Stroke in Children: What it looks like and How OT can Help

Usually when we think about the type of person who would have a stroke, most of us generally imagine an older adult patient. According to the National Stroke Association (NSA), stroke is still one of the top 10 causes of death in children and those in the first year of life are at the highest risk Impact of Stroke by National Stroke Association. Given that newborns and young children are just in the beginning stages of movement and language, they cannot usually communicate to parents the obvious symptoms as seen in adults. However, according to Dr. Adam Kirton of the Child Neurology Foundation, stroke in children can display some unique signs that parents or other adults can see: weakness on or tendency to use one side of the body, dizziness, trouble with balancing or walking, seizures, headaches, vomiting, sleepiness, and difficulty speaking (Stroke in Children by Children Neurology Foundation).

Post-stroke conditions in children vary depending on what type of damage to the brain each child sustains. Despite the severity, parents will start to see certain abnormalities as their child grows. Examples may include (but are not limited to):

  • Gross motor development delays: If the child sustained nerve damage (which is most likely), he or she may have trouble moving certain aspects of their body. Hemiplegia is a common side effect from a stroke, which means that the child to some degree can no longer voluntarily move one side of the body. With time, movement and sensation can return but in some cases it never does. Hemiplegia can drastically delay the child's ability to learn how to roll, sit up, furniture crawl, stand, and walk.
  • Fine motor development delays: If a stroke has impacted the child's movement and dexterity in their hands, then fine motor skill development becomes a problem. This could change their ability to feed themselves, to color, to pick up a toy, to write, to wipe themselves, to button their clothes, etc.
  • Postural issues:  If hemiplegia is present, the affected side of the torso will cause their body to go asymmetrical, making it very difficult for the child to sit upright without support. This means that the child could struggle with sitting independently on a toilet, at the dinner table, in a desk at school, etc. Postural alignment can also make it impossible to stand or walk without help if the damage is severe enough.
  • Cognitive delays: A stroke can cause an array of cognitive impairments, given the very nature of the condition. When damage occurs to brain tissue, children are looking at all sorts of possible problems: reduced reasoning skills, impulsive behavior, aggression, decreased attention span, and poor judgment/safety awareness to name a few.
  • Visual abnormalities: If damage occurs to the visual centers of the brain, then the child could be looking at visual impairments that are more complicated than near/far-sightedness. Visit the following link for specific visual disorders post-stroke: Stroke Survivors by National Stroke Association.
  • Speech and language impairments: Finally, stroke can dramatically change a child's ability to acquire typical speech and language. The following link describes common, aphasic conditions that can occur after stroke: What is stroke? by National Aphasia Association

Young children experiencing post-stroke effects will most likely experience challenges in the functional tasks that matter to them including playing, appropriately interacting with others, eating, dressing, toileting, bathing, and eventually participating in school or community obligations. This is where pediatric occupational therapy comes in:

  • Ranging and Therapeutic Exercise: If the child is living with a hemiplegic condition, the muscle tone can go two ways: hyper or hypo. The OT would apply passive and voluntary ranging programs for the affected joints in order to promote or restore voluntary movement and to prevent muscle atrophy/joint breakdown.
  • Constraint-Induced Movement Therapy (CIMT): Children are just as stubborn as adults. So, as they learn to move and crawl like their typical peers they will try to compensate for hemiplegia and avoid using the affected side if possible. CIMT is used to teach a child how to use the affected limbs by constraining movement of the other side of the body.
  • Fine motor/gross motor activities: Through play activities, the OT can teach the child strategies on how to use affected limbs in play in order to either restore movement of the hemiplegic side or to compensate for loss of movement.
  • Activities of Daily Living Training: The OT can run the child through the necessary daily tasks including toileting, dressing, showering, and eating but with a twist. The therapist would assess the child's abilities to complete these tasks with post-stroke conditions, and then apply compensatory techniques for the child to use in order to successfully complete those tasks by themselves.
  • Splinting/Bracing: Depending on the results of evaluations, the child may benefit from the use of a splint or brace program in order to protect affected muscles and joints, to enhance functional movement, or to prevent muscle atrophy and skin breakdown.
  • Cognitive Retraining: To an extent, OT can provide techniques for cognitive conditions in order for the child to succeed at their desired tasks such as school, playing with friends, etc. In some cases, speech therapy might come into play for consultation or co-treatment.

Why Does OT for my child look like a Play Date?

Let’s put this into context: you are the parent or guardian of a young child who is need of early intervention services. You have already been through the run-down including the first consultation as well as the standardized assessments. The early intervention program has determined that your child qualifies for occupational therapy, its interventions in which will take place in your own home. The first treatment day approaches and your new OT arrives at the door. You’ve cleared some space in the living room, and you introduce your kiddo to the OT. The next thing you know, the OT pulls out a massive duffle bag only to reveal a collection of common toys inside (some toys in which maybe your child already owns).

After being exposed to the therapist’s so-called bag of tricks, several thoughts and maybe verbalized opinions surface: What the heck am I paying for? How is bringing a bunch of toys in my house therapy? If I knew therapy was going to be about giving my child toys, I should just do it myself! Am I completely wasting my time with this? Fortunately, these questions are not new for most pediatric OTs. Therapy sessions with young children, toddlers, and/or infants will very much look like a play date to the untrained eye. Here are a few bullet points explaining why this “play date” is in fact therapy, and included in these bullet points are some tips on how to view these therapy sessions from the point-of-view of an OT:

  • “Play” is a child’s primary occupation: By occupation, OTs mean tasks or activities that are meaningful to the client. In the case of a young child, participating in play is the most common occupation because it is the most relevant. Unlike adults, children are not expected to hold down a job, attend higher education schools, run a household, or go on daily errands. Their focuses include playing, eating, completing basic living tasks (toileting, dressing, bathing), and social participation. Bringing toys to a session is merely a method for getting the child to participate in age-appropriate play.
  • Toys are comfortable for the child: Because play is a normal activity for children, introducing toys into the session provides most children comfort. It gives the child and their therapist time to develop some rapport or connection. Therapy sessions will be more effective if the child trusts their therapist and creates a healthy relationship with him or her.
  • Toys facilitate developmental milestones: Therapists may use toys to help the child achieve certain developmental milestones. This could include gross motor movement (rolling, crawling, standing, walking, etc.), fine motor movement (sorting blocks, picking up finger food, drawing or coloring, etc.), social interaction skills, and cognitive/behavioral skills. Toys are an excellent motivator for encouraging the child to progress through their milestones and to develop friendships with children their age.
  • Toys facilitate appropriate social interaction: Social interaction comes in many forms starting from birth. A baby has a very complex communication with his/her mother in order to have their basic needs met (feeding, diaper change, sleeping, illness, etc.). As children get older, they start to see the benefit in friendships with other kids. Toys facilitate appropriate social interactions and etiquette including sharing toys, imaginary play, simple competitive games, and conversation.
  • Each toy is specifically chosen and catered to the child: If your OT is bringing in a bag of toys for your child’s therapy session, there are most likely specific reasons as to why those toys were towed in. Prior to the appointment, the OT needs to review your child’s testing scores, his or her goals for therapy, and where the child sits developmentally. OTs use their trained eye to select toys that are going to best meet the child’s needs. Details may include colors, the weight, buttons, sound effects, the number of pieces involved, the size, etc. Therapists are looking for whether or not the toy will address specific milestone needs: fine motor skills, gross motor skills, social interaction, speech, and social interaction. The OT is also looking ahead to see what toys and methods of play will lead into other tasks that matter such as self-feeding, hand-writing, dressing, toileting, playing with friends, and completing basic house chores.

As a parent, you are always welcome to ask questions about your child’s therapy sessions. OTs are usually more than happy to explain the purpose behind chosen activities for your child.