Intervention Strategies for Pediatric Stroke
Planning for best possible quality of life
By Terrie Price, PhD, ABPP
Dr. Price is the Director of Neuropsychology and Family Services of the Rehabilitation Institute of Kansas City. Her primary clinical work is in neuropsychological assessment.
1 in 4,000 live births and
11 in every 100,000 children age birth to 18 (National Stroke Association, nsa.org)
12 in 100,000 newborns and
12 in every 100,000 children (American Stroke Association, asa.org)
Stroke is a neurological condition often associated with senior adulthood, but strokes can occur in any age group, including children. While the effects of pediatric stroke vary based on many factors, parents should be encouraged that treatment and management of neurological, cognitive and psychological effects offers great potential for better functioning in daily life, academic progress and social integration.
Specialists can provide treatment including neurology and physical medicine and rehabilitation. Based on the child’s individual needs, other specialists may participate in treatment plans including speech, occupational, and physical therapy, neuropsychologists, assistive technology, and orthopedics. Certainly, early intervention is critical but as the child continues to develop and mature, interventions may be recommended through childhood and adolescence towards optimal outcome, giving the child every opportunity to pursue their personal dreams and aspirations.
Causes and Effects
A review of literature on perinatal stroke (Murias et al) indicates that maternal history of infertility, gestational diabetes, preeclampsia, and placental abnormalities have been implicated as risk factors for stroke. A review by Childers (2011) lists potential cause of stroke among children and adolescents as abnormalities of the arteries in the brain, chickenpox and other infections, anemia caused by a diet that is deficient in iron, sickle cell disease, certain types of congenital heart disease such as valve abnormalities, autoimmune disorders such as lupus or type 1 diabetes, problems with blood clotting, and excessive consumption of energy drinks containing high levels of caffeine.
As to effects, Murias et al (2014) report that among those with perinatal stroke, 60 percent are diagnosed with Cerebral Palsy (mostly spastic hemiplegia), 30-60 percent develop epilepsy, 25 percent experience language delay and 22 percent evidence behavioral (attention, hyperactivity) problems. Similar effects are reported among children and adolescents who experience stroke after birth. Murias et al (2014) reports that stroke impact may be noted within a few days of birth by way of decreased activity, seizure activity, apneas and encephalopathy. However, the perinatal stroke may be asymptomatic until later in infancy or during toddler years with delayed motor milestones, early hand preference, or seizures. In older children or adolescents, initial stroke symptoms are similar to what is noted among adults: sudden onset of weakness or numbness of the face, arms or leg, particularly on one side, onset of difficulty with speech production and comprehension, trouble with vision, loss of balance, trouble walking and dizziness and onset of a severe headache.
Quality of Life
Neurological recovery in children differs from that of adults, primarily because the pediatric and adolescent brain is still developing. Subsequently, there is an interaction between the timing of the stroke with the development of brain functions and networks. Studies suggest better outcomes for children ages 5-10 versus 0-5 and 11-18 (Murias et al 2014). While Allman and Scott (2013) report that children ages 1-6 performed better on neuropsychological testing than children with stroke less than age 1 or children experiencing stroke at ages 6-16.
Additional factors impacting long term functional outcome include lesions in the cortical and subcortical regions, large intraparencymal lesions and symptomatic epilepsy. There tends to be a higher percentage of strokes in the left middle cerebral artery, leading to right side motor impairments. Whereas a left hemisphere stroke can often have a significant impact on language for stroke survivors, children may show early language delays that tend to catch up by school age. There appears to be atypical localization of language into other brain regions leading to less impact on language.
Visual spatial test performance is often lower though possibly related to fine motor delay. Attention appears to be effected as well. Other cognitive areas such as information processing speed may be impacted related to the stroke site and size. However, the Murias et al (2014) review suggests that IQ tends to be normal but not as strong as age matched children without stroke history. Studies suggest the potential of decline in IQ and some increasing deficits overtime where the cumulative impact of seizures is implicated as potentially interfering with ongoing learning. We are reminded that due to the developing brain, specific developmental functions cannot be assessed earlier than it would normally appear leading to emerging areas of difficulty.
As to quality of life, Murias et al (2014) reports that children with stroke history often report higher quality of life than adult stroke survivors. Socially, these children reported similar concerns as same age peers regarding autonomy, relationship with parents and social acceptance. Parent quality of life ratings for their children were related to their child’s cognitive functions. Parents also reported concerns about mood and social acceptance.
Early childhood services such as First Steps through Missouri, are offered for children from birth to age 3. A range of rehabilitation services are available as deemed beneficial through an Individualized Family Service Plan. From age 3-5, Early Childhood Special Education program involves developing an Individual Education Plan (IEP) for the child and provision of rehabilitation services, typically in a preschool program, to meet the child’s educational needs.
From age 5 through the school years, the IEP is regularly reviewed and modified to fit the child’s educational needs and can include school based occupational, speech and physical therapy, counseling services, social work services, behavior plans and special education support. Given that school based rehabilitation services are specifically geared toward educational goals, parents may wish to speak with their physician about community-based rehabilitation services to augment school based services and focus on specific functional independence goals.
Neuropsychological assessment is a broad based cognitive assessment toward identifying the child’s cognitive status relative to their age and can be helpful in developing educational plans, treatment options, social integration issues and psychological development. An assessment may be recommended at key developmental and educational stages, to monitor neurocognitive development. See the chart below for examples.
|Attention||Visual Spatial||Physical Therapy||Executive Functions||Processing Speed|
Decrease external distractions around student,
Decrease items on page,
Break longer tasks into shorter tasks
Provide cues to stay on/return to task.
|Establish organizational skills, such as:
Planner calendar, Established location for keeping school items at home,
Labeling placement of items,
Using outline for written work,
Reduce visual clutter
|Playground modifications and help,
Modify space to ambulate- distance between classes, locker
|Assistance with analysis tasks-book reports,
Test format using multiple choice, matching versus long essay,
Break tasks into smaller steps and define steps and processes,
Use outlines or mind maps to organize thoughts
|Allow extended time for tasks,
Avoid speed/timed tasks,
Reduce items on test or worksheet,
Extended time for tests including standardized tests,
Allow extended time for physical tasks at school
An important component of the long-term plan is providing critical and timely information to parents on medical, rehabilitation, cognitive, social and cognitive issues. Parents are encouraged to pursue education and support through community based groups including National Orange Popsicle Week (NOPW.org) whose mission includes raising awareness of stroke in young people and building communities of young stroke survivors. Other resources include the American Heart Association (www.heart.org) and the National Stroke Association (www.stroke.org).Social engagement becomes increasingly important as the child matures. Parents and school staff can assist by being mindful of ways to fully integrate children in social activities from the playground, to the lunchroom into sports and social clubs. Fostering meaningful peer relationships is very helpful for young people. A major developmental task is for children to learn to advocate for their needs, to become increasingly involved in identifying useful strategies, modifications and accommodations, and learning to tell their own story.
This article provides a short review of basic facts about stroke, with information drawn from a comprehensive review of literature by Murias et al (2014) and Childers (2011). For additional research refer to Murias, K., Brooks, B., Kirton, A., Iaria, G. (2014) A Review of Cognitive Outcomes in Children Following Perinatal Stroke. DEVELOPMENTAL NEUROPSYCHOLOGY, 39(2), 131–157 Childers, L (2011) Pediatric Stroke Primer: What you need to know about risk factors, signs to look for and treatment options. Hear Insight Magazine, May 2011.