Functional outcome following stroke in children

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 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.

Outcome in Childhood Stroke: Comparing Functional Outcome by Modified Rankin Scale with Neurological Outcome by Pediatric Stroke Outcome Measure

Different scales are used as outcome predictors following arterial ischemic stroke (AIS) in children. Pediatric stroke outcome measure (PSOM) gives information about neurological deficits and function and modified Rankin scale (mRS) about functional outcome. Research examining the relationship between the two measures is scarce. The aim of this study is to correlate the two different scales and to get some information on the long course of outcomes according to these outcome measures. Sixty-one children with the diagnosis of AIS and normal neurodevelopment prior to stroke were investigated. Results of outcome measures (PSOM and mRS) from ≥ 2 years of follow-up were analyzed. Changes of neurological deficits (subcategories of PSOM) over time (discharge, 6 months, and ≥2 years) and prognostic impact on the outcome of the Pediatric National Institutes of Health Stroke Scale and etiology/risk factors are presented.

Cramer's V with a coefficient of 0.836 (df-1) indicates a strong association between dichotomized total PSOM and mRS scores. The correlation between the total scales was strong (rho = 0.983, p < 0.001). The correlation coefficient was highest for sensorimotor (rho = 0.949, p < 0.001), then for language (rho = 0.464, p < 0.001) and cognitive (rho = 0.363, p = 0.004) subscales. PSOM scores improved at 6 months compared to the discharge state in sensorimotor (p<0.001) and language (p<0.026) domains, however, there was no statistically significant difference between PSOM scores at 6 months and >2 years follow-up. There was no improvement in cognitive PSOM scores during the follow-up period.

There was a high concordance level between the two scales, illustrating that long-term neurological deficits after stroke are related to poor functional outcome. Significant improvement of sensorimotor and language function happened within the period from onset to 6 months of follow-up. Thus, early mobilization of appropriate rehabilitative therapy might improve the outcome. We conclude that both outcome classifications are applicable for assessing outcome after childhood AIS.

Movement-specific keyboard playing for hand function in adolescents and young adults with acquired brain injury

Background

Patients with acquired brain injury (ABI) suffer from deficits in fine motor function in hands which affect independent self-care function in daily life. This study aimed to examine the effects of movement-specific keyboard playing for improved hand function in adolescents and young adults with ABI.

Method

A total of 23 patients with ABI participated in this study. Twelve were assigned to the intervention group and eleven to the control group. The intervention group engaged in movement-specific keyboard playing three to four times a week for 3 weeks in addition to standard care, while the control group received only standard care.

Results

The results of a mixed model of repeated measures ANOVA showed that the time effects were significant in the functional independence measure, key-pressing force, and most of the hand function tests measured. In terms of the interaction effect between group and time, a significant effect was found only in the checker-stacking task as a subtest of the Jebsen-Talyor Hand Function Test.

Discussion

These results indicate that the specified movements required to play the keyboard may involve more precise and dexterous manipulation with hands and fingers. These results also suggest that movement-specific keyboard playing has potential in optimizing the intervention effect of keyboard playing while maximizing the benefits of music for motivating young patients with ABI.

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.

Functional outcomes in children related to self-care, mobility, and social function after stroke in early childhood: a cohort study

ABSTRACT Background: Stroke has been increasingly recognized as an important morbidity and mortality factor in neonates and children. Children have different and more diverse risk factors than adults, commonly related to an underlying disease. Stroke may compromise functional capacity in children. Few studies have focused on functional outcomes related to activities and participation. Objectives: To investigate post-stroke functionality of children related to self-care, mobility, and social function. Methods: We assessed the functional outcome of 14 children younger than 7.5 years who suffered a stroke in early childhood through the use of the Pediatric Evaluation of Disability Inventory (PEDI). Results: The average age of the sample at assessment was 3.6 ± 1.4 years (2 - 6 years). The average scores in the PEDI functional domains of self-care, mobility, and social function were, respectively, 37.6 ± 15.4, 36.2 ± 15.4, and 48.7 ± 11.1. Children showed age-appropriate functional outcomes in the PEDI functional domains: 71.4% of them in self-care and mobility and 92.9% in social function. Children with bilateral injuries (p = 0.05) and longer hospital stays (r = -0.79, p = 0.001) showed the worst scores in PEDI's social function domains. Conclusions: Overall, our sample of preschool children showed age-appropriate functional outcomes on self-care, mobility, and social function domains after stroke. However, children with bilateral injuries and longer hospital stays showed the worst scores in social function domains. We recommend focusing on functional rehabilitation to promote activities and participation and to monitor the development of children's social skills after stroke.

Measuring Health-Related Quality of Life in Pediatric Neurology

Health-related quality of life (HRQOL) is central to how clinicians and parents make choices about medical care for pediatric neurology patients. To provide parents with the information they need to make these decisions and plan for the future, it is necessary for parents and clinicians to understand how HRQOL is defined and measured in the setting of pediatric neurodevelopmental impairment. We review challenges that exist in measuring HRQOL in pediatric neurology, examine existing measures, and outline key principles to guide selection and interpretation of HRQOL measures in children with neurologic conditions.

Additional validation study and French cross-cultural adaptation of the Pediatric Stroke Outcome Measure-Summary of Impressions (PSOM-SOI)

BACKGROUND

The Pediatric Stroke Outcome Measure-Summary of Impressions (PSOM-SOI) measures neurological function across right and left sensorimotor domains (Item A), language production (Item B), language comprehension (Item C), and cognition/behaviour (Item D).

OBJECTIVE

This study was a cross-cultural adaptation into French of the PSOM-SOI and an assessment of its reliability and limitations of use.

MATERIAL AND METHODS

The translation and adaptation of the PSOM-SOI was followed by the assessment of its reliability in a cohort of 69 children with diagnosed acute neonatal arterial ischemic stroke. Three independent raters retrospectively scored the PSOM-SOI based on data from in-person neurological examination and results of standardized tests performed at age 7 in the cohort database. Comparison 1 (C1) involved a less experienced rater and an experienced rater and comparison 2 (C2) involved 2 experienced raters. Inter-rater reliability (IRR) was measured with Kappa coefficients.

RESULTS

The cross-cultural adaptation was easily performed, and no rater had difficulties using the French PSOM-SOI. The IRR was better in C1 than C2. For Item A, the agreement in C1 (κ=0.47) and C2 (κ=0.44) was moderate. The C1 agreement was substantial for Items B (κ=0.71) and C (κ=0.70); the C2 agreement was fair for Item B (κ=0.23) and slight for Item C (κ=0.16). For Item D, the agreement was moderate in C1 (κ=0.52) and fair in C2 (κ=0.35). In all but one comparison, agreement or minor disagreement (≤0.5 points) was obtained for more than 90% of the item scores. Regarding the total score, agreement for normal function (≤0.5) versus abnormal function (>0.5) was achieved for 90% in C1 and 67% in C2.

CONCLUSION

The IRR of the French PSOM-SOI gave variable results depending on the item and rater's experience, but the extent of disagreements was minor for individual items and total score. Additional prospective validation studies using the French PSOM-Short Neurological Exam to score the PSOM-SOI are needed. A dichotomised total score (cut-off≤0.5) could be used to define normal function versus poor outcome.

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.

Health related quality of life and manual ability 5 years after neonatal ischemic stroke

AIM

To investigate health-related quality of life (HRQOL) and manual ability five years after neonatal arterial ischemic stroke (NAIS).

METHODS

Data was prospectively obtained by the Swiss Neuropaediatric Stroke Registry between 2000 and 2010. Two years after NAIS, cognitive and motor outcomes was assessed using the Bayley Scales of Infant Development (BSID-II). After 5 years, HRQOL was assessed with the KIDSCREEN-27 and manual ability with the ABILHAND-Kids. Manual ability and HRQOL were compared between children with and without cerebral palsy (CP) and HRQOL was correlated with manual ability.

RESULTS

Seventy-four patients were examined at the age of 2 years, at the age of 5 years 61 patients underwent a follow-up examination. Two years after NAIS, 29 children (39.1%) were diagnosed with CP. HRQOL 5 years after NAIS was comparable to normative values. Children with CP had a significantly lower HRQOL-index (p = 0.013) and lower scores in the subscale psychological well-being (p = 0.012) and social support & peers (p = 0.048). The ABILHAND-Kids measure was significantly lower in children with CP compared to children without CP (p < 0.001). Manual ability correlated significantly with HRQOL.

CONCLUSION

Five years after NAIS, HRQOL is comparable to that of typically developing peers, but reduced in children with CP. Poorer manual ability is associated with lower HRQOL. Interventions improving hand function might influence HRQOL and should be considered early on.

Pediatric Stroke Caregiver Well-Being: A Holistic Wellness Perspective

Evidence-based models are critical for understanding caregiver well-being and treatment interventions from a holistic perspective. This study introduces the Indivisible Self: An Evidence-Based Model of Wellness (IS-WEL) as a means for examining the holistic wellness of pediatric stroke caregivers. In this exploratory study, 161 participants completed a demographic survey and the Five-Factor Wellness Inventory (FF-WEL). Results indicate significant wellness score differences between the current sample of pediatric stroke caregivers and the FF-WEL norming sample on the higher order Total Wellness factor, the second-order wellness factors of Creative Self and Social Self, and the third-order wellness factors of thinking, emotions, control, positive humor, and love. These results support the veracity of the IS-WEL as an additional empirically sound holistic approach for understanding and addressing the well-being of stroke caregivers. The authors discuss practical clinical and research implications for utilizing the IS-WEL with pediatric stroke caregivers.

Risk factors and motor outcome of paediatric stroke patients

BACKGROUND

Childhood stroke causes significant morbidity and mortality. In this study, we aimed to define the presenting findings, causes, risk factors and motor outcomes of our patients.

METHODS

We retrospectively analysed patients aged from 1 month to 18 years who were diagnosed as having the first onset of stroke between January 2006 and December 2015. Presenting features, causes, risk factors, recurrence rate and motor outcomes were recorded. Motor outcome was evaluated by the gross motor function classification system.

RESULTS

Forty-seven children were included in the study. Thirty-eight (78.7%) children had an arterial stroke, 9 (19.1%) had a venous stroke. The median age at the time of presentation was 60 months (3-214). Thirty-two patients (68%) presented with a focal neurological sign and 9 presented with seizure (19.1%). Patients who had a venous stroke presented with more diffuse neurological symptoms than those who had an arterial stroke. At least one risk factor for stroke was identified in 74.5% of the patients; the most common causative factor was prothrombotic state seen in 16 patients (33.5%). Stroke recurred in 5 patients (10.6%); coexistence of multiple factors was a risk factor for recurrence. Presenting with seizure was not a facilitator for epilepsy. Thirty-two (68%) patients had a favourable motor outcome. Younger age (24 months versus 114 months) and presenting with focal neurological signs were related to non-favourable motor outcome.

CONCLUSION

Our cohort demonstrates that most of the children had a risk factor for stroke and have had favourable motor outcome. However, younger age and presenting with focal seizures are related to non-favourable motor outcome.

[Long term outcome of perinatal stroke]

Neonatal Arterial Ischemic Stroke (NAIS) affects 6-17 newborns on 100 000-birth term neonates, most of these children keeping long-term motor and cognitive impairments. Based on a literature review, the objectives of this paper are to describe motor and cognitive outcomes after a NAIS and to propose a consensual monitoring of these children to improve their management. About 30 % of children after a NAIS will develop a unilateral cerebral palsy requiring a management by a team with expertise in physical medicine and rehabilitation. Unlike adults, especially after a left NAIS, children will not present aphasia but between 50 and 90 % will present disorders of speech and language in expression and/or reception. After NAIS, the global intellectual efficiency is usually preserved except when the size of the lesion is very important or when severe epilepsy occurs. Several studies are also in favor of vulnerability in visuospatial functions. To quantify impairments, activity limitations and participation restrictions resulting from this NAIS, early and at least yearly evaluations with reliable tools must be carried out systematically until puberty. A multidisciplinary team with a longitudinal follow-up, in all the different developmental dimensions, must conduct these evaluations in term of motor skills, cognitive impairment, behavior, autonomy, quality of life, and participation. Consequences on family functioning need to be evaluate in order to help children and family coping with this event.

Health-related quality of life and its determinants in paediatric arterial ischaemic stroke survivors

OBJECTIVE

Health-related quality of life (HRQL) instruments are patient or proxy-reported outcome measures that provide a comprehensive and subjective assessment of patient's well-being and hence vital for health outcomes evaluation. A clear and thorough understanding of HRQL and its determinants is especially important to appropriately guide health-improving interventions. In this study, HRQL of paediatric arterial ischaemic stroke survivors was assessed using guidelines recommended for interpretation and reporting of the patient-reported outcome data. Determinants of HRQL were also explored.

METHODS

Children diagnosed with arterial ischaemic stroke between 2003 and 2012 were assessed at least 1 year poststroke using the parent-proxy report versions of the Pediatric Quality of Life Inventory 4.0 and Pediatric Stroke Recurrence and Recovery Questionnaire. HRQL data were compared with population norms and used as outcome in multiple linear regression analysis.

RESULTS

59 children were evaluated. Mean age at diagnosis of stroke was 2.2 years. Mean age at assessment and time elapsed since stroke was 7 years and 5 years, respectively. A total of 41% children had normal global outcome, whereas 51% had moderate to severe deficits. A lower overall HRQL was observed in both self and proxy reports. Parents reported the maximum impairment in emotional domain, whereas children indicated physical functioning to be the most affected. Neurological outcome, site of stroke and socioeconomic status were independently associated with overall HRQL.

CONCLUSIONS

Lower HRQL was demonstrated in children who survived arterial ischaemic stroke. Socioeconomic status of families was an important determinant of HRQL, over and above clinical parameters.

Self-reported needs after pediatric stroke

BACKGROUND

Pediatric stroke has the potential for long term impact on the lives of children and their families. Child-centred intervention depends on understanding of needs from diagnosis onwards. However, little is known about the health and care support self-reported needs of this population.

AIMS

This study aimed to describe the nature and extent of needs (met and unmet) of pediatric stroke patients and their families and compare these with previously reported adult stroke needs.

METHODS

The questionnaire, adapted from a previously published adult stroke study, was conducted with parents of children who had an ischemic or haemorrhagic stroke between birth - 18 years, and young people with stroke now aged between 12 and 18 years. Participants were recruited from three tertiary pediatric stroke clinics in England. Levels and type of needs, and self-reported neurological impairment were captured. Comparisons of needs was reported descriptively and explored using Chi-square test.

RESULTS

Of 44 participants (39 parents, 5 young people), over two thirds reported at least one unmet need. Over half had difficulties in school-related activities, and over one-third in leisure activities and social relationships. Participants reported similar nature and extent of need when compared to previously reported adult stroke needs. Higher severity of neurological impairment was associated with higher number of needs.

CONCLUSIONS

Children and young people and their parents have high levels of unmet need across a range of health domains in the months and years after pediatric stroke. This information supports the importance of a needs-based approach to maximising health and well-being.

Deterioration of functional abilities in children surviving the Fontan operation

Functional abilities are needed for activities of daily living. In general, these skills expand with age. We hypothesised that, in contrast to what is normally expected, children surviving the Fontan may have deterioration of functional abilities, and that peri-Fontan stroke is associated with this deterioration. All children registered in the Western Canadian Complex Pediatric Therapies Follow-up Program who survived a Fontan operation in the period 1999-2016 were eligible for inclusion. At the age of 2 years (pre-Fontan) and 4.5 years (post-Fontan), the Adaptive Behavior Assessment System-II general adaptive composite score was determined (population mean: 100, standard deviation: 15). Deterioration of functional abilities was defined as ⩾1 standard deviation decrease in pre- to post-Fontan scores. Perioperative strokes were identified through chart review. Multivariable logistic regression analysis determined predictors of deterioration of functional abilities. Of 133 children, with a mean age at Fontan of 3.3 years (standard deviation 0.8) and 65% male, the mean (standard deviation) general adaptive composite score was 90.6 (17.5) at 2 years and 88.3 (19.1) at 4.5 years. After Fontan, deterioration of functional abilities occurred in 34 (26%) children, with a mean decline of 21.8 (7.1) points. Evidence of peri-Fontan stroke was found in 10 (29%) children who had deterioration of functional abilities. Peri-Fontan stroke (odds ratio 5.00 (95% CI 1.74, 14.36)) and older age at Fontan (odds ratio 1.67 (95% CI 1.02, 2.73)) predicted functional deterioration. The trajectory of functional abilities should be assessed in this population, as more than 25% experience deterioration. Efforts to prevent peri-Fontan stroke, and to complete the Fontan operation at an earlier age, may lead to reduction of this deterioration.

Development and validation of the Pediatric Stroke Quality of Life Measure

AIM

To develop and validate a disease-specific parent proxy and child quality of life (QoL) measure for patients aged 2 to 18 years surviving cerebral sinovenous thrombosis (CSVT) and arterial ischaemic stroke (AIS).

METHOD

Utilizing qualitative and quantitative methods, we developed a 75-item Pediatric Stroke Quality of Life Measure (PSQLM) questionnaire. We mailed the PSQLM and a standardized generic QoL measure, Pediatric Quality of Life Inventory (PedsQL), to 353 families. Stroke type, age at stroke, and neurological outcome on the Pediatric Stroke Outcome Measure were documented. We calculated the internal consistency, validity, and reliability of the PSQLM.

RESULTS

The response rate was 29%, yielding a sample of 101 patients (mean age 9y 9mo [SD 4.30]; 69 AIS [68.3%], 32 CSVT [31.7%]). The internal consistency of the PSQLM was high (Cronbach's α=0.94-0.97). Construct validity for the PSQLM was moderately strong (r=0.3-0.4; p<0.003) and, as expected, correlation with the PedsQL was moderate, suggesting the PSQLM operationalizes QoL distinct from the PedsQL. Test-retest reliability at 2 weeks was very good (intraclass correlation coefficient [ICC] 0.85-0.95; 95% confidence interval 0.83-0.97) and good agreement was established between parent and child report (ICC 0.63-0.76).

INTERPRETATION

The PSQLM demonstrates sound psychometric properties. Further research will seek to increase its clinical utility by reducing length and establishing responsiveness for descriptive and longitudinal evaluative assessment.

WHAT THIS PAPER ADDS

A pediatric stroke-specific quality of life (QoL) measurement tool for assessments based on perceptions of importance and satisfaction. Moderate-to-high reliability and validity established for a new clinical scale evaluating QoL among children with stroke. Perceived QoL measured using the Pediatric Stroke Quality of Life Measure appears lower in children with neurological impairment.

Improving cognitive outcomes for pediatric stroke

PURPOSE OF REVIEW

The past 20 years have seen a 35% increase in prevalence of pediatric stroke. Contrary to widely held views, children do not recover better than adults. This review explores the impact of pediatric stroke on cognitive domains, including intellectual and executive functions, memory and behavior, and the influence of age, lesion characteristics, and comorbidities on outcome.

RECENT FINDINGS

Cognitive problems occur in up to half of ischemic and hemorrhagic stroke survivors. Single-center studies have shown intelligence quotient scores skewed to the lower end of the average range, with greater impairment in performance than verbal domains. Executive function, such as attention and processing speed are particularly vulnerable to the effects of pediatric stroke. Age at stroke, larger infarct size, cortical/subcortical lesion location, epilepsy, and comorbid physical deficits are associated with poorer cognitive outcomes.

SUMMARY

Cognitive impairment occurs relatively frequently following pediatric stroke but the nature, severity, and predictors of specific deficits are not well defined. Improving understanding of outcomes following pediatric stroke is a key priority for families but a paucity of data limits the ability to develop targeted disease, and age-specific pediatric rehabilitation strategies to optimize cognitive outcomes following pediatric stroke.

Could infarct location predict the long-term functional outcome in childhood arterial ischemic stroke?

OBJECTIVE

To explore the influence of infarct location on long-term functional outcome following a first-ever arterial ischemic stroke (AIS) in non-neonate children.

METHOD

The MRIs of 39 children with AIS (median age 5.38 years; 36% girls; mean follow-up time 5.87 years) were prospectively evaluated. Infarct location was classified as the absence or presence of subcortical involvement. Functional outcome was measured using the modified Rankin scale (mRS) for children after the follow-up assessment. We utilized multivariate logistic regression models to estimate the odds ratios (ORs) for the outcome while adjusting for age, sex, infarct size and middle cerebral artery territory involvement (significance < 0.05).

RESULTS

Both infarcts ≥ 4% of total brain volume (OR 9.92; CI 1.76 - 55.9; p 0.009) and the presence of subcortical involvement (OR 8.36; CI 1.76 - 53.6; p 0.025) independently increased the risk of marked functional impairment (mRS 3 to 5).

CONCLUSION

Infarct extension and location can help predict the extent of disability after childhood AIS.

Cognitive functioning over 2 years after intracerebral hemorrhage in school-aged children

AIM

Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke.

METHOD

Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed.

RESULTS

PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers.

INTERPRETATION

Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function.

WHAT THIS PAPER ADDS

In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children.

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.

Quality of life after paediatric ischaemic stroke

AIM

Paediatric arterial ischaemic stroke can lead to reduced quality of life (QoL). It is important to identify predictors of QoL to support recovery. We examined long-term QoL after arterial ischaemic stroke concerning different variables.

METHOD

Children registered in the Swiss Neuropediatric Stroke Registry and suffering from arterial ischaemic stroke between 2000 and 2008 were included. Two years post-stroke, assessments included intelligence quotient tests for cognitive impairment and modified Rankin Scale (mRS) for neurological impairment; 5 years post-stroke, the Kidscreen-27 was used for QoL, DSM-IV criteria screening was used for attention deficits, and the ABILHAND-Kids was used for manual motor skills. Age at stroke, sex, socioeconomic status, lesion characteristics, neuropsychological and motor outcome, and mRS were correlated with QoL measures.

RESULTS

Seventy children were examined (49 males, 21 females; mean age 7y 2wks). Age at stroke, sex, socioeconomic status, and lesion characteristics did not influence QoL; IQ below average and attention deficits partially influenced QoL. The highest predictive value for QoL was found for manual motor impairment (p=0.002) and mRS scores (p=0.013). Combined motor, cognitive, and attention impairment negatively affected QoL (p=0.001).

INTERPRETATION

Neurological and cognitive impairments after paediatric arterial ischaemic stroke negatively influence QoL. Children with motor and neurological problems, as well as those with combined motor, cognitive, and attention problems, are at higher risk for low QoL.

Educational Placement After Pediatric Intracerebral Hemorrhage

BACKGROUND

This study describes educational placement of school-aged children after spontaneous intracerebral hemorrhage and examines whether educational placement is associated with severity of neurological deficits.

METHODS

Children with spontaneous intracerebral hemorrhage presenting from 2007 to 2013 were prospectively enrolled at three tertiary children's hospitals. The Pediatric Stroke Outcome Measure and parental interview gathered information about neurological outcome, school attendance, and educational placement.

RESULTS

The cohort of 92 enrolled children included 42 school-aged children (6 to 17 years) with intracerebral hemorrhage. Four children died; one was excluded because of preexisting cognitive deficits. Thirty-seven children completed three-month follow-up, and 30 completed 12-month follow-up. At 12 months, 14 children (46.7%) received regular age-appropriate programming, 12 (40%) attended school with in-class services, three (10%) were in special education programs, and one child (3.3%) received home-based services because of intracerebral hemorrhage-related deficits. Of 30 children with three- and 12-month follow-up, 14 (46.7%) improved their education status, 13 (43.3%) remained at the same education level, and three (10%) began to receive in-class services. An increasing Pediatric Stroke Outcome Measure score predicted the need for educational modifications at three months (odds ratio, 3.3; 95% confidence interval, 1.4 to 7.9; P = 0.007) and at 12 months (odds ratio, 2.1; 95% confidence interval, 1.1 to 3.9; P = 0.025).

CONCLUSIONS

Most children returned to school within a year after intracerebral hemorrhage, and many had a reduction in the intensity of educational support. However, a great need for educational services persisted at 12 months after intracerebral hemorrhage with fewer than half enrolled in regular age-appropriate classes. Worse deficits on the Pediatric Stroke Outcome Measure were associated with remedial educational placement.

Environmental Contributions to Social and Mental Health Outcomes Following Pediatric Stroke

Mental health and social outcomes following acquired brain injury (ABI) in children are often considered to be due to brain insult, but other factors, such as environment, may also play a role. We assessed mental health and social function in children with chronic illness, with and without stroke (a form of ABI), and typically developing (TD) controls to examine environmental influences on these outcomes. We recruited 36 children diagnosed with stroke, 15 with chronic asthma, and 43 TD controls. Children and parents completed questionnaires rating child mental health and social function and distal and proximal environment. TD children had significantly less internalizing and social problems than stroke and asthma groups, and engaged in more social activities than children with stroke. Poorer parent mental health predicted more internalizing and social problems and lower social participation. Family dysfunction was associated with internalizing problems. Lower parent education contributed to children's social function. Children with chronic illness are at elevated risk of poorer mental health and social function. Addition of brain insult leads to poorer social participation. Quality of home environment contributes to children's outcomes, suggesting that supporting parent and family function provides an opportunity to optimize child mental health and social outcomes.

Brain attacks and stroke in children

Emergency physicians are often the first point of contact in children presenting with acute neurological disorders. Differentiating serious disorders, such as stroke, from benign disorders, such as migraine, can be challenging. Clinical assessment influences decision-making, in particular the need for emergent neuroimaging to confirm diagnosis. This review describes the spectrum of disorders causing 'brain attack' symptoms, or acute onset focal neurological dysfunction, with particular emphasis on childhood stroke, because early recognition is essential to improve access to thrombolytic treatments, which have improved outcomes in adults. Clues to diagnosis of specific conditions are discussed. Symptoms and signs, which discriminate stroke from mimics, are described, highlighting differences to adults. Haemorrhagic and ischaemic stroke have different presenting features, which influence choice of the most appropriate imaging modality to maximise diagnostic accuracy. Improvements in the care of children with brain attacks require coordinated approaches and system improvements similar to those developed in adults.

Do research studies in the UK reporting child neurodevelopment adjust for the variability of assessors: a systematic review

AIM

Neurodevelopment is a key outcome for many childhood trials and observational studies. Clinically important decisions may rest on finding relatively small differences in neurodevelopment between groups receiving complex and costly interventions. Our purpose was to determine whether studies which measure neurodevelopment report the numbers, training, and auditing of assessors and, for multiple assessor studies, whether the results were adjusted and if so by which method?

METHOD

Electronic searches were conducted using Medline, Embase, Cinahl, PsycINFO, and the Cochrane Library. A study was eligible if it reported neurodevelopmental outcome in children resident in the UK, less than or equal to 18 years and was published between 2000 and 2015. Trials and observational studies were included.

RESULTS

Three hundred and seven full papers were reviewed: 52% of papers did not report the number of assessors used; 21% used a single assessor; and 27% used multiple assessors. Thirty-five per cent mentioned that assessors were trained in the use of the neurodevelopmental tool; 13% of assessors were audited; and only 1% of studies adjusted statistically for the number of assessors.

INTERPRETATION

At the very least, the quality of reporting the use of assessors in these research publications is poor, while at worst, the variability of assessors may mask the true relationship between an intervention/observation and neurodevelopmental outcome.

Factors Associated with Six-Month Outcome of Pediatric Stroke

Background

Pediatric stroke outcome studies are often cross sectional in design. Prospective information regarding the clinical course following diagnosis is lacking, but may inform clinical management beyond the acute period.

Aims

To describe the outcome of arterial ischemic stroke in infants, children and adolescents at one-month and six-months post-stroke across health domains, and explore the relationship between lesion characteristics and early outcome with six-month adaptive behavior.

Methods

A single center prospective longitudinal study at a tertiary level children's hospital. Recruitment was undertaken from December 2007 to January 2012. Participants were children aged birth to 18 years presenting acutely with first diagnosed arterial ischemic stroke. Lesion characteristics on brain imaging were classified. Children were grouped according to age at diagnosis for analysis (neonates vs. those aged >30 days).

Results

In 50 children with a median age of 47 months at diagnosis, sensorimotor impairments were most evident upon neurological examination acutely, especially in the older children. At both one-month and six-months motor functioning was significantly impaired in the older age group but no significant cognitive or language sequelae were identified. Lesion characteristics alone were not associated with six-month adaptive behavior outcomes.

Conclusions

For patients surviving arterial ischemic stroke, the most significant clinical consequences both acutely and at six-months, are sensorimotor impairments, particularly evident in the older children. In contrast cognitive or language sequelae were not identified. Long-term surveillance is required to describe clinical course and rehabilitation needs, particularly for neonates and infants.

Hemiparesis and epilepsy are associated with worse reported health status following unilateral stroke in children

BACKGROUND

Perinatal and childhood stroke result in neurological impairment in the majority of survivors, but less is known about patient and parent perception of function following stroke in children. Our aim was to characterize parent-proxy and child-reported health status in children following unilateral arterial ischemic stroke or intraparenchymal hemorrhage.

METHODS

Fifty-nine children 2-18 years (30 girls, 29 boys) with unilateral arterial ischemic stroke or spontaneous intraparenchymal hemorrhage at least 6 months before evaluation were enrolled from a single center. The PedsQL version 4.0 Generic Short Form and PedsQL version 3.0 Cerebral Palsy Module were administered to childhood stroke subjects and parents. Generic PedsQL Inventory scores were compared between children with stroke and published data from healthy children. Reported health status scores for children with varying degrees of hemiparesis were compared.

RESULTS

Children with stroke had lower reported health status scores on the Generic PedsQL Inventory than healthy children. Children with moderate-severe hemiparesis had worse scores than children without hemiparesis on several measures of the Cerebral Palsy Module as reported by both parents and children. The parents of children with epilepsy reported worse scores on several measures compared with children without epilepsy, and the parent scores were lower on several measures for children with lower intelligence quotients. Agreement between parent and child scores was better on the Cerebral Palsy Module than on the Generic Inventory.

CONCLUSIONS

Children with stroke have worse reported health status than healthy controls. Degree of hemiparesis, epilepsy, and lower intelligence quotient affect reported health status on some measures. Agreement between parent-proxy and child scores ranges from slight to good which suggests that both provide useful information.

Social competence following pediatric stroke: contributions of brain insult and family environment

Limited information is available regarding predictors of psychosocial difficulties in children following stroke. This study aimed to (i) compare social competence of children with arterial ischemic stroke (AIS) to those with chronic illness and healthy controls and (ii) investigate the contribution of stroke pathology, neurological outcome and environment. Thirty-six children with AIS > 12 months prior to recruitment were compared with children with chronic illness (asthma) (n = 15) and healthy controls (n = 43). Children underwent intellectual assessment, and children and parents completed questionnaires to assess social competence. Children with AIS underwent MRI scan and neurological evaluation. Child AIS was associated with poorer social adjustment and participation, and children with AIS were rated as having more social problems than controls. Lesion volume was not associated with social outcome, but subcortical stroke was linked to reduced social participation and younger stroke onset predicted better social interaction and higher self-esteem. Family function was the sole predictor of social adjustment. Findings highlight the risk of social impairment following pediatric stroke, with both stroke and environmental factors influencing children's social competence in the chronic stages of recovery. They indicate the potential for intervention targeting support at the family level.

Risk factors and imaging characteristics of childhood stroke in china

There are scarce reports of childhood stroke from China. Our objective was to describe the clinical spectrum, risk factors, and imaging characteristics of childhood stroke in China. Using a hospital discharge database, children with stroke who were first admitted from 2002 to 2011 were retrospectively enrolled. We identified 478 first admissions with childhood stroke, including 229 cases of ischemic stroke and 249 hemorrhagic stroke. Boys accounted for more than 60% in all stroke types (62.2% for ischemic stroke, intracerebral hemorrhage for 66.2%). The leading cause was moyamoya for ischemic stroke and arteriovenous malformations for intracerebral hemorrhage. Hemiplegia and headache were the most common presenting features. Internal carotid artery and middle cerebral artery were the most involved arteries according to imaging examination in the ischemic stroke. A total of 8 patients died of intracerebral hemorrhage. The prevalence of hemorrhagic stroke was more than that of ischemic stroke. As Western countries, arteriopathy was the most common cause of childhood stroke.

Long-Term Functional Outcome of Pediatric Stroke Survivors

PURPOSE

To examine the long-term functional, psychosocial, and medical outcome of pediatric stroke survivors.

METHOD

This was a descriptive survey performed on patients with childhood stroke who participated in an earlier study. Measures included the Vineland Adaptive Behavior Scales (VABS) and the Diener Satisfaction with Life Scale. Current information on living situation, school placement, employment, and medical outcome were obtained.

RESULTS

Twenty-nine (58%) patients participated. The mean age was 19.3 years (SD = 6.6), mean age of onset of stroke was 7.0 years (SD = 5.4), and mean follow-up time was 11.9 years (SD = 3.9). Diagnoses included hemorrhagic (31%) and ischemic (69%) stroke. All but one adult had finished high school, and the majority of participants had gone to college. 60% of patients over age 16 were employed. The average VABS levels for communication, daily living skills, socialization, and adaptive behavior fell into the moderately low range. Use of seizure medications and ADL dependence were the predictors for lower VABS levels (p <.05). Younger age, ischemic stroke, and previous dependence in mobility were risk factors for lower scores for the self-care domain, but not for lower life satisfaction. Patients who scored below adequate on VABS tended toward lower life satisfaction.

CONCLUSION

Pediatric stroke survivors had good educational and mobility outcomes, but communication, ADL, and socialization fell into the low-moderate range. The different predictors of functional and subjective quality of life outcomes suggest that functional outcomes may mediate the relations between medical factors and satisfaction with life.

Health-related quality of life in children with sickle cell anemia: impact of blood transfusion therapy

The completion of the Multicenter Silent Infarct Transfusion Trial demonstrated that children with pre-existing silent cerebral infarct and sickle cell anemia (SCA) who received regular blood transfusion therapy had a 58% relative risk reduction of infarct recurrence when compared to observation. However, the total benefit of blood transfusion therapy, as assessed by the parents, was not measured against the burden of monthly blood transfusion therapy. In this planned ancillary study, we tested the hypothesis that a patient centered outcome, health-related quality of life (HRQL), would be greater in participants randomly assigned to the blood transfusion therapy group than the observation group. A total of 89% (175 of 196) of the randomly allocated participants had evaluable entry and exit HRQL evaluations. The increase in Change in Health, measured as the child's health being better, was significantly greater for the transfusion group than the observation group (difference estimate = -0.54, P ≤ 0.001). This study provides the first evidence that children with SCA who received regular blood transfusion therapy felt better and had better overall HRQL than those who did not receive transfusion therapy.

Pediatric stroke outcome measure: predictor of multiple impairments in childhood stroke

The ability to anticipate deficits would help with implementation of interventions for children affected by stroke. The pediatric stroke outcome measure (measure) measures neurological impairment after stroke, but there has been little research examining the relationship between the measure and functional outcomes. We hypothesized the Measure correlates with cognitive and behavioral outcomes. Thirty-six children with stroke were assessed with the Measure, and tested for cognitive ability, problem behavior, adaptive behavior, and social participation. We examined the correlation between the total Measure and outcomes and determined how subscale scores associated with outcomes. Higher total Measure scores correlated with poorer outcomes in cognitive ability, problem behaviors, adaptive behaviors, and social participation. Specific subscale scores correlated with poorer outcomes in multiple domains. The total Measure can be used to anticipate poor outcomes in multiple domains after stroke and can help the clinician in the treatment of children as they recover.

Central auditory processing outcome after stroke in children

OBJECTIVE

To investigate central auditory processing in children with unilateral stroke and to verify whether the hemisphere affected by the lesion influenced auditory competence.

METHOD

23 children (13 male) between 7 and 16 years old were evaluated through speech-in-noise tests (auditory closure); dichotic digit test and staggered spondaic word test (selective attention); pitch pattern and duration pattern sequence tests (temporal processing) and their results were compared with control children. Auditory competence was established according to the performance in auditory analysis ability.

RESULTS

Was verified similar performance between groups in auditory closure ability and pronounced deficits in selective attention and temporal processing abilities. Most children with stroke showed an impaired auditory ability in a moderate degree.

CONCLUSION

Children with stroke showed deficits in auditory processing and the degree of impairment was not related to the hemisphere affected by the lesion.

Measurement properties of gait-related outcomes in youth with neuromuscular diagnoses: a systematic review

BACKGROUND

Sound measurement properties of outcome tools are essential when evaluating outcomes of an intervention, in clinical practice and in research.

PURPOSE

The purpose of this study was to review the evidence on reliability, measurement error, and responsiveness of measures of gait function in children with neuromuscular diagnoses.

DATA SOURCES

The MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched up to June 15, 2012.

STUDY SELECTION

Studies evaluating reliability, measurement error, or responsiveness of measures of gait function in 1- to 18-year-old children and youth with neuromuscular diagnoses were included.

DATA EXTRACTION

Quality of the studies was independently rated by 2 raters using a modified COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. Studies with a fair quality rating or better were considered for best evidence synthesis.

DATA SYNTHESIS

Regarding the methodological quality, 32 out of 35 reliability studies, all of the 13 measurement error studies, and 5 out of 10 responsiveness studies were of fair or good quality. Best evidence synthesis revealed moderate to strong evidence for reliability for several measures in children and youth with cerebral palsy (CP) but was limited or unknown in other diagnoses. The Functional Mobility Scale (FMS) and the Gross Motor Function Measure (GMFM) dimension E showed limited positive evidence for responsiveness in children with CP, but it was unknown or controversial in other diagnoses. No information was reported on the minimal important change; thus, evidence on measurement error remained undetermined.

LIMITATIONS

As studies on validity were not included in the review, a comprehensive appraisal of the best available gait-related outcome measure per diagnosis is not possible.

CONCLUSIONS

There is moderate to strong evidence on reliability for several measures of gait function in children and youth with CP, whereas evidence on responsiveness exists only for the FMS and the GMFM dimension E.

Costs of pediatric stroke care in the United States: a systematic and contemporary review

A substantial literature exists regarding cost-of-care outcomes in adult stroke, however less is known about pediatric stroke. The objective of this review of the literature was to examine studies of costs associated with pediatric stroke care. Six studies reporting data from individuals who experienced a pediatric stroke were included in the review. Cost data (charges and payments) were generally limited to one year and ranged from approximately US$15,000-140,000 depending upon stroke type. Pediatric stroke is linked to substantial costs but studies primarily emphasize the direct cost of care during the first year post-stroke onset. However, since many pediatric stroke survivors experience normal lifespans, they can also accumulate a significantly greater long term cost of care than strokes that occur in adulthood. Future studies are needed to examine long term direct costs, short and long term indirect costs and other economic outcomes in this population.

Functioning and disability after stroke in children: using the ICF-CY to classify health outcome and inform future clinical research priorities

AIM

The International Classification of Functioning Disability and Health, Child-Youth version (ICF-CY) provides a framework for describing and evaluating health, intervention outcomes, and needs assessment. It can, however, also serve as a system for classifying the focus of outcome studies and identification of gaps in current knowledge.

METHOD

The paediatric arterial ischaemic stroke (AIS) population was targeted. Multiple databases were systematically searched for AIS outcome studies focussing on functioning or disability. Findings were rated using the ICF-CY framework.

RESULTS

Twenty-eight studies were identified. Most were cross-sectional and age range at assessment varied widely. Sixty-seven different standardized measures were used, predominantly evaluating body functions. The most common domains of activity and participation reported were learning and applying knowledge, general tasks and demands, and self-care skills. Health-related quality of life was measured in nine papers. Environmental factors were rarely evaluated.

INTERPRETATION

AIS outcome studies addressing the relationship between body structures and functions (e.g. brain lesion characteristics, neurological examination findings) and activities, participation, and quality of life have emerged in recent years. Comparison of findings across studies is complicated by design and tool selection. The relationship between components of activity limitation and participation restriction is rarely explored.

Social competence following neonatal and childhood stroke

BACKGROUND

Social functioning encompasses a range of important skills that an individual uses to interact with the social world. Previous studies suggest that social functioning (outcomes) may be impaired after childhood stroke, but research is limited.

AIMS

We examined the following: (1) the effect of ischemic stroke upon social outcomes in children; (2) the correlation of cognitive abilities and problem behaviors with social outcomes; and (3) the role of infarct characteristics as predictors of social outcomes.

METHODS

We conducted an observational case-controlled study to compare children with neonatal or childhood onset stroke and controls with chronic asthma. Neurological deficits were measured with the Pediatric Stroke Outcome Measure. Cognitive abilities, problem behavior, adaptive behavior, and social outcomes were assessed with standardized measures.

RESULTS

Overall stroke cases were impaired in several areas of adaptive behaviors but not in cognitive ability, problem behaviors, or social outcomes. Children with more severe neurological deficits had impairments in a range of adaptive behaviors, social adjustment, and social participation. Impaired cognitive ability and more problem behaviors correlated with impaired social adjustment, particularly in stroke cases. Larger infarcts correlated with greater neurological impairment, lower IQ, and poorer social participation.

CONCLUSIONS

Stroke can result in impaired adaptive and social functioning without apparent deficits in IQ or behavior. Infarct size, residual neurological deficits, impaired cognitive ability, and problem behaviors increase the risk for poor social adjustment and participation. These findings can help the clinician anticipate impaired social functioning after pediatric stroke, which is important because age-specific treatments are available.

Ecological assessment of cognitive functions in children with acquired brain injury: a systematic review

BACKGROUND

Childhood acquired brain injury (ABI) often leads to impairment in cognitive functioning, resulting in disabilities in both the home and school environment. Assessing the impact of these cognitive deficits in everyday life using traditional neuropsychological tests has been challenging. This study systematically reviewed ecological measures of cognitive abilities available for children with ABI.

METHOD

Eight databases were searched (until October 2011) for scales: (1) focused on ecological assessment of cognitive functioning; (2) with published data in an ABI population; (3) applicable to children up to 17;11 years of age; and (4) in English. The title and abstract of all papers were reviewed independently by two reviewers.

RESULTS

Database searches yielded a total of 12 504 references, of which 17 scales met the inclusion criteria for the review, focusing on executive functions (n = 9), memory (n = 3), general cognitive abilities (n = 2), visuo-spatial skills (n = 2) and attention (n = 1). Four tasks used observation of actual performance in a natural environment, five were proxy-reports and six were functional paper and pencil type tasks, performed in an office.

CONCLUSION

Overall, few measures were found; eight were still experimental tasks which did not provide norms. Executive functions were better represented in ecological assessment, with relatively more standardized scales available.