Secondary attention-deficit/hyperactivity disorder following perinatal and childhood stroke: impact on cognitive and academic outcomes

Causal association between mental disorders and cerebrovascular diseases: Evidence from Mendelian randomization study

BACKGROUND AND OBJECTIVE

Observational studies have suggested that mental disorders and cerebrovascular diseases (CVDs) may be risk factors for each other, but genetic evidence of a causal relationship is still lacking. We used Mendelian randomization (MR) studies to explore the causal relationship between mental disorders and CVDs from the genetic perspective.

METHODS

To investigate the causal association between major depressive disorder (MDD), anxiety, attention deficit/hyperactivity disorder (ADHD), bipolar disorder and schizophrenia five kinds of mental disorders and CVDs using two-sample two-way MR analysis based on publicly available genome-wide association study (GWAS) data. We used as instrumental variables (IVs) single-nucleotide polymorphisms (SNPs) that were strongly associated with mental disorders and CVDs. IVW method was used as the main analysis method, and MR-IVW, MR-Egger methods, MR-PRESSO test, leave-one-out analysis and funnel plot were used for sensitivity analysis. We further conducted a meta-analysis to summarize the currently available MR analyses.

RESULTS

The results of forward MR study showed that there was a significant causal relationship between ADHD and AS (any stroke) (p(AS) = 0.001, OR (95%CI) =1.118 (1.047-1.195)), any ischemic stroke (AIS) (p(AIS) = 0.004, OR (95%CI) =1.118(1.035-1.206)) and large artery stroke (LAS) (p(LAS) = 0.026, OR (95%CI): 1.206(1.023-1.422)). No heterogeneity, pleiotropy and outliers were found in sensitivity analysis. The reverse MR study showed that IA (intracranial aneurysm) (p(IA) = 0.033, OR (95%CI) = 1.123(1.009-1.249)) and UIA (unruptured intracranial aneurysm) (p(UIA) = 0.015, OR (95%CI) =1.040(1.008-1.074)) were risk factors for schizophrenia. Sensitivity analysis showed no pleiotropy, but there was heterogeneity. After excluding outliers, MR analysis showed that IA and UIA were still risk factors for schizophrenia. Our meta-analyses found statistical significance in causal relationships between ADHD and LAS (OR (95%CI) =1.18 (1.06-1.32), p = 0.003), IA and schizophrenia (OR (95%CI) =1.05 (1.02-1.08), p = 0.002) and UIA and schizophrenia (OR (95%CI) =1.03 (1.01-1.06), p = 0.010).

CONCLUSION

The MR study and meta-analysis suggest that genetically predicted ADHD is a risk factor for LAS, and IA and UIA increase the risk of schizophrenia. The result has implications for the development of feasible prevention strategies in the future.

Predictors of externalizing behavior outcomes following pediatric stroke

Children who experience pediatric stroke are at higher risk for future behavioral problems in childhood. We examined the prevalence of parent reported externalizing behaviors and executive function problems in children following stroke and neurological predictors. This study included 210 children with pediatric ischemic stroke (mean age 9.18 years (SD = 3.95)). The parent form of the Behavioral Assessment System for Children-Second Edition (BASC-2) and Behavior Rating Inventory of Executive Function (BRIEF) were used to evaluate externalizing behavior and executive function. No externalizing behavior or executive function differences were found between perinatal (n = 94) or childhood (n = 116) stoke, except for the shift subscale which had higher T-scores among the perinatal group (M = 55.83) than childhood group (M = 50.40). When examined together, 10% of children had clinically elevated hyperactivity T-scores as opposed to the expected 2%. Parents endorsed higher ratings of concern on the behavior regulation and metacognition indices of the BRIEF. Externalizing behaviors were correlated moderately to strongly with executive functions (r = 0.42 to 0.74). When examining neurological and clinical predictors of externalizing behaviors, only female gender was predictive of increased hyperactivity (p = .004). However, there were no significant gender differences in diagnosis of attention deficit hyperactivity disorder (ADHD). In summary, in this cohort, children with perinatal and childhood stroke did not differ on parent reported externalizing behavior or executive function outcomes. However, compared to normative data, children with perinatal or childhood stroke are significantly more likely to experience clinically elevated levels of hyperactivity.

Alterations in cortical morphometry of the contralesional hemisphere in children, adolescents, and young adults with perinatal stroke

Perinatal stroke causes most hemiparetic cerebral palsy and cognitive dysfunction may co-occur. Compensatory developmental changes in the intact contralesional hemisphere may mediate residual function and represent targets for neuromodulation. We used morphometry to explore cortical thickness, grey matter volume, gyrification, and sulcal depth of the contralesional hemisphere in children, adolescents, and young adults after perinatal stroke and explored associations with motor, attention, and executive function. Participants aged 6-20 years (N = 109, 63% male) with unilateral perinatal stroke underwent T1-weighted imaging. Participants had arterial ischemic stroke (AIS; n = 36), periventricular venous infarction (PVI; n = 37) or were controls (n = 36). Morphometry was performed using the Computational Anatomy Toolbox (CAT12). Group differences and associations with motor and executive function (in a smaller subsample) were assessed. Group comparisons revealed areas of lower cortical thickness in contralesional hemispheres in both AIS and PVI and greater gyrification in AIS compared to controls. Areas of greater grey matter volume and sulcal depth were also seen for AIS. The PVI group showed lower grey matter volume in cingulate cortex and less volume in precuneus relative to controls. No associations were found between morphometry metrics, motor, attention, and executive function. Cortical structure of the intact contralesional hemisphere is altered after perinatal stroke. Alterations in contralesional cortical morphometry shown in perinatal stroke may be associated with different mechanisms of damage or timing of early injury. Further investigations with larger samples are required to more thoroughly explore associations with motor and cognitive function.

Roadmap for the Assessment and Management of Outcomes in Pediatric Stroke

Neurological morbidity is common after pediatric stroke, with moderate to severe deficits that can significantly impact education and social function. Care and recovery occur in phases distinguished by the time interval after stroke onset. These phases include the hyperacute and acute periods in which the focus is on cerebral reperfusion and prevention of neurological deterioration, followed by the subacute and chronic phases in which the focus is on secondary stroke prevention and mitigation of disability through rehabilitation, adaptation, and reintegration into the community. In this article, a multidisciplinary group of pediatric stroke experts review the stages of recovery after pediatric stroke with an emphasis on critical assessment time points. Our goal is to encourage increased standardization of outcome assessment to facilitate future clinical trials comparing various treatment and intervention options and advance optimized care for children with stroke.

Pandemic Perils and Promise: Implementation of a Virtual Parenting Intervention during COVID-19 among Children with Early Neurological Conditions

OBJECTIVE

In this study, we examined feasibility, acceptability, and preliminary efficacy of a telepsychological positive parenting intervention (I-InTERACT-North, Internet-basedInteracting Together Everyday: Recovery After Childhood Traumatic Brain Injury) during the COVID-19 pandemic among Canadian families of children at-risk for neurodevelopmental challenges given congenital or neonatal conditions. I-InTERACT-North was developed to improve behavioral and emotional outcomes in children with neurological conditions by utilizing and adapting parenting strategies from several established family-focused programmes.

METHODS

A pragmatic prospective pre-post single-site pilot study design was used to assess feasibility, acceptabilty, and preliminary efficacy of I-InTERACT North during the COVID-19 pandemic.

RESULTS

Thirty-five families of children ages three to nine years were referred between March 2020 and January 2021. Eighteen families enrolled, and 12 (67% adherence) completed the programme. Parents reported strong therapeutic alliance and programme acceptability with barriers due to competing time demands. Therapists reported high acceptability but perceived parental burnout. Parenting confidence (d = 0.70), and child behavior (d = 1.30) improved following the intervention.

CONCLUSIONS

Results demonstrate the programme's value to families during the pandemic, while underscoring unique participation barriers. Future research and clinicial implications are discussed.

Lessons Learned: Achieving Consensus About Learning Disability Assessment and Diagnosis

The current paper describes the process used for developing the Guidelines for Diagnosis and Assessment of Children, Adolescents, and Adults with Learning Disabilities-Consensus Statement and Supporting Documents, and the rationale for some of the decisions. The guidelines were developed by a cross-sectoral working group of psychologists who achieved a consensus on the criteria for diagnosis and the assessment process. We outline key features of the guidelines, describe topics where the group achieved consensus quickly and topics for which there was considerable debate (e.g., intelligence testing, ability/achievement discrepancy, and processing deficits). The group members shared information with each other about topics such as the advantages of early assessment, the importance of formally assessing effort and motivation, and assessment of culturally and linguistically diverse individuals. We conclude with the lessons learned and professional challenges regarding contextual influences on LD assessment and diagnosis and dissemination of research to practitioners.

Psychosocial Intervention Outcomes for Children with Congenital and Neonatal Conditions: Systematic Review

 

There has been a historic lack of psychosocially geared treatment studies for congenital and neonatal conditions that impact brain development, despite well-established knowledge that these conditions impact cognitive development, quality of life (QoL), mental health, and academic success.

OBJECTIVE

The aim of the present study was to systematically investigate the research literature focusing on the effects of interventions in psychosocially geared programs for children with neonatal brain injury on school and psychological outcomes.

METHODS

Psychosocially geared programs broadly refer to interventions to improve parenting and school functioning, or child behavior, as well as other interventions that have a psychological component but may be more physically oriented, such as goal-directed physiotherapy. A comprehensive search of PubMed, Medline, PsychINFO, and Embase was completed between June and July 2020. The methodological quality of included articles was assessed using the Cochrane Risk of Bias Tool for Randomized Trials (RoB-2).

RESULTS AND CONCLUSION

Twenty studies met the inclusion criteria and demonstrated adequate risk of bias (i.e., low risk of bias or some concerns). The studies included family (n = 2), parenting (n = 7), and child (n = 10) interventions. There is some evidence supporting the effectiveness of psychosocial interventions for children with neonatal brain injury and their families on academic outcomes, behavior, and QoL, indicated by positive intervention effects in 65% (n = 13) of studies.

Association of Perinatal and Childhood Ischemic Stroke With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Early detection of attention-deficit/hyperactivity disorder (ADHD) plays a crucial role in reducing negative effects on everyday life, including academic failure and poor social functioning. Children who survive ischemic strokes risk major disabilities, but their risk of ADHD has not been studied in nationwide cohorts.

OBJECTIVE

To assess the risk of ADHD in children after pediatric ischemic stroke.

DESIGN, SETTING, AND PARTICIPANTS

Participants in this Swedish nationwide cohort study included 1320 children diagnosed with ischemic stroke recorded in linked Swedish national registers from January 1, 1969, to December 31, 2016, without prior ADHD diagnosis. Ten matched controls were identified for each index case, and first-degree relatives were identified for index individuals and controls. Analyses were stratified by perinatal and childhood strokes and presence of comorbid adverse motor outcomes and/or epilepsy. End of follow-up was the date of ADHD diagnosis, death, or December 31, 2016, whichever occurred first. Data analyses were performed August 1 to 28, 2021.

EXPOSURES

Pediatric ischemic stroke.

MAIN OUTCOMES AND MEASURES

Attention-deficit/hyperactivity disorder identified using codes from the International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, and/or prescribed ADHD medication recorded in the Medical Birth Register, National Patient Register, or Prescribed Drug Register after stroke. Cox proportional hazards regression was used to assess adjusted hazard ratios (aHRs) for ADHD after pediatric stroke, adjusting for parental age and ADHD in first-degree relatives.

RESULTS

Of 1320 children with stroke included in the analysis (701 boys [53.1%]), 75 (45 boys [60.0%]) were diagnosed with ADHD after stroke compared with 376 (252 boys [67.0%]) among the controls (aHR, 2.00 [95% CI, 1.54-2.60]). The risk was increased after both perinatal (aHR, 2.75 [95% CI ,1.65-4.60]) and childhood (aHR, 1.82 [95% CI, 1.34-2.48]) strokes and were similar if children born preterm or small for gestational age were excluded. Compared with controls, risks of ADHD were higher among children with perinatal stroke and adverse motor outcomes and/or epilepsy (aHR, 6.17 [95% CI, 2.80-13.62]) than among those without these comorbidities (aHR, 1.65 [95% CI, 0.80-3.42]). However, findings were similar in childhood stroke for children with adverse motor outcomes and/or epilepsy (aHR, 1.80 [95% CI, 1.12-2.89]) and among those without these comorbidities (aHR, 1.92 [95% CI, 1.28-2.90]).

CONCLUSIONS AND RELEVANCE

This cohort study of 1320 children with pediatric ischemic stroke suggests that there is an increased risk of ADHD, particularly in children with adverse motor outcomes and/or epilepsy, compared with controls. The risk increases after childhood strokes regardless of comorbidities.

Frontal interhemispheric structural connectivity, attention, and executive function in children with perinatal stroke

Perinatal stroke affects ∼1 in 1000 births and concomitant cognitive impairments are common but poorly understood. Rates of Attention Deficit/Hyperactivity Disorder (ADHD) are increased 5-10× and executive dysfunction can be disabling. We used diffusion imaging to investigate whether stroke-related differences in frontal white matter (WM) relate to cognitive impairments. Anterior forceps were isolated using tractography and sampled along the tract. Resulting metrics quantified frontal WM microstructure. Associations between WM metrics and parent ratings of ADHD symptoms (ADHD-5 rating scale) and executive functioning (Behavior Rating Inventory of Executive Function (BRIEF)) were explored. Eighty-three children were recruited (arterial ischemic stroke [AIS] n = 26; periventricular venous infarction [PVI] n = 26; controls n = 31). WM metrics were altered for stroke groups compared to controls. Along-tract analyses showed differences in WM metrics in areas approximating the lesion as well as more remote differences at midline and in the nonlesioned hemisphere. WM metrics correlated with parental ratings of ADHD and executive function such that higher diffusivity values were associated with poorer function. These findings suggest that underlying microstructure of frontal white matter quantified via tractography may provide a relevant biomarker associated with cognition and behavior in children with perinatal stroke.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

The Response to Stress Questionnaire for Parents Following Neonatal Brain Injury

OBJECTIVE

The Response to Stress Questionnaire-Brain Injury (RSQ-BI) was adapted utilizing a patient-oriented approach, exploring parental stress, coping, and associated mental health outcomes in parents of children with neonatal brain injury. The contributions of social risk, child adaptive functioning, and brain injury severity were also explored.

METHODS

Using a mixed-method design, this study explored adapted stressor items on the RSQ-BI. Parents and clinicians engaged in semistructured interviews to examine key stressors specific to being a parent of a child with neonatal brain injury. The adapted RSQ-BI was piloted in a parent sample (N = 77, child mean age 1 year 7 months) with established questionnaires of social risk, child adaptive functioning, severity of the child's injury, coping style, and parent mental health. Descriptive statistics and correlations examined parent stress, coping, and their association with parent mental health.

RESULTS

The final RSQ-BI questionnaire included 15 stressors. Factor analysis showed stressors loaded onto two factors related to (a) daily role stressors and (b) brain injury stressors. Using the RSQ-BI, parents reported brain injury stressors as more stressful than daily role stressors. When faced with these stressors, parents were most likely to engage in acceptance-based coping strategies and demonstrated lower symptoms of parent depression and anxiety.

CONCLUSIONS

The RSQ-BI provides a valuable adaptation to understand both stressors and coping specific to being a parent of a child with neonatal brain injury. Relevant interventions that promote similar coping techniques are discussed for future care and research.

[Formula: see text] Executive function following pediatric stroke. A systematic review

OBJECTIVE

Pediatric strokes are rare events that can lead to neuropsychological impairment or disability. While motor deficits are relatively easy to identify and investigate, cognitive outcomes after stroke are more complex to define. Many studies have focused on global cognitive outcomes, while only a few recent studies have focused on specific cognitive processes. The aims of the present review were to provide an overview of the effects of pediatric strokes on executive function and to investigate the relations between executive functioning and clinical factors.

METHOD

Studies concerning executive functioning after pediatric stroke were identified using PsycInfo, PsycArticles and PubMed. A total of 142 studies were identified, and 22 met the inclusion criteria.

RESULTS

The review of the 22 studies included clearly indicates that childhood and perinatal strokes can affect executive function, and in particular inhibition. In contrast, the results concerning clinical factors related to EF outcomes are inconsistent.

DISCUSSION

Our results highlight the importance to assess EF following pediatric stroke. Early identification of difficulties in EF is crucial to provide adequate training to the children and to prevent the development of other correlated difficulties, such as behavioral problems or learning difficulties. Methodological issues regarding the heterogeneity of samples and measurement difficulties limit the conclusions that can be made about the clinical predictors of the outcomes. Studies are needed to better understand this aspect and to develop adequate EF interventions for children following stroke.

Bridging gaps in care for children with acquired brain injury: Perceptions of medical and educational service providers

PURPOSE

Significant gaps in service delivery for children with acquired brain injury exist between healthcare and educational systems, such as the lack of coordinated efforts to transfer rehabilitation strategies to school settings. This paper attempts to address these issues and offer recommendations to bridge these gaps in care.

METHODS

The American Congress of Rehabilitation Medicine (ACRM), Brain Injury-Interdisciplinary Special Interest Group (BI-ISIG), Pediatric-Adolescent Task Force constructed and disseminated a survey to medical rehabilitation (N= 44) and education professionals (N= 40). Responses were analyzed quantitatively and qualitatively, achieving > 85% inter-coder reliability.

RESULTS

Results highlighted differences between groups in methods for seeking new information, opinions on advocacy needs, and differing priorities given to various resources.

CONCLUSIONS

These discrepancies have important implications for improved collaboration needed for assuring an appropriate continuum of service for this population. Recommendations include: 1) providing education and training regarding brain injury in the most cost-effective ways utilizing technology that crosses the barriers identified and reaches people in multiple settings; 2) direct and active communication between medical and educational professionals; and 3) developing an interdisciplinary Community of Practice to help bridge medical rehabilitation and school systems.

Recent developments and new frontiers in childhood arterial ischemic stroke

This review will discuss important developments in childhood arterial ischemic stroke over the past decade, focusing on improved understanding of the causes, consequences, and targets for intervention. Risk factors for childhood arterial ischemic stroke are different to adults. Infections, particularly herpes group viruses, are important precipitants for stroke. Non-atherosclerotic arteriopathies are the most common cause of childhood arterial ischemic stroke and an important predictor of recurrent events. Recent advances include the identification of serum biomarkers for inflammation and endothelial injury, and imaging biomarkers to monitor for vascular progression. Multicenter trials of immunotherapies in focal cerebral arteriopathies are currently in development. Recognition of clinical and radiological phenotypic patterns has facilitated the discovery of multisystem disorders associated with arterial ischemic stroke including ACTA2 arteriopathy and adenosine deaminase 2 deficiency. Identification of these Mendelian disorders provide insights into genetic mechanisms of disease and have implications for medical and surgical management. In contrast to adults, there are long diagnostic delays in childhood arterial ischemic stroke. Refinement of pediatric Code Stroke protocols and clinical decision support tools are essential to improve diagnostic certainty and improve access to reperfusion therapies. Children do not recover better than adults following arterial ischemic stroke, with more than half of survivors having long-term impairments. The physical, cognitive, and behavioral consequences of childhood arterial ischemic stroke are increasingly reported but further research is required to understand their impact on participation, quality of life, psychosocial, and family functioning. Longitudinal studies and the use of advanced imaging techniques, to understand neurobiological correlates of functional reorganization, are essential to developing targeted intervention strategies to facilitate recovery.