Association of a HABIT-ILE Course and a Home Programme on the Bimanual Performance of Children With Cerebral Palsy

The Assisting Hand Assessment (AHA) is a valid tool to assess children's ability to perform bimanual tasks, focusing on the functional use of the impaired hand. Its validity, reliability and responsiveness have been demonstrated, and it is regularly used in studies of children with unilateral CP.

The raw AHA scores (min: 22 to max: 88) will be covered to a logit scale from 0 to 100 in order to obtain an interval scale, a proprety that the raw scores do not have. The conversion to this scale is based on a Rasch model. An increase in the AHA score indicates an improvement in the child's hability to perform bimanual taks.

This study falls into the "Balanced Advantages" model of non-inferiority study designs. In this model, it is common to accept an inferiority level of 10 to 50% of the experimental treatment compared with the reference treatment. For this study, we set the accepted inferiority at -10% of the known values for the reference HABIT-ILE treatment; approximately 5 points.

The Canadian Measure of Occupational Performance (COPM) will be used to define therapeutic goals, and to quantify the change in the child's performance and the parents' level of satisfaction for each functional goal. Using the COPM, the therapist conducts a semi-structured interview with the child's parent to identify difficulties in self-care, productivity, and leisure. The parent rates the importance of each indetified issue(1-10) and selects five priorities. For each, they rate their child's performance and their satisfaction with that performance (1-10, Higher ratings indicate greater importance, performance, and satisfaction). Average scores (out of 10) are calculated for performace and satisfaction. A change of two points or more is considered clinically significant.

For this secondary outcome, the assumption is a maximum non-inferiority of 10% (T2-T0), ie, 0.4 points on average for the COPM, based on the results of Arenada et al..

The Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) will measure the change in functional skills in the domains of daily activities and mobility. These reliable questionnaires are used in clinical practice and research to determine changes in activity and participation in children with CP. These reliable questionnaires are used in clinical practice and research to determine changes in activity and participation in children with CP. The minimal score of PEDI CAT is 20 and the maximum 80, a higher score translates to higher function functional ability.

For this secondary outcome, the assumption is a maximum non-inferiority of 10% (T2-T0), ie, 0.2 points for PEDI-CAT, based on the results of Arenada et al..

Gross motor activity (whole-body movements such as walking, cycling or jumping) and upper limb activity (movements of the arms, hands, and fingers, such as reaching, grasping or manipulating objects) will be measured using inertial sensors worn on each wrist and the trunk during the entire intervention time (35h+15h for the PARTNER group, 50h for the HABIT-ILE group). The main outcome will be the percentage of time spent performing movement during the sessions. The amount of activity performed at home out with sessions will also be measured in both groups.

To complete the questionnaire and participate in the semi-structured interviews, families will be asked to designate the child's main carer, who will agree to participate in the entire study and complete the questionnaires and interviews alone.

The WHOQOL-Bref will measure parents' perceptions of their quality of life. This scale is derived from the WHOQOL-100 developed by the WHO (1995). It measures peopol's perception of their quality of life. The scale comprises 26 items divided into four areas: physical health, physiological health, social relationships end the environment. A hign score indicates a good quality of life, while a low score indicates a poorer quality of life. The 26 items are rated on a 5-point Likert scale (scores from 1 to 5). It is possible to obtain a score in each of the 4 domains (average score). These domain scores must be multiplied by 4 to be comparable with the WHOQOL-100. Two items can be analysed separately.

To complete the questionnaire and participate in the semi-structured interviews, families will be asked to designate the child's main carer, who will agree to participate in the entire study and complete the questionnaires and interviews alone.

The Enabling Practice Scale (EPS) will be used to assess the parents' perception of the nature of the support provided by the referral workers. The total score will be analysed, EPS assesses parets' perceptions of the nature of the support provided by professionals providing care. This is a self-questionnaire containing 24 questions, each of which is scored on a 5-point Likert-type scale (from 1 to 5). The minimu score is 24, the maximum 120. A higher score indicates a higher level of enabling. The PES can be completed in 5 to 10 minutes. The overall score will be used in this study.

The Psychological Scale (PES) will be used to estimate changes in family empowerment in 3 dimensions: attitudes of control and competence, knowledge and kno-how, and participation behaviours. The Psychological Empowerment Scale (PES) evaluates parent's power to act on the basis of 32 items divided into three dimensions: attitudes of control and competence, knowledge and know-how, and participation behaviours. Each item is scored from 1 to 5 (minimum total score: 32, maximum: 160). A higher score indicates a higher level of empowerment. The total empowerment score will be analysed.

The Parental Stress Inventory (PSI) will be used to measure the level of parental stress in the child's domain (eg, hyperactivity/distrac) ISP is a French translation of Abidin's Parental Stress Index (PSI). It measures the level of parental stress on the basis of 120 items belonging to two main categories: related to the child's domain: depression, feeling of competence, attachment, marital relationship, social isolation, parent's health, restrictions of the parent's role. The parent's answers are given on a likert-type scale ranging from 1 to 5, and it is possible to obtain a total stress score (raw score or percentage) or 15 sub-scores representing the child's and parent's domains. The inventory has been validated for use with parents of children with disabilities.

The Affordances in the Home Environment for Motor Development Self-Report (AHEMD-SR) will be used to inventory the quantity and quality of resources available in the home to stimulate the child's motor development. The tool includes five dimensions: outdoor space, indoor space, variety of stimulation, gross motor toys, and fine motor toys. Each dimension is scored from 1 (very low) to 4 (very high), for a total score ranging from 5 to 20. Higher scores indicate a more favorable home environment for motor development.

PCERA measures the quality of the relationship between a parent and child aged 1 to 4.5 years. PCERA includes a total of 65 individual items composed of 29 parental, 28 child, and 8 dyadic items. The PCERA manual outlines six subscales: (1) Parent Positive Affective Involvement, Sensitivity, and Responsiveness; (2) Parent Negative Affect and Behavior; (3) Infant Positive Affect, Communication, and Social Skills; (4) Infant Dysregulation and Irritability; (5) Dyadic Mutuality and Reciprocity; and (6) Dyadic Tension. All items are coded into a three-point scale describing areas of concern (scores 1 and 2), areas of some concern (score 3) and areas of strength (scores 4 and 5). The overall minimum score is 65 and the maximal 325. Higher PCERA scores reflect more positive affect and/or behavior (subscales 1, 3 and 5). Consequently, higher scores on subscales 2, 4, and 6 indicate lower levels of negative affect and/or behavior.

The impact of the PARTNER programme on parental representations of their child's disability and abilities will be assessed using semi-structured interviews. Changes in the parents' representations from before to after the programme will be assessed, and representations will be compared between each group with a sample of parents. The quality of responses will be related to the scores obtained on the various quantitative measures.

The costs (structural and family) will be measured for children taking part in both types of camp The cost-effectiveness analysis will be conducted by calculating the incremental cost-effectiveness ratio (ICER), defined as the ratio between the average difference in costs between the intervention and the comparator (ΔC) and the average difference in effectiveness measured by the improvement in the AHA score (ΔE). The uncertainty around the ICER will be explored using a cost-effectiveness plane, and a cost-effectiveness acceptability curve (CEAC) will estimate the probability that the intervention is cost-effective for different willingness-to-pay (WTP) thresholds. Non-parametric tests (Mann-Whitney (Wilcoxon) test for two groups) will be implemented for cost comparison.

The actual care consumption of each child will be collected automatically by consulting the RNIPP register (National Register of Identification of Natural Persons).

• The difference in care consumption between groups up to 6 months after the end of the intervention will be calculated.