Utility of the General Ability Index (GAI) and Cognitive Proficiency Index (CPI) with survivors of pediatric brain tumors: Comparison to Full Scale IQ and premorbid IQ estimates

INTRODUCTION

Pediatric brain tumor survivors are at risk for working memory and processing speed impairment. The General Ability Index (GAI) provides an estimate of intellectual functioning that is less influenced by working memory and processing speed than a Full Scale IQ (FSIQ). The Cognitive Proficiency Index (CPI) provides a measure of efficient information processing derived from working memory and processing speed tasks. We examined the utility of the GAI and CPI to quantify neurocognitive outcomes in a sample of pediatric brain tumor survivors.

METHOD

GAI, CPI, and FSIQ scores from the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) were examined for 57 pediatric brain tumor survivors (ages 6-16 years) treated with cranial radiation therapy (RT).

RESULTS

GAI scores were higher than FSIQ and CPI scores, both p < .001. Lower CPI scores were associated with history of craniospinal irradiation and time since RT. Lower FSIQ and GAI scores were associated with higher RT dose and time since RT. The rate of clinically significant GAI-FSIQ discrepancies in our sample was greater than that observed in the WISC-IV standardization sample, p < .001. Estimated premorbid IQ scores were higher than GAI, p < .01, and FSIQ scores, p < .001.

CONCLUSIONS

Pediatric brain tumor survivors exhibit weaker cognitive proficiency than that expected for age, while general reasoning ability remains relatively spared. The GAI may be useful to quantify the intellectual potential of a survivor when appropriate accommodations are in place for relative cognitive proficiency weaknesses. The CPI may be a particularly sensitive outcome measure of treatment-related cognitive change in this population.

Comparing Intelligence Quotient Change After Treatment With Proton Versus Photon Radiation Therapy for Pediatric Brain Tumors

PURPOSE

Compared with photon radiation (XRT), proton beam radiation therapy (PBRT) reduces dose to normal tissues, which may lead to better neurocognitive outcomes. We compared change in intelligence quotient (IQ) over time in pediatric patients with brain tumors treated with PBRT versus XRT.

PATIENTS AND METHODS

IQ scores were available for 150 patients (60 had received XRT, 90 had received PBRT). Linear mixed models examined change in IQ over time since radiation therapy (RT) by RT group, controlling for demographic/clinical characteristics. Craniospinal and focal RT subgroups were also examined.

RESULTS

In the PBRT group, no change in IQ over time was identified (P = .130), whereas in the XRT group, IQ declined by 1.1 points per year (P = .004). IQ slopes did not differ between groups (P = .509). IQ was lower in the XRT group (by 8.7 points) versus the PBRT group (P = .011). In the craniospinal subgroup, IQ remained stable in both the PBRT (P = .203) and XRT groups (P = .060), and IQ slopes did not differ (P = .890). IQ was lower in the XRT group (by 12.5 points) versus the PBRT group (P = .004). In the focal subgroup, IQ scores remained stable in the PBRT group (P = .401) but declined significantly in the XRT group by 1.57 points per year (P = .026). IQ slopes did not differ between groups (P = .342).

CONCLUSION

PBRT was not associated with IQ decline or impairment, yet IQ slopes did not differ between the PBRT and XRT groups. It remains unclear if PBRT results in clinically meaningful cognitive sparing that significantly exceeds that of modern XRT protocols. Additional long-term data are needed to fully understand the neurocognitive impact of PBRT in survivors of pediatric brain tumors.

Predictors of adaptive functioning and psychosocial adjustment in children with pediatric brain tumor: a report from the Brain Radiation Investigative Study Consortium

BACKGROUND

Children are at risk for psychosocial and adaptive morbidities following diagnosis of and treatment for a pediatric brain tumor. This study examined whether familial/demographic, developmental, diagnostic, or treatment-related variables best predict the acute psychosocial adjustment and adaptive functioning of children soon after an initial diagnosis.

PROCEDURE

Participants included 56 children (mean age = 10.72, SD = 4.02) newly diagnosed with a pediatric brain tumor. Parents completed background/demographic forms and completed ratings of children's behavioral and emotional symptoms, and adaptive behavior. Diagnostic and treatment-related information was abstracted from medical records.

RESULTS

Parent ratings of behavioral symptoms and adaptive functioning were within normative expectation, although rates of clinical impairment in adaptive functioning exceeded expected rates. A combination of familial/demographic and diagnostic variables were associated with acute functioning. In multiple regressions, tumor size best predicted adaptive functioning after initial diagnosis, whereas tumor location best predicted variance in behavioral symptoms.

CONCLUSIONS

Children may be more vulnerable to acute impairment in adaptive functioning following diagnosis of a pediatric brain tumor, but rates of behavioral symptoms were within expectation. Familial, sociodemographic, and diagnostic variables may help to identify those most at risk of impairment. Screening of these factors within tertiary care settings will be useful to identify those most in need of psychosocial care during the initial phases of treatment.

Oxandrolone for the treatment of bone marrow failure in Fanconi anemia

BACKGROUND

A majority of Fanconi anemia (FA) patients will experience bone marrow failure (BMF) and androgen therapy (most often oxymetholone) may be utilized as a treatment to improve BMF-related cytopenias. However, oxymetholone is associated with toxicities making identification of other agents of interest. In this study we aimed to evaluate the toxicity profile and hematologic response in patients with FA who are treated with low-dose oxandrolone, a synthetic non-fluorinated anabolic steroid, similar to oxymetholone, with known dosing thresholds for virilization.

PROCEDURE

A single arm, Phase I/II study was designed to treat patients on low-dose oxandrolone. If no toxicity or hematologic response was noted at 16 weeks, a single dose escalation was offered. Subjects were regularly assessed for toxicity, including determinations of virilization, behavioral changes, and liver and kidney function. At 32 weeks, those who demonstrated hematologic response were allowed to continue study treatment, and those without improvement were deemed non-responsive.

RESULTS

Nine subjects completed the study and were followed for a median of 99 weeks (46-136 weeks). Three (33.3%) subjects developed mild sub-clinical virilization and continued treatment with a dose reduction. None (0%) had adverse behavioral changes. Two (22.2%) developed elevated liver function tests at 42 and 105 weeks. Seven (77.8%) subjects had a hematologic response.

CONCLUSION

Oxandrolone appears to be well-tolerated, has limited toxicities at the administered doses in FA with patients, and may be an alternative androgen for the treatment of BMF in FA.

Intellectual and academic outcome following two chemotherapy regimens and radiotherapy for average-risk medulloblastoma: COG A9961

PURPOSE

Assess the intellectual and academic outcomes as well as risk factors associated with treatment for average-risk medulloblastoma in childhood using 23.4 Gy of craniospinal radiotherapy plus adjuvant chemotherapy.

METHODS

From an overall sample of 379 enrolled in the parent study (COG A9961), 110 patients received a total of 192 assessments over more than 5 years with standardized IQ and academic achievement tests. Random coefficient models of the various outcomes were developed that incorporated covariates including chemotherapy regimen, age at diagnosis, sex, initial Full Scale IQ, and mutism.

RESULTS

Participants in this study were found to be comparable to the overall sample in all demographic, disease, and treatment factors, except there were more gross total resections in the subsample undergoing intellectual and academic assessment. Major findings include significant decline in both intellectual and academic domains over time that were greater in children who were younger at diagnosis and had higher initial intelligence test scores. Children with mutism were at higher risk for initial effects on intelligence. No effects of sex were found.

CONCLUSION

These results show progressive decline over several years post-treatment in standardized intellectual and academic scores. Despite recent improvements in therapies for these children, most notably a decrease dose of craniospinal radiation, they remain at risk. The pursuit of less toxic treatments, particularly for younger children, should continue. Neuropsychological surveillance should be routine at centers treating children with brain tumors.

IQ change within three years of radiation therapy in pediatric brain tumor patients treated with proton beam radiation therapy versus photon radiation therapy

10009

Background: Radiation therapy (RT), an essential treatment for pediatric brain tumors, increases the risk of cognitive impairment. Advanced RT techniques reduce the volume of normal tissues receiving radiation dose. Proton beam radiation therapy (PBRT) minimizes irradiation to surrounding healthy brain tissue, with the potential to preserve cognitive function better than photon radiotherapy (XRT). We examined change in IQ over time between patients treated for pediatric brain tumors with PBRT versus XRT. Methods: IQ scores obtained in the first 3 years post-RT were abstracted for pediatric brain tumor patients treated with PBRT or XRT. Results: Baseline and follow-up IQ scores were available for 53 survivors (31 PBRT, 22 CRT). A linear regression model predicted follow-up IQ scores controlling for baseline IQ, age-at-RT, time-since-RT, and craniospinal irradiation (CSI), F(7,45)=23.4, p<.001. Follow-up IQ scores were significantly lower in the XRT group compared to the PBRT group (p<.05). The XRT group lost 10.3 IQ points on average with each additional year post-RT (p<.01), while the PBRT group remained stable, losing only 0.1 points per year on average (p<.05). CSI was associated with IQ decline in both groups (p<.05), while age-at-RT was not in either group (p=.154). Total RT dose was not associated with IQ with the above variables in the model. Conclusions: Findings suggest significant cognitive risk is associated with XRT, with IQ scores declining by more than half a standard deviation with each additional year post-RT. In contrast, IQ remained stable in the PBRT group. Preliminary findings suggest that PBRT may spare cognitive functioning in the first 3 years post-RT. Future research should replicate these findings with a larger sample and should study longer-term cognitive outcomes in patients treated with PBRT versus XRT. [Table: see text]

Neuropsychological late effects and rehabilitation following pediatric brain tumor

The modern era of research into the neurobehavioral late effects of pediatric brain tumor has been one of refinement in outcome measurement and advances in identification of risk factors for neurobehavioral impairment. There is no neuropsychological phenotype that encompasses all tumor types, treatments, and risk factors, though attention, working memory, processing speed, new learning, visuospatial and visuomotor functioning, executive functioning, and areas of academic achievement have been found to be at particular risk. Additional socioemotional and broader quality of life problems have been found in both survivors and their families. Past research has identified neuropsychological risk factors that include tumor location, radiation therapy and dose, certain chemotherapy agents, neurological complications, and demographic factors such as young age and female gender. Recent refinement in measurement of risk is improving our prediction of neurobehavioral outcomes. Neuropsychological and psychosocial interventions are now being developed, and the evidence base supporting these interventions is growing. Simultaneous advances in each of these areas will facilitate translation of research into risk-adapted rehabilitative care such that resources can be most effectively re-allocated and the best possible outcomes achieved.

The association between sleep disordered breathing, academic grades, and cognitive and behavioral functioning among overweight subjects during middle to late childhood

STUDY OBJECTIVES

(1) to determine the associations of sleep disordered breathing (SDB) with behavioral functioning, cognitive test scores, and school grades during middle- to late-childhood, an under-researched developmental period in the SDB literature, and (2) to clarify whether associations between SDB and school grades are mediated by deficits in cognitive or behavioral functioning.

DESIGN

cross-sectional correlative study.

SETTING

Office/hospital, plus reported functioning at home and at school.

PARTICIPANTS

163 overweight subjects aged 10-16.9 years were divided into 4 groups based upon their obstructive apnea+hypopnea index (AHI) during overnight polysomnography and parent report of snoring: Moderate-Severe OSA (AHI > 5, n = 42), Mild OSA (AHI = 1-5, n = 58), Snorers (AHI < 1 + snoring, n = 26), and No SDB (AHI < 1 and nonsnoring, n = 37).

MEASUREMENTS

inpatient overnight polysomnography, parent- and self-report of school grades and sleep, parent- and teacher-report of daytime behaviors, and office-based neuropsychological testing.

RESULTS

The 4 groups significantly differed in academic grades and parent- and teacher-reported behaviors, particularly inattention and learning problems. These findings remained significant after adjusting for subject sex, race, socioeconomic status, and school night sleep duration. Associations with SDB were confined to reports of behavioral difficulties in real-world situations, and did not extend to office-based neuropsychological tests. Findings from secondary analyses were consistent with, but could not definitively confirm, a causal model in which SDB affects school grades via its impact on behavioral functioning.

CONCLUSIONS

SDB during middle- to late-childhood is related to important aspects of behavioral functioning, especially inattention and learning difficulties, that may result in significant functional impairment at school.

Cognitive and adaptive outcome in extracerebellar low-grade brain tumors in children: a report from the Children's Oncology Group

PURPOSE

To determine whether pediatric patients treated with surgery only for low-grade tumors in the cerebral hemispheres, supratentorial midline, and exophytic brainstem evidence neurocognitive, academic, adaptive, or emotional/behavioral sequelae.

PATIENTS AND METHODS

Ninety-three patients from a natural history study of low-grade astrocytomas were tested an average of 111 days after surgery. Rates of below average (< or = 25th percentile) scores in this sample were compared with test norms, and performances were compared across anatomic sites. Finally, the relationships of pre-, peri-, and postsurgical complications to outcome were investigated.

RESULTS

For the entire sample, there was a significantly elevated rate of below average scores across intelligence quotient, achievement, and adaptive behavior, but not behavioral/emotional adjustment measures. Patients with hemispheric, midline, and brainstem tumors did not differ significantly. Patients with left hemisphere tumors generally performed worse than those with right hemisphere tumors. Finally, neurobehavioral outcome was unrelated to pre-, peri-, or postsurgery complications.

CONCLUSION

After surgery for low-grade brain tumors, a significant number of patients was found to function below average, by as much as 55% compared with 25% in the normative population. Moreover, these results suggest greater risk for patients with lesions situated in the left cerebral hemisphere. Routine neuropsychological follow-up of children after treatment for low-grade tumors is recommended.

Factors of biological risk and reserve associated with executive behaviors in children and adolescents with spina bifida myelomeningocele

This study examined differences between healthy children (n = 35) and those with spina bifida myelomeningocele (SBM; n = 42) on the Behavior Rating Inventory of Executive Function (BRIEF), a measure of executive function behaviors. It also examined whether aspects of biological risk associated with SBM and reserve factors within the family could account for variability in BRIEF scores for children and adolescents with SBM. Patients in the SBM group exhibited more problems than both published norms and a local comparison group of healthy children in metacognition but not behavior regulation. Behavior regulation problems in children with SBM were predicted by parent psychological distress. More shunt-related surgeries and history of seizures predicted poorer metacognitive abilities.

Association of prenatal and childhood blood lead concentrations with criminal arrests in early adulthood

BACKGROUND

Childhood lead exposure is a purported risk factor for antisocial behavior, but prior studies either relied on indirect measures of exposure or did not follow participants into adulthood to examine the relationship between lead exposure and criminal activity in young adults. The objective of this study was to determine if prenatal and childhood blood lead concentrations are associated with arrests for criminal offenses.

METHODS AND FINDINGS

Pregnant women were recruited from four prenatal clinics in Cincinnati, Ohio if they resided in areas of the city with a high concentration of older, lead-contaminated housing. We studied 250 individuals, 19 to 24 y of age, out of 376 children who were recruited at birth between 1979 and 1984. Prenatal maternal blood lead concentrations were measured during the first or early second trimester of pregnancy. Childhood blood lead concentrations were measured on a quarterly and biannual basis through 6.5 y. Study participants were examined at an inner-city pediatric clinic and the Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio. Total arrests and arrests for offenses involving violence were collected from official Hamilton County, Ohio criminal justice records. Main outcomes were the covariate-adjusted rate ratios (RR) for total arrests and arrests for violent crimes associated with each 5 microg/dl (0.24 micromol/l) increase in blood lead concentration. Adjusted total arrest rates were greater for each 5 microg/dl (0.24 micromol/l) increase in blood lead concentration: RR = 1.40 (95% confidence interval [CI] 1.07-1.85) for prenatal blood lead, 1.07 (95% CI 0.88-1.29) for average childhood blood lead, and 1.27 (95% CI 1.03-1.57) for 6-year blood lead. Adjusted arrest rates for violent crimes were also greater for each 5 microg/dl increase in blood lead: RR = 1.34 (95% CI 0.88-2.03) for prenatal blood lead, 1.30 (95% CI 1.03-1.64) for average childhood blood lead, and 1.48 (95% CI 1.15-1.89) for 6-year blood lead.

CONCLUSIONS

Prenatal and postnatal blood lead concentrations are associated with higher rates of total arrests and/or arrests for offenses involving violence. This is the first prospective study to demonstrate an association between developmental exposure to lead and adult criminal behavior.

Functional magnetic resonance imaging assessment of cognitive function in childhood-onset systemic lupus erythematosus: a pilot study

OBJECTIVE

To investigate changes in brain activation patterns detected by functional magnetic resonance imaging (FMRI), and the relationship between FMRI activation patterns and results of formal neuropsychological testing, in patients with childhood-onset systemic lupus erythematosus (SLE).

METHODS

Ten patients with childhood-onset SLE underwent formal neuropsychological testing and FMRI using 3 paradigms: a continuous performance task (CPT) to evaluate attention, an N-Back task to assess working memory, and verb generation to evaluate language processing. Composite Z maps were generated to summarize the brain activation patterns for each FMRI paradigm in patients with childhood-onset SLE and to compare these patterns with those observed in healthy controls. Between-group comparison Z maps showing differences in activation between childhood-onset SLE patients and controls were generated, using a significance level of P < 0.05 in a general linear model.

RESULTS

Compared with the control group, the childhood-onset SLE group showed statistically significant increased activation of brain areas involved in the CPT, N-Back, and verb generation tasks. In contrast, in the absence of active stimulus, e.g., during times of the paradigm control tasks, childhood-onset SLE patients consistently undersuppressed activity in the expected brain areas. Activation in selected cortical areas was found to correlate negatively with results of a subset of individual neuropsychological test scores.

CONCLUSION

FMRI abnormalities are present in childhood-onset SLE, manifesting as an imbalance between active and inhibitory responses to an array of stimuli. Differences in brain activation patterns compared with those observed in controls suggest that childhood-onset SLE may be associated with abnormalities in white matter connectivity resulting in neuronal network dysfunction, rather than injury of specific gray matter areas.

Lessons in pediatric neuropsycho-oncology: what we have learned since Johnny Gunther

OBJECTIVE

This article provides a commentary on the progression of research over the last six decades into the neurobehavioral outcomes of children treated for intracranial tumors.

METHODS

Published studies and literature reviews are surveyed, with illustrations from the author's ongoing longitudinal study.

RESULTS

Research on late effects in pediatric brain tumors continues to increase in both volume and quality. Samples are larger and more differentiated, scope of outcome measurement has increased, and more powerful developmental research designs are being used. Particularly promising recent developments are described, including research on: imaging-behavior relationships, improved modeling of dose-volume heterogeneity in radiation therapy, improved late effects measurement, and treatments for neurobehavioral sequelae.

CONCLUSIONS

There is now a large body of scientific evidence of increasing sophistication regarding the outcomes of patients receiving the most toxic treatments. It is argued that more research into the neuropsychological effects associated with "benign" tumors of childhood is needed.

Taxonicity of nonverbal learning disabilities in spina bifida

As currently defined, it is not clear whether Nonverbal Learning Disabilities (NLD) should be considered a matter of kind or magnitude (Meehl, 1995). The taxonicity of NLD, or the degree to which it is best construed as discrete versus continuous, has not been investigated using methods devised for this purpose. Latent Class Analysis (LCA) is a method for finding subtypes of latent classes from multivariate categorical data. This study represents an application of LCA on a sample of children and adolescents with spina bifida myelomeningocele (SBM) (N = 44), those presenting with features of NLD (N = 28) but no medical condition, and control volunteers (N = 44). The two-class solution provided evidence for the presence of a taxon with an estimated base-rate in the SBM group of .57. Indicator validities (the conditional probabilities of indicator endorsement in each latent class) suggest a somewhat different priority for defining NLD than is typically used by researchers investigating this disorder. A high degree of correspondence between LCA classifications and those based on a more conventional algorithm provided evidence for the validity of this approach.

The impact of early childhood lead exposure on brain organization: a functional magnetic resonance imaging study of language function

OBJECTIVES

The purpose of this work was to assess the long-term impact of childhood lead exposure on the neurosubstrate of language function and brain organization.

METHODS

Young adults from the Cincinnati Lead Study were recruited to undergo functional magnetic resonance image scanning while performing a verb generation task. These subjects have been followed from birth through early childhood with extensive documentation of lead exposure, neuropsychology, and behavior. Forty-two subjects provided useful imaging data. The locale, strength, and the correlation between brain language activation and childhood blood lead concentration were studied.

RESULTS

After adjusting for potential confounders, the activation in left frontal cortex, adjacent to Broca's area, and left middle temporal gyrus, including Wernicke's area, were found to be significantly associated with diminished activation in subjects with higher mean childhood blood lead levels, whereas the compensatory activation in the right hemisphere homolog of Wernicke's area was enhanced in subjects with higher blood lead levels.

CONCLUSION

This study indicates that childhood lead exposure has a significant and persistent impact on brain reorganization associated with language function.

Cognitive and adaptive outcome in low-grade pediatric cerebellar astrocytomas: evidence of diminished cognitive and adaptive functioning in National Collaborative Research Studies (CCG 9891/POG 9130)

PURPOSE

Clinicians often assume that children with posterior fossa tumors are at minimal risk for cognitive or adaptive deficits if they do not undergo cranial irradiation. However, small case series have called that assumption into question, and have also suggested that nonirradiated cerebellar tumors can cause location-specific cognitive and adaptive impairment. This study (1) assessed whether resected but not irradiated pediatric cerebellar tumors are associated with cognitive and adaptive functioning deficits, and (2) examined the effect of tumor location and medical complications on cognitive and adaptive functioning.

PATIENTS AND METHODS

The sample was composed of 103 children aged 3 to 18 years with low-grade cerebellar astrocytomas, who underwent only surgical treatment as part of Children's Cancer Group protocol 9891 or Pediatric Oncology Group protocol 9130. The sample was divided into three groups based on primary tumor location: vermis, left hemisphere, or right hemisphere. Data were collected prospectively on intelligence, academic achievement, adaptive skills, behavioral functioning, and pre-, peri-, and postsurgical medical complications.

RESULTS

The sample as a whole displayed an elevated risk for cognitive and adaptive impairment that was not associated consistently with medical complications. Within this group of children with cerebellar tumors, tumor location had little effect on cognitive, adaptive, or medical outcome.

CONCLUSION

We did not replicate previous findings of location-specific effects on cognitive or adaptive outcome. However, the elevated risk of deficits in this population runs contrary to clinical lore, and suggests that clinicians should attend to the functional outcomes of children who undergo only surgical treatment for cerebellar tumors.

Melatonin treatment of pediatric residents for adaptation to night shift work

BACKGROUND

Night float rotations are used in residency training programs to reduce residents' sleep deprivation. Night shift work, however, is accompanied by deleterious effects on sleep, mood, and attention.

OBJECTIVE

To test whether melatonin reduces the deleterious effects of night shift work on sleep, mood, and attention in pediatric residents during night float rotation.

DESIGN/METHODS

Double-blind, randomized, placebo-controlled crossover. Participants took melatonin (3 mg) or a placebo before bedtime in the morning after night shift; completed a sleep diary and an adverse-effects questionnaire daily; and completed the Profile of Mood States and the Conners Continuous Performance Test 3 times in each study week to test mood and attention, respectively.

SETTING

A university-affiliated, tertiary-care pediatric hospital.

PARTICIPANTS

Healthy second-year pediatric residents working 2 night float rotations.

OUTCOME MEASURES

Standardized measures of sleep, mood, and attention.

RESULTS

Twenty-eight residents completed both treatments; 17 completed 1 treatment (10 placebo, 7 melatonin). There was not a statistically significant difference in measures of sleep, mood, and 5 of 6 measures of attention during melatonin and placebo treatment. One measure of attention, the number of omission errors, was significantly lower on melatonin (3.0 +/- 9.6) than on placebo (4.5 +/- 17.5) (z = -2.12, P = .03).

CONCLUSIONS

The isolated finding of improvement of 1 single measure of attention in a test situation during melatonin treatment was not sufficiently robust to demonstrate a beneficial effect of melatonin in the dose used. Other strategies need to be considered to help residents in adaptation to night shift work.

An improved methodology for modeling neurobehavioral late-effects of radiotherapy in pediatric brain tumors

BACKGROUND

Technical advances in radiation oncology provide new opportunities to study neurobehavioral outcomes of radiation therapy (RT) in children treated for brain tumors.

METHODS

In this study, we describe an approach to modeling late-effects using integral biologically effective dose (IBED) combined with improved measurement of critical neuropsychological functions.

RESULTS

IBED was found to provide more differentiated information about dose distribution than prescribed dose in five subjects treated for brain tumors. Furthermore, IBED was more closely related than was prescribed dose to specific changes in Attention 2-3 years post-RT.

CONCLUSIONS

Results support the feasibility of this methodology as well as promising preliminary evidence of the relationship of IBED to the construct of Attention. Improved modeling could lead to more refined radiation therapy protocols that preserve critical neuropsychological functions and also provide new insights into the treatment of neurobehavioral sequelae.

Board certification in clinical neuropsychology: a response to Rohling et al

Board certification is intended to protect the public by identifying practitioners that have met minimum standards for education and training in their specialty or discipline. For varied reasons, clinical neuropsychology, like professional psychology as a whole, has struggled to achieve levels of board certification comparable to the medical profession. Rohling, Lees-Haley, Langhinrichsen-Rohling, & Williamson (2003) have recently published a critique of the board certification process in clinical neuropsychology as it is conducted by American Board of Clinical Neuropsychology (ABCN), arguing that one reason for this failure is the overly restrictive nature of the process. In their paper, Rohling et al. provide a signal detection analysis that makes several assumptions about the process and conclude with recommendations for improving the process to better identify "competent" neuropsychologists in practice. While we agree in principle with many of their recommendations, and ABCN had, in fact, implemented several prior to publication of their article, the article contains many faulty assumptions and logical inconsistencies that we believe are harmful to constructive review of the certification process. In this article, we provide a critical review of their analysis and present new and additional data that demonstrate the procedure is not overly restrictive. A primary consideration is the low incidence of seeking board certification among professionals who identify themselves as neuropsychologists (i.e., a low application rate), rather than an overly restrictive process. We describe steps taken to improve the process and conclude that there are numerous areas of agreement with Rohling et al., including the need for ongoing review and continued improvement in the board certification process in all psychological specialties.

Relationship of structural magnetic resonance imaging, magnetic resonance perfusion, and other disease factors to neuropsychological outcome in sickle cell disease

OBJECTIVE

To investigate the relationship between neuropsychological functioning and radiographic findings in children with sickle cell disease (SCD) with no history of clinical neurological events.

METHODS

Thirty-one patients with SCD randomly selected from a regional treatment center underwent neuropsychological and disease severity assessments. Of these, 22 also had structural magnetic resonance imaging and magnetic resonance perfusion studies performed.

RESULTS

Forty-five percent of the imaged subgroup showed imaging abnormalities that were found to be correlated with disease severity but not neuropsychological level of performance indices. A significant relationship, however, was found between imaging abnormalities and increased variability in neuropsychological performance.

CONCLUSIONS

These results corroborate the high rate of rheologic and vascular pathology in SCD and underscore the importance of representing neuropsychological functioning in multiple ways.

Executive Functioning and Memory for the Rey-Osterreith Complex Figure Task Among Community Adolescents

Although there is empirical support for the link between executive functioning (EF) and visual memory among adults, there has been less exploration of this link among children, especially adolescents. We examined the relation between several EF measures and performance on the Rey-Osterrieth Complex Figure (RCF) in a sample of 160 community adolescents. Each was administered the Wisconsin Card Sorting Test (WCST), Conners Continuous Performance Test (CPT), and the RCF, scored using Bernstein and Waber's (1996) Developmental Scoring System (DSS). Ability to organize the RCF related to memory encoding/retrieval, but not to long-term storage. Indexes derived from the WCST and CPT failed to correlate with any RCF index, raising questions about the relation between DSS scores and EF. Even so, data supported the convergent validity of the DSS system as a reflection of visual-constructional ability and provided evidence of the importance of organizational strategies to visual memory among adolescents.

Early exposure to lead and neuropsychological outcome in adolescence

One hundred and ninety-five participants in the Cincinnati Lead Study were neuropsychologically evaluated in mid-adolescence. The neuropsychological measures yielded five factors labeled Memory, Learning/IQ, Attention, Visuoconstruction, and Fine-Motor. Prenatal, Average Childhood, and 78 month blood lead (PbB) levels were used in a series of multiple regression analyses. Following rigorous covariate pretesting and adjustment, a significant main effect of 78 month PbB on the Fine-Motor factor was found (p <.004). Significant interactions were also found between gender and lead exposure parameters for both Attention and Visuoconstruction indicating heightened risk in males. Finally, a trend toward significance was found for the PbB x SES interaction for Learning/IQ, consistent with previous evidence of increased educational and cognitive vulnerability for youth from more disadvantaged backgrounds. These results provide new evidence from the longest continuing prospective study of the remote effects of early lead exposure. They indicate the presence of selective neuropsychological effects in this population, and also that males and females are not uniformly affected. These results also underscore the complexity of models of neurobehavioral development, and the modest predictive power of any single determinant.