI], 3.7-12.6 months). There was no significant difference in time of recognition of problems between the premature (10.2 months) and full-term (11.9 months) groups. Even after controlling for risk group, parental concern occurred later than physician concern (β coefficient, 7.3; 95% CI, 2.5-12.2). The child’s age at the time of initial concern was associated with the child’s age at referral to rehabilitation (β coefficient, 0.04; 95% CI, 0.01-0.06). Conclusions Early recognition is important if a child is to benefit from early rehabilitation. It may be important to improve primary care screening of children for neuromotor problems and to increase parental awareness regarding normal motor development of their children. Prompt, simultaneous referral to medical evaluation and rehabilitation resources may decrease delays in rehabilitation.