Neonatal brain structure, cognitively stimulating parenting and behavioural outcomes in preschool children with congenital heart disease and controls

Children with congenital heart disease (CHD) are at increased risk of altered early brain development and neurodevelopmental impairments. Although environmental factors are known to influence neurodevelopmental outcomes, the interplay between neonatal brain structure and the home environment in shaping behavioural outcomes remains unclear. We investigated associations between neonatal structural covariance networks (SCNs), cognitively stimulating parenting, and behavioural outcomes at 4-6 years in 44 preschool children with CHD and 117 controls. Principal component analysis of 19 parent-reported questionnaires identified distinct components of childhood behaviour. Parents completed the cognitively stimulating parenting scale (CSPS) to assess cognitive stimulation at home. Forty SCNs were extracted from Jacobian determinants of neonatal T2-weighted MRI using independent component analysis. In children with CHD, anterior thalamus and cingulum morphometry was associated with empathy in childhood. Higher CSPS scores were associated with fewer neurodevelopmental difficulties in CHD, but not controls. In both groups, CSPS moderated the relationship between superior temporal gyrus morphometry and empathy while, in CHD only, CSPS moderated the relationship between inferior temporal gyrus morphometry and empathy. These findings identify early neurobiological and environmental determinants of behavioural outcomes in children with CHD and highlight the home environment as a modifiable factor in supporting neurodevelopment in this population.