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Social and behavioural outcomes following paediatric stroke
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posted on 09.02.2017by Gomes, Alison
Paediatric stroke (PS) is a heterogeneous, acute neurological condition that occurs in approximately 7 per 100 000 children. Associated sequelae, including intellectual impairment, specific cognitive deficits, and functional and emotional problems, have the potential to impact on social and psychiatric outcomes. However there has been limited research into psychosocial outcomes following focal brain insult such as PS. Considering the heterogeneous neuropathology and developmental timing of stroke, studies in this emerging area have the potential to inform the relationship between age at brain injury, lesion location and plasticity/vulnerability for psychosocial function. Findings may be clinically relevant to non-brain injured populations, considering the emerging neural understanding for social function.
To clarify the nature of recovery in these ‘psychosocial’ domains after PS, a series of empirical papers were utilised to examine various aspects of social and behavioural adjustment as well as investigate the influence of brain insult-related factors and non-insult factors, including attention and family function. Firstly, a review paper examined the existing literature in psychosocial outcomes following PS. The paper highlighted the variability in outcomes, the potential impact of brain-related and non-insult factors and the dearth of theoretical research in the area. A series of studies was conducted, involving parent, child and teacher questionnaires, neurobehavioural assessment and brain imaging. A pilot study aimed to describe attention and social functioning in children with two types of early brain insult: malformations of cortical development (MCD) and stroke. Children with pre-natal MCD experienced more generalised, numerous and clinical levels of impairment than children with acquired stroke, though impairment was present in both groups. A strong association between everyday attention and social functioning was observed. Complex attention processes were also associated with social functioning. The next empirical paper examined PS specifically and aimed to describe attention and social adjustment and their inter-relationships. The stroke cohort was found to have significantly poorer outcomes in attention compared to normative expectations. Frontal and more diffuse lesions were associated with poorer attention skills. Impairment in shifting attention was predictive of social problems in the PS group. The third empirical paper investigated the impact of stroke pathology, including timing of insult, lesion location, lesion volume and functional outcome on measures of social adjustment, social participation and psychiatric functioning. There was a high frequency of psychosocial impairments following paediatric stroke. Generally, insult related characteristics, (lesion volume and broad lesion location) did not impact on social and behavioural outcomes. Findings regarding age at insult were inconclusive. Functional outcome was predictive of social participation. The final empirical paper examined the impact of non-insult factors, such as family function, on social outcomes in PS compared to a control group with a chronic illness not involving the central nervous system. The study also investigated the influences of the child's social environment, i.e. peer relationships on psychiatric outcomes. Notably, there were largely no differences between the stroke and control groups in social and psychiatric outcomes. Family function was found to be predictive of social problems in the entire cohort of children. In the PS group, level of peer group integration was found to be predictive of externalizing problems.
Together, results of these papers indicate that the presence of a brain injury in early life such as PS is associated with an elevated risk of social and attentional dysfunction, with heterogeneous social and behavioural outcomes. Early insults prior to 12 months of age are associated with poorer outcomes. It appears that the injury-related risk factors (lesion volume, lesion location), established as predictors of cognitive and physical outcomes, are unable to predict social outcomes in isolation. Rather, findings suggest that environmental factors, such as family function, play a key role. Complex attention processes also appear to play a critical role in efficient social functioning. Findings emphasise the reciprocity between cognitive, behavioural and social outcomes, and highlight the prevalence of social problems in children with stroke. The similarities in social and behavioural outcomes across PS and chronic illness control groups further highlight the role of having a chronic illness and the importance of a child's adjustment to illness in determining social and behavioural outcomes.