Prevalence and Predictors of Learning and Psychological Diagnoses Following Pediatric Arterial Ischemic Stroke

Positive parenting practices support children at neurological risk during COVID-19: a call for accessible parenting interventions

Children and youth with neurological and/or neurodevelopmental conditions were at high risk for behavioral and mental health challenges during the COVID-19 pandemic. Positive and responsive parenting practices may be one way to prevent and manage potential difficulties in families. We aimed to identify whether positive parenting practices were associated with reduced behavioral concerns in children at neurological risk during the late stages and aftermath of the COVID-19 pandemic. In addition, we examined whether ongoing parental stress, anxiety, and depression impacted parenting practices during this time period. Families (N = 179) with children 4 to 15 years old (M = 7.11y, SD = 2.02) diagnosed with neurological (84.3%), neurodevelopmental (54.8%) or comorbid neurological and/or neurodevelopmental conditions (21.2%) were contacted to complete online questionnaires regarding demographics, parent stress, child behavior, COVID-19 conditions, and parenting practices. Multivariable linear regression (MLR) analyses examined the association between positive parenting practices and parenting competency measures with child behavioral outcomes, controlling for relevant covariates, including COVID-19 related stress. MLR were also run to determine whether parental mental health impacted parenting practices. More positive parenting practices predicted fewer child problem behaviors and lower intensity of problem behaviors. Similarly, a higher sense of satisfaction with parenting competence also predicted fewer child problem behaviors and lower intensity of problem behaviors. In addition, higher reported parental depression, anxiety, and stress significantly predicted fewer reported positive parenting practices. Findings points to the promising application of positive parenting interventions to support vulnerable families, as well as the need for parental mental health intervention to support parenting practices.

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.

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.

Adjusting to life after pediatric stroke: A qualitative study

AIM

To examine adjustment after stroke in adolescence from the perspective of affected young people.

METHOD

Fourteen participants (10 female) aged 13 to 25 years with a history of ischemic or hemorrhagic stroke in adolescence participated in one-on-one semi-structured interviews at the Hospital for Sick Children, Toronto, Canada. Interviews were audio-recorded and transcribed verbatim. Two independent coders conducted a reflexive thematic analysis.

RESULTS

Five themes were identified as representative of adjustment after stroke: (1) 'Processing the story'; (2) 'Loss and challenges'; (3) 'I've changed'; (4) 'Keys to recovery'; and (5) 'Adjustment and acceptance'.

INTERPRETATION

This qualitative study provides medical professionals with a personal, patient-driven lens through which to better understand the challenges of adjusting to life after pediatric stroke. Findings highlight the need to provide mental health support to patients to assist them in processing their stroke and adapting to long-lasting sequelae.

WHAT THIS PAPER ADDS

Processing the onset event is a key component of adjustment to stroke. Feelings of anxiety, sadness, frustration, and self-consciousness impede adjustment to stroke. Young people may feel overwhelmed academically owing to neurocognitive deficits. Sequelae may rid young people of hobbies and passions, and alter plans for the future. To adjust to stroke, survivors draw on resilience, patience, determination, and social support.

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.

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.

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.

The contribution of whole-exome sequencing to intellectual disability diagnosis and knowledge of underlying molecular mechanisms: A systematic review and meta-analysis

Whole-exome sequencing (WES) is useful for molecular diagnosis, family genetic counseling, and prognosis of intellectual disability (ID). However, ID molecular diagnosis ascertainment based on WES is highly dependent on de novo mutations (DNMs) and variants of uncertain significance (VUS). The quantification of DNM frequency in ID molecular diagnosis ascertainment and the biological mechanisms common to genes with VUS may provide objective information about WES use in ID diagnosis and etiology. We aimed to investigate and estimate the rate of ID molecular diagnostic assessment by WES, quantify the contribution of DNMs to this rate, and biologically and functionally characterize the genes whose mutations were identified through WES. A PubMed/Medline, Web of Science, Scopus, Science Direct, BIREME, and PsycINFO systematic review and meta-analysis was performed, including studies published between 2010 and 2022. Thirty-seven articles with data on ID molecular diagnostic yield using the WES approach were included in the review. WES testing accounted for an overall diagnostic rate of 42% (Confidence interval (CI): 35-50%), while the estimate restricted to DNMs was 11% (CI: 6-18%). Genetic information on mutations and genes was extracted and split into two groups: (1) genes whose mutation was used for positive molecular diagnosis, and (2) genes whose mutation led to uncertain molecular diagnosis. After functional enrichment analysis, in addition to their expected roles in neurodevelopment, genes from the first group were enriched in epigenetic regulatory mechanisms, immune system regulation, and circadian rhythm control. Genes from uncertain diagnosis cases were enriched in the renin angiotensin pathway. Taken together, our results support WES as an important approach to the molecular diagnosis of ID. The results also indicated relevant pathways that may underlie the pathogenesis of ID with the renin-angiotensin pathway being suggested to be a potential pathway underlying the pathogenesis of ID.

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.

Building I-INTERACT-North: Participatory Action Research Design of an Online Transdiagnostic Parent-Child Interaction Therapy Program to Optimize Congenital and Neurodevelopmental Risk

To adapt an existing virtual family-based mental health intervention learning platform (I-InTERACT-North), using participatory action research design, to meet the needs of parents and children with congenital, neonatal, and neurodevelopmental conditions that impact development. A purposive sample of parent knowledge users recruited from a large pediatric hospital (n = 21) and clinician stakeholders (n = 16) participated in one interview. An iterative process was adopted to implement feedback in the adaption of the learning platform. Qualitative thematic analysis was used to examine themes across participant feedback. Initial satisfaction with the adapted website was high. Qualitative results revealed four themes: acceptability, usability, recommendations, and dissatisfaction. Addressed with iterations, technical difficulties, wanting more information on content, resources, and intended audience were areas of dissatisfaction. This study reflects the importance of participatory action research methods in informing virtual mental health interventions. Future directions to improve the learning platform are discussed.

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.

Plasticity of the language system in children and adults

The language system is perhaps the most unique feature of the human brain's cognitive architecture. It has long been a quest of cognitive neuroscience to understand the neural components that contribute to the hierarchical pattern processing and advanced rule learning required for language. The most important goal of this research is to understand how language becomes impaired when these neural components malfunction or are lost to stroke, and ultimately how we might recover language abilities under these circumstances. Additionally, understanding how the language system develops and how it can reorganize in the face of brain injury or dysfunction could help us to understand brain plasticity in cognitive networks more broadly. In this chapter we will discuss the earliest features of language organization in infants, and how deviations in typical development can-but in some cases, do not-lead to disordered language. We will then survey findings from adult stroke and aphasia research on the potential for recovering language processing in both the remaining left hemisphere tissue and in the non-dominant right hemisphere. Altogether, we hope to present a clear picture of what is known about the capacity for plastic change in the neurobiology of the human language system.

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 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.

Mental health outcomes in children with acquired dystonia after basal ganglia stroke and associations with cognitive and motor outcomes

Pediatric arterial ischemic stroke involving the basal ganglia and/or thalamus is one of the most common causes of dystonia in children. Dystonia is a movement disorder in which excessive, involuntary muscle contractions result in twisting or repetitive movements, and abnormal posturing. The basal ganglia have been implicated in mood functioning and difficulties in these domains have been noted in adults with dystonia, yet little is currently known about these outcomes in children with dystonia following stroke. The objective of this study was to explore mental health outcomes in children with basal ganglia stroke and to determine whether children with post-stroke dystonia experience additional mental health difficulties. We also examined associations between mental health, cognitive, and motor outcomes. Participants were 75 children with stroke involving the basal ganglia and/or thalamus (dystonia n = 24, no dystonia n = 51). Results supported the presence of greater levels of anxiety and depression symptoms in children with post-stroke dystonia after stroke relative to those with similar patterns of stroke, but no dystonia. There were no significant associations between motor, cognitive, and mental health outcomes in children with post-stroke dystonia aside from depression and behavioral regulation. Motor and cognitive outcome were significantly associated in the stroke only group. These findings suggest maladaptive reorganization after stroke may contribute to motor, cognitive, and mental health outcomes in children with post-stroke dystonia, and that these outcomes are independent from one another.

Cognitive and Academic Outcomes Following Childhood Cortical Stroke

The majority of pediatric neuropsychological stroke research has focused on perinatal stroke outcomes given its relative frequency. Meanwhile, childhood-onset stroke is under-represented in the literature, resulting in limited knowledge about its neurocognitive sequelae. This retrospective study examined cognitive outcomes in children and youth (n = 27) with childhood arterial ischemic stroke (stroke occurring between 29 days and 18 years of life) isolated to the cortical region. Intellectual, academic, language, visual-perception, visual-motor integration, fine motor coordination, and executive function scores were examined relative to normative means. Results indicate that although these children are doing well in terms of general intellectual ability, they demonstrate lower scores on tasks of processing speed and fine motor coordination. Exploratory analysis also revealed that of the personal and neurologic factors examined, age at stroke was positively correlated with perceptual reasoning and fine motor control, age at assessment was negatively correlated with math calculation abilities, and maternal education was positively correlated with working memory and parent-reported behavioral regulation and impulse inhibition abilities. While neurologic variables were not predictive of cognitive neuropsychological outcomes, those with significant poorer performance had higher rates of medium/large, right-sided lesions with frontal lobe involvement. Our results highlight the overall resilience of the injured developing brain but also the vulnerability of specific cognitive skills within this unique population.

Characterizing language outcomes following childhood basal ganglia stroke

The basal ganglia are important for movement and executive function, but its contribution to language is less understood. This study explored language outcomes associated with childhood basal ganglia stroke. A detailed language coding scheme, which examined expressive and receptive language, verbal fluency, narrative discourse, pragmatic/applied language, and academics, was developed from qualitative and quantitative data acquired from neuropsychological testing and reports. Overall intellectual functioning and verbal comprehension was in the average range. Twelve participants had psychological diagnoses, including Learning Disorder. No one had a Language Disorder diagnosis. Among the 18 children who did not receive a diagnosis, many exhibited language issues in the mild to severe range according to our coding scheme. These children had higher-order language difficulties in verbal fluency, narrative, and pragmatic language rather than overt expressive difficulties noted in Diagnostic and Statistical Manual (DSM) diagnostic criteria. There was an association between infarct size and ESL/immersion education, math performance, and presence of a psychological diagnosis. Psychological diagnosis was also associated with literacy skills. The results highlight that language issues following basal ganglia stroke may not be fully captured by standardized neuropsychological tests and psychological diagnoses. Findings reinforce the need to integrate quantitative and qualitative findings when examining language functioning.

Predictors of Cognitive and Academic Outcome following Childhood Subcortical Stroke

Childhood arterial ischemic stroke often involves basal ganglia and thalamus but little is known about neuropsychological outcomes in this group. We examined intellectual ability, academics, attention, executive function, and psychological diagnoses in children and adolescents (6-20 years of age) with childhood stroke involving the basal ganglia (n = 32) or thalamus (n = 12). Intellectual ability was age-appropriate but working memory was significantly lower than expected. Compared to the normative mean, the stroke group exhibited significantly weaker performance in reading comprehension, math fluency, attention, and greater challenges with executive function. Children with basal ganglia stroke had weaker working memory and were more likely to receive diagnoses of Attention Deficit Hyperactivity Disorder and Anxiety Disorder than those with thalamic stroke. Lesion size was most important in predicting working memory ability, whereas age at stroke and age at test were important in predicting academic ability.