Environmental Contributions to Social and Mental Health Outcomes Following Pediatric Stroke

Neurocognitive outcomes following intracerebral hemorrhage in childhood

Neurocognitive deficits commonly occur following intracerebral hemorrhage (ICH) in childhood, yet this population remains understudied. The current study is a preliminary exploration of neurocognitive outcomes in this population. At the Hospital for Sick Children in Toronto, Canada, 17 patients (Mage = 14.2, SD = 4.6) with a history of childhood ICH completed a neuropsychological assessment evaluating perceptual reasoning, verbal reasoning, processing speed, working memory, verbal learning, verbal memory, visuomotor integration, selective attention, and executive functioning. Mean Full Scale IQ (FSIQ; M = 98.1, SD = 13.6) fell within the clinically average range compared to population norms, though it was skewed toward lower ranges. Furthermore, approximately 50-60% of the participants scored under the clinically average range on tests of verbal learning, verbal memory, processing speed, and visuomotor integration. Youth with childhood ICH may present with FSIQ within the average range, but as a group they skew toward lower ranges and are more likely to demonstrate deficits in distinct neurocognitive domains. Clinical evaluation of a wide range of neuropsychological skills is warranted. Clinical implications encompass informing of intake interviews, development of test batteries, and appraisal of prognosis. Findings contribute to the limited knowledge base about neurocognitive outcomes following childhood ICH.

Looking beyond body structure and function: a scoping review of non-impairment impacts of stroke on adolescents

BACKGROUND

Much of the childhood stroke literature has not distinguished impacts for adolescents from those of younger children. Research has also focused on body impairments. With adolescence being a unique period, this scoping review aimed to identify the impacts of childhood stroke on activity, participation, and quality of life for adolescents 13-18 years, and identify how these impacts were determined.

METHOD

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data pertaining to non-impairment impacts of childhood stroke for adolescents, participant and study characteristics, and measurement instruments were extracted.

RESULTS

Following screening, 79 articles were included, and 33 measurement instruments identified. Only 6 studies reported separate data for adolescents, identifying difficulties with daily activities, social and academic impacts, and reduced quality of life. Impacts of post-stroke communication difficulties on daily activities and schooling were also noted. Measurement instruments developed specifically for adolescents with stroke are lacking.

INTERPRETATION

The review identified limited research reporting non-impairment impacts of childhood stroke for adolescents. Further research specific to this population and the development of measurement instruments for adolescents who have experienced childhood stroke is required to support future research and clinicians working with this population.

Predictors of neurocognitive outcome in pediatric ischemic and hemorrhagic stroke

This clinical study examined the impact of eight predictors (age at stroke, stroke type, lesion size, lesion location, time since stroke, neurologic severity, seizures post-stroke, and socioeconomic status) on neurocognitive functioning following pediatric stroke. Youth with a history of pediatric ischemic or hemorrhagic stroke (n = 92, ages six to 25) underwent neuropsychological testing and caregivers completed parent-report questionnaires. Hospital records were accessed for medical history. Spline regressions, likelihood ratios, one-way analysis of variance, Welch's t-tests, and simple linear regressions examined associations between predictors and neuropsychological outcome measures. Large lesions and lower socioeconomic status were associated with worse neurocognitive outcomes across most neurocognitive domains. Ischemic stroke was associated with worse outcome in attention and executive functioning compared to hemorrhagic stroke. Participants with seizures had more severe executive functioning impairments than participants without seizures. Youth with cortical-subcortical lesions scored lower on a few measures than youth with cortical or subcortical lesions. Neurologic severity predicted scores on few measures. No differences were found based on time since stroke, lesion laterality, or supra- versus infratentorial lesion. In conclusion, lesion size and socioeconomic status predict neurocognitive outcome following pediatric stroke. An improved understanding of predictors is valuable to clinicians who have responsibilities related to neuropsychological assessment and treatments for this population. Findings should inform clinical practice through enhanced appraisals of prognosis and the use of a biopsychosocial approach when conceptualizing neurocognitive outcome and setting up support services aimed at fostering optimal development for youth with stroke.

Brain-Derived Neurotrophic Factor in Pediatric Acquired Brain Injury and Recovery

We review emerging preclinical and clinical evidence regarding brain-derived neurotrophic factor (BDNF) protein, genotype, and DNA methylation (DNAm) as biomarkers of outcomes in three important etiologies of pediatric acquired brain injury (ABI), traumatic brain injury, global cerebral ischemia, and stroke. We also summarize evidence suggesting that BDNF is (1) involved in the biological embedding of the psychosocial environment, (2) responsive to rehabilitative therapies, and (3) potentially modifiable. BDNF's unique potential as a biomarker of neuroplasticity and neural repair that is reflective of and responsive to both pre- and post-injury environmental influences separates it from traditional protein biomarkers of structural brain injury with exciting potential to advance pediatric ABI management by increasing the accuracy of prognostic tools and informing clinical decision making through the monitoring of therapeutic effects.

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.

Emotional and social functioning after stroke in childhood: a systematic review

PURPOSE

To provide an overview of the effects of pediatric stroke on emotional and social functioning in childhood.

METHODS

A literature review was completed in accordance with the Preferred Reporting Items for Systematic Reviews. A systematic search of studies on internalizing problems and social functioning after pediatric stroke in PsycInfo, PsycArticles, and PubMed databases was conducted from inception to November 2021. A total of 583 studies were identified, and 32 met the inclusion criteria.

RESULTS

The review suggests that children after stroke are at risk of developing internalizing problems and a wide range of social difficulties. Internalizing problems are often associated with environmental factors such as family functioning and parents' mental health. In addition, a higher risk of developing psychosocial problems is associated with lower cognitive functioning and severe neurological impairment.

CONCLUSIONS

The assessment of psychological well-being and social functioning after pediatric stroke is helpful to provide adequate support to children and their families. Future studies are needed to better investigate these domains and to develop adequate methodologies for specific interventions.Implication for rehabilitationThis paper reviews research concerning emotional and social functioning following pediatric stroke in order to provide helpful information to clinicians and families and to improve rehabilitation pathways.Emotional and social functioning should be addressed during post-stroke evaluation and follow-up, even when physical and cognitive recovery is progressing well.Care in pediatric stroke should include volitional treatment and address emotional and social issues.

Language and Cognitive Outcomes Following Ischemic Stroke in Children With Monolingual and Bilingual Exposure

Aim: Although many children who experience ischemic stroke come from bilingual backgrounds, it is unclear whether bilingual exposure affects poststroke development. Our research evaluates bilingual and monolingual exposure on linguistic/cognitive development poststroke across 3 stroke-onset groups. Method: An institutional stroke registry and medical charts were used to gather data on 237 children across 3 stroke-onset groups: neonatal, <28 days; first-year, 28 days to 12 months; and childhood, 13 months to 18 years. The Pediatric Stroke Outcome Measure (PSOM), administered several times poststroke, was used to evaluate cognition and linguistic development. Results: Similar cognitive outcomes were observed across language groups. However, an interaction effect with stroke-onset group was observed, with monolinguals in the first-year group having worse productive language outcomes as compared to bilinguals. Interpretation: Overall, no detrimental effects of bilingualism were found on children's poststroke cognition and linguistic development. Our study suggests that a bilingual environment may facilitate language development in children poststroke.

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.

A cross-sectional study on gaming intensity and social vulnerability in adolescents that have a chronic condition

Background

Adolescents growing up with a chronic condition might experience more social vulnerabilities compared to their healthy peers as an indirect result of their conditions. This can lead to a relatedness need frustration for these adolescents. Consequently, they might spend more time playing video games compared to their peers. Research shows that both social vulnerability and gaming intensity are predictors for problematic gaming. Therefore, we investigated if social vulnerability and gaming intensity are more pronounced in adolescents that have a chronic condition compared to the general population; and if these levels reflect the levels of a clinical group being treated for Internet Gaming Disorder (IGD).

Methods

Data on peer problems and gaming intensity were compared from three separate samples: a national representative sample of adolescents, a clinical sample of adolescents that are undergoing treatment for IGD, and a sample of adolescents diagnosed with a chronic condition.

Results

No differences were found on either peer problems or gaming intensity between the group of adolescents that have chronic conditions and the national representative group. The group with chronic conditions scored significantly lower on gaming intensity than the clinical group. No significant differences were found between these groups on peer problems. We repeated the analyses for boys only. Similar results were found for the group with chronic conditions compared to the national representative group. The group with chronic conditions now scored significantly lower on both peer problems and gaming intensity than the clinical group.

Conclusion

Adolescents growing up with a chronic condition appear similar in their gaming intensity and peer problems compared to their healthy peers.

The influential factors and non-pharmacological interventions of cognitive impairment in children with ischemic stroke

Background

The prevalence of pediatric ischemic stroke rose by 35% between 1990 and 2013. Affected patients can experience the gradual onset of cognitive impairment in the form of impaired language, memory, intelligence, attention, and processing speed, which affect 20-50% of these patients. Only few evidence-based treatments are available due to significant heterogeneity in age, pathological characteristics, and the combined epilepsy status of the affected children.

Methods

We searched the literature published by Web of Science, Scopus, and PubMed, which researched non-pharmacological rehabilitation interventions for cognitive impairment following pediatric ischemic stroke. The search period is from the establishment of the database to January 2022.

Results

The incidence of such impairment is influenced by patient age, pathological characteristics, combined epilepsy status, and environmental factors. Non-pharmacological treatments for cognitive impairment that have been explored to date mainly include exercise training, psychological intervention, neuromodulation strategies, computer-assisted cognitive training, brain-computer interfaces (BCI), virtual reality, music therapy, and acupuncture. In childhood stroke, the only interventions that can be retrieved are psychological intervention and neuromodulation strategies.

Conclusion

However, evidence regarding the efficacy of these interventions is relatively weak. In future studies, the active application of a variety of interventions to improve pediatric cognitive function will be necessary, and neuroimaging and electrophysiological measurement techniques will be of great value in this context. Larger multi-center prospective longitudinal studies are also required to offer more accurate evidence-based guidance for the treatment of patients with pediatric stroke.

Rehabilitation in Pediatric Stroke: Cognition and Behavior

Pediatric stroke is associated with a range of maladaptive cognitive and behavioral outcomes that often require targeted intervention. Despite increasing research on neuropsychological outcomes over the past decade, evidence for effective therapies and interventions for the most commonly reported cognitive and behavioral challenges is still limited. The most widely prescribed interventions address more overt deficits in sensorimotor and speech/language functions, yet interventions for higher-order cognitive, linguistic and behavioral deficits are notably less defined. Moreover, concepts of rehabilitation in adult stroke cannot be easily translated directly to pediatric populations because the effect of stroke and recovery in the developing brain takes a very different course than in the mature brain. In pediatric stroke, neuropsychological deficits often emerge gradually over time necessitating a long-term approach to intervention. Furthermore, family and school context often play a much larger role. The goal of this review is to describe cognitive and behavioral interventions for perinatal and childhood stroke, as motor rehabilitation is covered elsewhere in this issue. We also discuss cognitive aspects of current rehabilitative therapies and technology. Acknowledging the current limited state of stroke-specific rehabilitation research in children, findings from pediatric acquired brain injury intervention and use of transdiagnostic approaches lend important insights. Because there is limited support for single domain (cognitive) trainings and translation of research rehabilitation programs to clinical practice can be challenging, the value of holistic multidisciplinary approaches to improve everyday function in children and adolescents following stroke is emphasized.

Social Functioning and Autistic Behaviors in Youth Following Acquired Brain Injury

Children and adolescents who survive the pediatric intensive care unit (PICU) with an acquired brain injury (ABI) often demonstrate a variety of physical, cognitive, emotional/behavioral, and social sequelae termed post-intensive care syndrome (PICS). Social communication and interaction challenges have also been observed clinically, and there is growing literature documenting these occurrences in youth following ABI. The extent of these social changes varies among patients, and a subset of patients go on to exhibit social and behavioral profiles closely resembling those of autistic youth. We reviewed empirical research regarding social functioning in youth following ABI, as well as the overlap between individuals with ABI and autistic youth, published from January 2009 to August 2022 on PubMed and Scopus databases. Clinical case examples from a well-established post-PICU follow-up program are also provided to exemplify the complexity of this phenomenon.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

COVID-19 mental health impact among children with early brain injury and associated conditions

This study describes the impact of COVID-19 among a clinical research sample of children with early brain injury and associated conditions. Between March 2020 and March 2021, 64 children and their parents participated. Children ranged in age between 3 and 14 years (M = 6 years, 3 months; SD = 2 years, 4 months) with a range of diagnoses (i.e., neonatal stroke, hypoxic ischemic encephalopathy (HIE), congenital heart disease (CHD) and preterm birth (<32 weeks)). The abbreviated CoRonavIrus Health Impact Survey (CRISIS) was completed by parents as part of their child's routine intake for neuropsychological services. Questions included COVID-19 specific ratings of child mental health impact, child, and parent stressors, with open-ended questions regarding negative and positive COVID-19 related changes. Over 40% of parents described moderate to extreme influence of COVID-19 on their child's mental health. Common child stressors reported included restrictions on leaving the home and social isolation. Among parents, the most common stress reported was caring for their child's education and daily activities. Children's mental health impact was associated with social isolation, parent mental health, COVID-19 economic concern, and number of siblings in the home. Child's age, sex, brain injury severity, or intellectual functioning were not associated with reported COVID-19 mental health impact. Some COVID-19 positives were identified, namely increased quality family time. Findings reflect the significant pandemic mental health impact among neurologically at-risk children and their families. Implications to future clinical needs and considerations for neuropsychological practice are discussed.

The Road to Family Resiliency: A Case Report of a Family's Experiences Following Adolescent Stroke

PURPOSE

This study generated an understanding of familial resiliency following an adolescent's stroke and what resiliency-related outcomes were important to this family.

DESIGN AND METHODS

A qualitative case study design was used to collect data during an in-person interview. The interview was transcribed verbatim and analyzed using thematic analysis.

FINDINGS

Participants' narratives revealed that reengaging and establishing new activities, reconstructing identities, and changing perceptions regarding health and life itself were important resiliency-related outcomes.

CONCLUSIONS

The findings from this case study highlight innovative strategies that can be used to facilitate resiliency during strenuous times in a family's life, such as following an adolescent's stroke.

CLINICAL RELEVANCE

Clinicians and service providers have the opportunity to help facilitate resiliency by identifying which protective factors and positive outcomes are most important to a family following an adolescent's stroke, allowing clinicians to assist in achieving these outcomes. This research illustrates ways for families to convert resources into personally meaningful resiliency-related outcomes. Further research is needed to study familial resiliency as a part of an intervention to promote occupational engagement.

Prevalence of Symptoms of Anxiety, Depression, and Post-traumatic Stress Disorder in Parents and Children Following Pediatric Stroke

Post-traumatic stress disorder (PTSD), anxiety, and depression are seen in parents and children following critical illness. Whether this exists in parents and children following pediatric stroke has not been thoroughly studied. We examined emotional outcomes in 54 mothers, 27 fathers, and 17 children with stroke. Parents of children 0-18 years and children 7-18 years who were within 2 years of stroke occurrence were asked to complete questionnaires to determine their emotional outcomes. Of participating mothers, 28% reported PTSD, 26% depression, and 4% anxiety; in fathers, 15% reported PTSD, 24% depression, and none reported anxiety. Further, children reported significant emotional difficulty, with 24% having depression, 14% anxiety, and 6% PTSD by self-report ratings. Maternal PTSD, anxiety and depression, and paternal anxiety were all negatively associated with the child's functional outcome. Clinically significant anxiety (based on clinical thresholds) was not found in fathers; however, continuous scores were still analyzed for association between subclinical anxiety and functional outcome, which revealed a statistically significant association between more reported symptoms and higher Recovery and Recurrence Questionnaire scores. Prevalence of PTSD and depression are greater in parents compared to the general population in this preliminary study.

Cognitive resilience following paediatric stroke: Biological and environmental predictors

Little is known about resilience after paediatric stroke (PS), or the factors that contribute to better outcomes. Rather, research emphasis has been on impairment, measured through cross-sectional or retrospective designs, often heavily weighted to children presenting for clinical or rehabilitation follow-up. Implementing a resilience framework, this study aimed to investigate cognitive recovery post-stroke and factors that contribute to cognitive resilience at 12 months following PS. In a single site, prospective, longitudinal study (baseline, 1, 6, 12 months post-stroke), 61 children (55.7% male) aged 0-18 years, with a diagnosis of acute arterial ischemic stroke were recruited. Neurological status, lesion and child characteristics were collected at diagnosis. Cognitive, language and motor skills were assessed directly using age-appropriate, standardised tools. Parents rated their mental health, and child social and adaptive abilities. Participants were classified as 'resilient' (74%) or 'vulnerable' based on 12-month cognitive scores. The resilient group demonstrated more intact acute neurological status and higher language and adaptive abilities 1-month post-stroke; 88% of the vulnerable group had strokes involving both cortical and subcortical regions. Neonatal stroke, large lesions, cortical-only lesions, and middle cerebral artery involvement were associated with poorer cognition over the 12 months post-stroke. Absence of seizures and older age at stroke predicted better cognitive outcomes. In summary, most children surviving PS are cognitively resilient at 12 months post-insult. Risk and protective factors identified may guide targeted clinical intervention for more vulnerable children. Future research is needed to explore cognitive resilience trajectories beyond 12 months post-stroke.

Ischemic sequelae and other vascular diseases

Although pediatric stroke is associated with higher survival rates compared with adult stroke, a substantial body of evidence indicates significant neuropsychologic morbidity in pediatric stroke survivors. Neuroplasticity does not guarantee good outcome in children. The general trends observed in the literature are reviewed as is the profile observed in common causes of pediatric stroke: congenital heart disease, moyamoya disease, and sickle cell disease. The neuropsychologic profile of pediatric stroke patients is heterogeneous due to the multiplicity of associated causes. Stroke in early infancy and large strokes are associated with cognitive impairment while more limited disorders, such as phasic deficit, are observed in childhood stroke. Executive dysfunction is common in pediatric stroke, but social interaction skills are usually preserved. Congenital heart disease and sickle cell disease are associated with global neuropsychologic dysfunction while cognition is usually preserved in moyamoya. Executive dysregulation is instead more frequently reported in this population. Further study of maladaptive processes after pediatric stroke will allow identification of predictors of functional and neuropsychologic outcomes and permit personalization of care.

Language and cognitive outcomes after childhood stroke: Theoretical implications for hemispheric specialization

The purpose of this study was to investigate language and cognitive outcomes following severe childhood stroke, and the role of age at stroke according to lesion lateralization. We retrospectively included children consecutively admitted to a physical medicine and rehabilitation department between 1992 and 2015 following childhood stroke (age at stroke 1 month to15 years). Data collection included demographic and clinical information, results of cognitive assessments on the Wechsler Intelligence scales, detailed language assessments by speech and language therapists, and long-term academic outcome. Overall, 184 children (52% boys; mean age at assessment = 8.5 years, range .7-15.4 years) were hospitalized following ischemic (n = 79) or hemorrhagic (n = 105) stroke. After a median time since stroke of 4 months (n = 135), mean Full-Scale, Verbal, and Performance Intellectual Quotient (FSIQ, VIQ and PIQ) were 85 (SD = 19), 93 (SD = 22), and 85 (SD = 20), respectively. In language tests (n = 130) assessing lexical and syntactic expression and comprehension, 26%-53% of the children exhibited impairments (scores <2SD). After a median follow-up of 40 months, only 27% of the children were following a normal curriculum without adaptations or delay, and 27% were attending special education programs. School situation was strongly associated with language and FSIQ scores. Language and verbal IQ scores were significantly lower (p < .01) among patients with lesions in the left hemisphere as opposed to the right. After a left hemisphere lesion, language skills were not associated with age at stroke, but for right hemisphere lesions, language was more impaired among children who were younger at stroke onset. PIQ tended to correlate positively with age at stroke in left hemisphere lesions (poorer PIQ in early lesions) and negatively for right hemisphere lesions (poorer PIQ in late lesions). These findings, discussed in the light of the brain vulnerability and plasticity hypotheses, are in favor of a developmental view of hemispheric specialization.

What do Kids with Acquired Brain Injury Want? Mapping Neuropsychological Rehabilitation Goals to the International Classification of Functioning, Disability and Health

OBJECTIVE

To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs).

METHOD

Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2-19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer's V were used to identify demographic and injury-related associations of goal type.

RESULTS

The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and &lt;1% body structures (BS). The number of EF goals increased with age at assessment (V = .14). Non-traumatic causes of ABIs were associated with more EF goals (V = .12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY.

CONCLUSIONS

Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies. (JINS, 2019, 25, 403-412).

How Do Parents Influence Child Disruptive Behavior After Acquired Brain Injury? Evidence From a Mediation Model and Path Analysis

OBJECTIVES

Children with acquired brain injury (ABI) can present with disruptive behavior, which is often a consequence of injury and parent factors. Parent factors are associated with child disruptive behavior. Furthermore, disinhibition in the child also leads to disruptive behavior. However, it is unclear how these factors interact. We investigated whether parental factors influence child disruptive behavior following ABI and how these factors interact.

METHODS

Parents of 77 children with ABI participated in the study. Parent factors (executive dysfunction, trait-anxiety), potential intervention targets (dysfunctional parenting practices, parental stress, child disinhibition), and child disruptive behavior were assessed. A hypothetical model based on the literature was tested using mediation and path analysis.

RESULTS

Mediation analysis revealed that child disinhibition and dysfunctional parenting practices mediated the association of parent factors and child disruptive behavior. Parents' executive dysfunction mediated the association of dysfunctional parenting practices, parental stress and parent trait-anxiety. Parenting practices mediated the association of executive dysfunction and child disruptive behavior. Path analysis indices indicated good model adjustment. Comparative and Tucker-Lewis Index were &gt;0.95, and the root mean square error of approximation was 0.059, with a chi-square of 0.25.

CONCLUSIONS

A low level of parental trait-anxiety may be required to reduce dysfunctional parenting practices and child disinhibition. Impairments in child disinhibition can be exacerbated when parents present with high trait-anxiety. Child disinhibition is the major contributor of disruptive behavior reported by parents and teachers. The current study provides evidence of parent anxiety and child disinhibition as possible modifiable intervention targets for reducing child disruptive behavior. (JINS, 2019, 25, 237-248).

Medication adherence in pediatric renal transplant patients: The role of family functioning and parent health locus of control

Children and adolescents with renal disease experience daily social, emotional, and medical challenges. Renal transplantation can help to improve quality of life but requires a lifelong regimen of immunosuppressant medication to maintain health. Adherence to a daily complex regimen can be difficult, particularly for adolescents who are beginning to develop autonomy from caregivers and are faced with a unique set of socio-emotional challenges. This study examines two factors that have shown to influence adherence in other pediatric populations, namely family functioning and parent health locus of control, from mothers' perspectives, in predicting medication non-adherence for adolescents (ages 12-19 years) 1 year post-transplant. Non-adherence was defined as the percentage of missed doses and late doses of the weekly immunosuppressant doses prescribed. Regression results demonstrated that mothers' perceptions of poorer overall family functioning predicted missed medication doses (ΔR²  = 0.383, F(7, 21) = 2.570, P = 0.044) with significant contributions in the domains of problem-solving (β = -0.795, t(21) = -2.927, P = 0.008) and affective involvement (β = 0.872, t(21) = 3.370, P = 0.003). Moreover, mothers who perceived that their adolescent had control over his/her health also predicted more missed medication doses (ΔR²  = 0.133, F(1, 27) = 5.155, P = 0.031). Important implications for these findings include implementation of family-based interventions that promote developmentally appropriate skills for adolescents and cultivate emotional involvement within the family.

Seeking normality: Parents' experiences of childhood stroke

BACKGROUND

Incidence of paediatric stroke has been estimated to range from 1.2 to 13 per 100,000 children under 18 years of age. It is a significant cause of long-term morbidity in children with long-term impacts on physical, cognitive, psychological, and social outcomes. However, little is known about the experiences of parents caring for a child with stroke. Such information is needed to inform the development of child- and family-centred care.

METHODS

We conducted in-depth interviews with parents of children with stroke. Participants were purposively sampled from three regional specialist services in England, based on the age of the child at stroke onset and time since first stroke. Interviews used a topic guide and were audio recorded and transcribed in full. Thematic analysis was conducted to develop an account that reflected patients' experiences from their own perspectives.

RESULTS

Twelve parents participated with five children classified as having no to mild deficits and seven with moderate to severe deficits. Parents were concerned about the effects of stroke on the child's psychological, cognitive, and social well-being. Significant impacts on parents own well-being and on the family were reported. Although most experienced good quality acute care, meeting the child's needs after hospital discharge was problematic, with low levels of awareness of paediatric stroke among professionals and difficulties accessing relevant information and services. Meeting special education needs was variable. Parents were proactive in seeking to establish a sense of normality for the child and themselves.

CONCLUSIONS

The findings illuminate a wider picture of paediatric stroke than indicated by clinical outcomes alone. Parents' experiences varied according to the child's needs but also family's situation and geographical location. Particular attention should be paid to co-ordinating services to meet multiple needs after discharge from hospital.

Psychosocial outcome and quality of life following childhood stroke - A systematic review

OBJECTIVES

The aim of this paper was to critically review the recent literature on psychosocial and behavioral outcome following childhood stroke, to assess whether quality of life is affected and to investigate the factors related to psychosocial outcome.

METHODS

Literature searches were conducted and identified 36 relevant papers from the period 1908-2016.

RESULTS

The systematic review found that many children experience difficulties in a wide range of psychosocial domains. Quality of life can also be significantly reduced. Inconsistent findings regarding the correlates of outcome are likely due to methodological limitations. These issues include small and heterogeneous samples, lack of control groups, and measurement difficulties.

CONCLUSIONS

This systematic review strongly indicates that childhood stroke can affect a myriad of psychosocial domains and a child's quality of life. Methodological issues, particularly around heterogeneous samples and measures, limit the conclusions that can be drawn regarding the predictors of outcome.

Psychosocial function in the first year after childhood stroke

AIM

Childhood stroke disrupts brain development and emerging neural networks. Motor, cognitive, and language deficits are well recognized, yet little is known about psychosocial function after childhood stroke. This study aims to describe psychosocial function within the first year after childhood stroke, and to identify factors associated with outcome.

METHOD

Thirty-seven children were involved in a prospective, longitudinal study investigating recovery over the first year after childhood stroke. Children's social functioning was assessed at 6-months and 12-months poststroke and psychological function at 12-months poststroke, using standardized measures.

RESULTS

Mean social function was poorer at both 6-months and 12-months poststroke, compared to prestroke. Psychological problems were more common than expected, with emotional difficulties and hyperactivity-inattention most significantly affected. Poorer social function was associated with older age at onset, acute neurological impairment, and prestroke social impairment. Social and psychological problems were associated with parent mental health.

INTERPRETATION

While not all children are affected, psychosocial impairment affects a significant minority after childhood stroke. Older age at onset, acute neurological impairment, prestroke social problems, and poorer parent mental health were associated with deficits. Identifying early predictors of poorer outcome will facilitate early intervention. Of particular importance is parent mental health, suggesting support for families may improve child outcome.

Early predictors of psychosocial functioning 5 years after paediatric stroke

AIM

Little is known about psychological and social outcomes after paediatric stroke. This study aimed to evaluate psychosocial outcomes in children 5 years after paediatric stroke and explore the contribution of early presenting factors.

METHOD

Thirty-one children (19 males, 12 females) with arterial ischemic stroke were involved in this prospective, longitudinal study. Children underwent intellectual assessment at 12 months poststroke and parents completed questionnaires rating their own mental health and their child's functioning at 12 months and 5 years poststroke.

RESULTS

At 5-year follow-up, psychological and social function were significantly poorer than normative expectations. Exploration of early predictive factors showed poorer cognitive and psychological function at 12 months poststroke and older age at stroke onset was associated with poorer psychosocial function at 5 years. Larger lesion size was also associated with poorer psychological function at 5 years poststroke.

INTERPRETATION

These early predictors of poorer psychosocial outcome suggest that screening children within the first year after stroke may identify children most at risk of later problems and facilitate early intervention.

Lived experience of having a child with stroke: A qualitative study

OBJECTIVE

To assess the lived experience of parents whose child has suffered a stroke.

METHODS

A qualitative study model was chosen, comprising in-depth interviews with parents separately or altogether. A semi-structured interview guide was used. Interviews were audio-recorded, transcribed verbatim and analysed using constant comparison and content analysis. Participant checking was performed. Thirteen families of children aged 1 month to 17 years, having suffered ischaemic or haemorrhagic arterial stroke within one to five years, were recruited. Interviews were conducted within home setting.

RESULTS

After fourteen interviews, data saturation was met and six main narrative themes were identified, underlining a common path of stroke lived experience: brutality of diagnosis, lack of information regarding disease condition, feeling of abandonment after discharge from hospital, focus on functional recovery, late awareness of cognitive disorders, and need for psychological support and family adaptation.

CONCLUSION

This is the first qualitative study reporting lived experience of childhood stroke caregivers. In line with other qualitative studies exploring the feelings of parents coping with severe neurological conditions of childhood, our results advocate the need for evaluation of family centred health interventions.