Medical Professional Publications

Childhood Stroke Increases Adaptive and Social Behavior Impairment

(From the May 2015 Issue of PediatricsOnline)

The global outcomes of pediatric stroke have been the subject of much recent research, but few studies have examined the effect on social outcomes. Now, a study published in the International Journal of Stroke by researchers from Nationwide Children’s Hospital and the Royal Children’s Hospital in Melbourne, Australia, found that children who suffered a stroke may have impaired adaptive and social behaviors, even when cognition and behavior are within normal limits.

“Stroke can result in impaired social adjustment and participation, which are more likely to occur in those children who have more severe neurological deficits. These children can have a range of impairments that involve a range of life skills,” says Warren Lo, MD, lead author on the paper and director of the Stroke and Vascular Anomalies Clinic at Nationwide Children’s Hospital. “What is striking is these deficits can occur even when cognition and behavior are normal. Therefore, impaired social and adaptive behavior might not come to the attention of the physician.”

Social outcomes are important because they involve the skills necessary for successful interaction with peers, family members and others. Untreated, impaired social competence can lead to social isolation and reduced self-esteem. In the extreme cases, it can be associated with chronic unemployment, mental illness and antisocial or criminal behavior.

“This has clinical relevance because children with substantial neurological deficits may have impaired adaptive and social behaviors that a clinician might not suspect based on their academic ability or behavior alone,” says Dr. Lo. “The clinician may need to consider age-specific interventions for these children even when cognition and behavior do not seem affected.”

For the study, 36 children who had stroke were identified at Nationwide Children’s and Royal Children’s Hospital in Melbourne, Australia, who had clinical and radiological evidence of an arterial ischemic stroke between full-term birth and 17 years of age. The time between the stroke and evaluation was a minimum of one year, with a median of about eight years.

A novel aspect of this study is that children with asthma were used as controls rather than healthy children or published norms. The control group consisted of 15 children with asthma to control for effects of a single hospital admission and a chronic illness that did not injure the brain.

IQ, processing speed and behavior were assessed using selected subtests and subsections of the Wechsler Abbreviated Scale of Intelligence, the Processing Speed Index of the Wechsler Intelligence Scale for Children and the Child Behavior Checklist, respectively.

Social outcomes were assessed with using the Child and Adolescent Scale of Participation, Adaptive Behavior Assessment System-II social subscale and the Child Behavior Checklist social problems subscale.

Children with greater neurological deficits had more impairment in adaptive behaviors, social adjustment and social participation. In both stroke children and asthma controls, impaired cognition and more problem behaviors correlated with poorer social adjustment, especially so in stroke cases.

Dr. Lo and his team also investigated the relationship between infarct volumes and outcome. Infarct size was measured by manual segmentation, and infarct volumes were summed for all sections of the brain. They found that larger infarcts were associated with greater neurological impairment, lower cognition and poorer social participation.

“We expected infarcts involving both cortex and subcortex would predict poorer outcomes, but they only predicted impairment in one domain — Health and Safety — of adapted behavior,” Dr. Lo says.

Dr. Lo and his team are continuing to study the impact of stroke on social competence. They are currently funded by The Research Institute at Nationwide Children’s Hospital for a pilot study that is an extension of the study presented here.

“We are using functional MRI to measure resting state connectivity to selected regions of the brain that are associated with social competence and exploring whether we can demonstrate a cerebral connectivity basis for our earlier findings,” Dr. Lo says.


Lo W, Gordon A, Hajek C, Gomes A, Greenham M, Perkins E, Zumberge N, Anderson V, Yeates KO, Mackay MT. Social competence following neonatal and childhood stroke. International Journal of Stroke. 2014 Dec, 9:1037-1044.

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