Parental report of everyday cognitive abilities among children treated for acute lymphoblastic leukemia

Compared ratings of everyday cognitive functioning made by parents of leukemic children to ratings made by parents of normal control and learning disabled (LD) children. The leukemic children had been randomly assigned to one of two CNS prophylaxis treatments, one including cranial irradiation and intrathecal methotrexate and another including only intrathecal methotrexate and intermediate dose infusions of methotrexate. Leukemic children were rated significantly worse than controls in areas related to schooling and academic skills. The type of CNS prophylaxis was not discriminated by parent ratings. LD children were rated as significantly worse than either of the two groups in all areas of cognitive functioning. Leukemic and LD children were both rated as having poor academic skills. Leukemic children missed significantly more school than control and LD children, and their poor ratings on academic skills were partially attributed to academic deprivation. These results suggest that studies should control for academic deprivation when evaluating the neuropsychological outcome of CNS prophylactic treatment and that reintegration and normalization programs should be designed to address the intellectual problems resulting from missed academic experiences.

Midazolam premedication for pediatric bone marrow aspiration and lumbar puncture

The ability of midazolam, a benzodiazepine, to reduce the distress associated with lumbar puncture and bone marrow aspiration was examined in 23 children with acute lymphocytic leukemia. Patients were randomized to receive 0.2 mg/kg midazolam HCl or placebo intravenously 3-5 min before the procedures, under double-blind conditions. Based on prior experiences, children in both groups anticipated severe pain from these procedures. Postprocedure pain ratings by patients were markedly reduced in the midazolam but not the placebo group. Both physicians and parents judged the midazolam group as significantly less distressed than controls during and after the procedures. Trained observers recorded significantly fewer pain- and anxiety-related behaviors in the midazolam group immediately before and after, but not during the procedures. The amnestic effects of midazolam, confirmed in a visual recall/recognition test, appear to account for the decreased pain ratings since the behavioral manifestations were similar in the two groups. There were no adverse drug reactions or significant changes in vital signs. Midazolam warrants further investigation as a premedication for painful diagnostic and treatment procedures in children with cancer.

Subtle neuropsychological deficits in children with sickle cell disease

Forty-three children and adolescents (8-16 years old) with sickle cell disease (SCD) and no overt neurologic dysfunction were evaluated with the Wechsler Intelligence Scale for Children-Revised (WISC-R), the Wide Range Achievement Test (WRAT), and an age-appropriate version of the Luria-Nebraska Neuropsychological Battery (LNNB). Thirty similar-aged siblings were controls. WISC-R performance and full-scale IQs were lower (p less than 0.05) for patients than sibling controls. No significant differences were seen on the WRAT. Patients with SCD missed more school days than controls (p less than 0.001) but did not differ from controls in academic performance or the proportion in special education. On the LNNB, scores for patients and controls 13 years and older did not differ. However, young patients had significantly elevated (abnormal) scores compared with controls on the following scales: expressive speech, writing, reading, arithmetic, memory, and pathognomonic. The possibility that subtle neuropsychological deficits in younger patients with SCD reflect either subclinical strokes or a predisposition for strokes merits further investigation in a large multi-institution study.

Preirradiation cisplatin and etoposide in the treatment of high-risk medulloblastoma and other malignant embryonal tumors of the central nervous system: a phase II study

Medulloblastoma, pineoblastoma, and cerebral neuroblastoma are malignant embryonal tumors of the CNS that may demonstrate similar histologic features, a propensity for neuraxis dissemination and sensitivity to radiation therapy and, in certain cases, chemotherapy. To evaluate the activity of preirradiation chemotherapy in such tumors, 11 newly diagnosed children with measurable residual disease and characteristics indicative of poor prognosis were treated postoperatively with cisplatin (CDDP) and etoposide (VP-16). Responses graded on the basis of radiographic findings in areas of either macroscopic residual tumor or metastatic disease included two complete responses (CRs), eight partial responses (PRs), and one stable disease (SD). Acute and subacute toxicity consisted of high-frequency hearing loss in four patients, reversible signs and symptoms of increased intracranial pressure in two patients, and transient neutropenia. Seven of eight patients with high-risk medulloblastoma and two of two with pineoblastoma remain free of tumor progression following neuraxis irradiation at 8 to 48 months postdiagnosis (median, 18 months). CDDP and VP-16 is a highly active drug combination when given before irradiation in children with high-risk medulloblastoma and other malignant embryonal tumors of the CNS, producing objective responses in at least one site of measurable disease in 10 of 11 newly diagnosed patients, including all of five with gross neuraxis dissemination.

Neurodevelopmental status of infants and young children treated for brain tumors with preirradiation chemotherapy

In an effort to reduce the severity of late neurotoxicities associated with cranial irradiation, 14 infants and young children with malignant brain tumors were given preirradiation chemotherapy for 2 to 22 months (median, 8 months). Prospective neurodevelopmental evaluations were routinely conducted and now extend from 35 to 60 months (median, 41 months) postdiagnosis, and 10 to 52 months (median, 31 months) postirradiation in the 12 surviving children. At the initiation of chemotherapy, less than one fourth of the patients displayed normal performance status or mental functioning on age-corrected tests; the majority remained stable or declined while receiving chemotherapy. Declining mental development and adaptive behavior were noted in six patients following radiation therapy with only two patients now functioning in the normal range for age. The analysis suggests that neurodevelopmental progress is a function of multiple factors, including neurologic and sensorimotor deficits associated with the tumor, surgical intervention, and chemotherapy that antedated radiation therapy. This implies that delaying irradiation will not necessarily improve the patients' functional status. Whether the interval of postponement of irradiation evidenced in this sample will translate into an ultimately better quality of life remains unknown. Given the probable interaction of multiple risk factors, well-controlled prospective clinical trials are needed to definitively analyze this issue.

Lorazepam pharmacodynamics and pharmacokinetics in children

We evaluated the effects of low doses of lorazepam on episodic versus long-term memory, attention, and somatic and affective symptoms, as well as its pharmacokinetics, in a group of 16 children aged 2.8 to 14.2 years. Psychologic assessments of each child were performed twice before intravenous administration of lorazepam (0.03 mg/kg), and 1 1/2 hours and 24 hours after lorazepam; there were no significant changes in long-term memory, attention, or somatic symptoms. There was a significant decrease in affective symptoms at 1 1/2 hours (p = 0.011), with a trend toward decreased anxiety at 1 1/2 and 24 hours after lorazepam (p = 0.026 and 0.028, respectively). There was also a selective anterograde amnestic effect in 5 of 16 children after lorazepam (p = 0.06). Mean (+/- SD) lorazepam systemic clearance was 1.3 +/- 0.4 ml/min/kg, with a terminal half-life of 10.5 +/- 2.9 hours and an unbound clearance of 15.9 +/- 5.2 ml/min/kg. A group of healthy adult volunteers who were given lorazepam had a mean systemic clearance of 1.0 +/- 0.4 ml/min/kg, somewhat less than that of the children (p = 0.069). There were no significant differences in any lorazepam pharmacokinetic parameter between those children who did versus those who did not have changes in affective symptoms or amnesia. These data should be helpful in establishing the dose of lorazepam in children, as the drug becomes more widely used as an antiemetic, premedicant, and anticonvulsant agent.

Long-term follow-up of parental adjustment following a child's death at home or hospital

The adjustment of parents whose children had died from cancer 6 to 8 years earlier was assessed using structured interviews and standardized inventories. Forty parents had participated in a home hospice program during the terminal phase of their child's illness whereas 22 were parents of children who died in the hospital. Home care parents reported significantly stronger relationships with spouse and remaining children, firmer religious convictions, more adequate coping abilities, and less residual guilt than non-home care parents. On the Minnesota Multiphasic Personality Inventory (MMPI), non-home care parents exhibited more frequent indications of maladjustment including somatization, depression, and interpersonal problems. The results confirm that the more optimal adjustment of home care parents which was first reported 5 years earlier has been maintained. Support and expansion of pediatric home hospice programs are strongly encouraged in light of the positive results of our longitudinal studies.

Social competence and behavioral adjustment of children who are long-term survivors of cancer

Relatively little is known about the special needs of long-term survivors of childhood cancer or the factors that make this growing population vulnerable to chronic psychologic disorders. We therefore surveyed 183 children who had been treated for cancer at St Jude Children's Research Hospital and were free of the disease for greater than or equal to 2 years after completing therapy. Parental responses to the Child Behavior Checklist, a standardized inventory of social competence and behavioral problems, were analyzed in relation to demographic and medical variables, as well as the children's appearance and functional status. School-related problems and somatic complaints of undetermined origin were increased fourfold relative to age- and gender-adjusted rates for peer groups in the general population. The presence of functional but not cosmetic impairments increased the risk of academic and adjustment problems. An older age at evaluation, treatment with cranial irradiation, and residence in a single-parent household were also associated with an increased risk of psychologic problems. General pediatricians must eventually assume responsibility for the extended follow-up care of children who have survived a malignancy. Their awareness of the high-risk groups described in this report should facilitate more timely identification of problems and referral of the children to appropriate services.

Neuropsychological status of children with acute lymphoblastic leukemia treated for central nervous system relapse

Approximately 10% of children treated with contemporary therapy for acute lymphoblastic leukemia (ALL) will experience an isolated relapse in the central nervous system (CNS). From 5 to 25% of this group will become long-term survivors, but only after additional, more aggressive therapy. A review of the limited number of studies of children surviving treatment for CNS relapse disclosed a strikingly higher incidence of intellectual impairment than was found in similarly treated patients who remain in complete remission. Specific risk factors for this complication included the number of courses of cranial irradiation, a young age at treatment, increasing time since treatment, neuropathological changes apparent on abnormal computed tomography scans of the brain, and seizures. The methodological problems inherent in neurobehavioral research in childhood acute lymphoblastic leukemia are critically reviewed and suggestions for future studies are offered. Children with a CNS relapse should be serially evaluated for psychoeducational performance to facilitate early intervention in cases of learning difficulties.

Cognitive processing of children with Williams syndrome

The Illinois Test of Psycholinguistic Abilities was administered to 22 children with Williams syndrome and to 22 children with non-specific development disabilities, matched for age, sex and global intelligence. Visual processing abilities significantly differentiated the two groups. The children with Williams syndrome had substantially more problems with visual reception, visual closure and visual memory tasks. They appeared to adhere more rigidly than controls to a global deployment of visual attention. Their visual processing difficulties were not related to the level of mental ability. Visual reception, closure and memory scores correctly classified 82 per cent of the children with Williams syndrome and 68 per cent of the controls. Instructional and remedial programs are needed for these children.

Late effects of antileukemic treatment

Increasing numbers of childhood ALL survivors have increased the need to assess the physical and psychosocial functioning of this group in a careful manner. This article reviews data on the frequency and types of second malignancies, structural and functional changes in the central nervous system, endocrine effects on growth and reproduction, and psychosocial aspects of development. Most long-term survivors of ALL do not have serious or life-threatening medical problems; however, medical and psychosocial problems may not be insignificant and may require coordinated management over prolonged periods.

Feasibility and efficacy of preirradiation chemotherapy for pediatric brain tumors

Preirradiation chemotherapy is a potentially important component of combined treatment for brain tumors; however, concerns over its side effects and antitumor activity have impeded its evaluation in clinical trials. To determine the feasibility of administering such therapy to children, we assessed the responses of 38 brain tumor patients (median age, 2 years) to 12 weeks of combination chemotherapy given after surgical resection but before irradiation. Transient myelosuppression was noted in all patients, but was not associated with infections or complications of surgical wounds. The ability of the patients to perform activities of daily life, as rated with the Karnofsky performance scale, was either improved (n = 14) or unchanged (n = 18) at the end of the evaluation period. In the remainder of the group, functional deterioration was clearly related to causes other than drug treatment. Prior chemotherapy did not compromise the delivery of radiation except for a brief interruption of spinal irradiation in 3 patients. Objective responses to chemotherapy, defined as a greater than 50% decrease in tumor masses, occurred in 16 of the 31 patients who had subtotal resections; only 6 patients in the entire group showed disease progression during the 12 weeks of drug administration. We conclude that chemotherapy of the type used in this study is well tolerated and produces beneficial effects in children with brain tumors.

Brain tumors in the very young child. Postoperative chemotherapy in combined-modality treatment

Twelve consecutively diagnosed children with brain tumors, ages 7 to 27 months, were treated by a combined-modality approach featuring aggressive surgical resection followed by chemotherapy and delayed irradiation. Patients received multiple clinical neurologic examinations and psychological evaluations, as well as diagnostic imaging studies, to monitor the efficacy of chemotherapy and toxic effects of therapy. Six of the eight children with residual tumor evident postoperatively on computed tomography scans had objective responses to chemotherapy. The efficacy of chemotherapy was further demonstrated by the lack of disease progression for 7 months or longer in eight children, seven of whom remain free of tumor 19 to 57 months (median, 28 months) from the date of diagnosis. The neurologic status of ten patients improved during treatment. Developmental progress was normal in two, low average in three, and frankly deficient in four of ten children formally evaluated. These results indicate that postoperative chemotherapy, added to a regimen of surgical resection and delayed irradiation, prolong survival with only minimal short term neurotoxicity in the majority of very young children with malignant brain tumors.

Memory function in disease-free survivors of childhood acute lymphocytic leukemia given CNS prophylaxis with or without 1,800 cGy cranial irradiation

Previous studies have found that CNS prophylaxis of children with leukemia, especially young children receiving cranial irradiation, causes neuropsychologic deficits. In the present study, 40 children in continuous complete remission from acute lymphocytic leukemia (ALL) were given a battery of tests to assess memory functioning 5 years after CNS prophylaxis. All children were free of CNS disease at diagnosis and had been randomly assigned to receive CNS prophylaxis with either 1,800 cGy cranial irradiation (CRT) plus intrathecal (IT) methotrexate (MTX) or IT MTX plus intravenous (IV) high-dose MTX (HDMTX). No treatment- or age-related differences were seen on 16 standardized memory measures. However, scores of the combined sample were significantly lower than age-corrected norms on a test of visual-spatial memory and on four scales of verbal memory. Differences in methods or intensity of CNS prophylaxis and study group selection criteria are proposed to explain our findings and to resolve discrepancies with previous reports. The long-term neuropsychological sequelae in these survivors of ALL may be attributable to some common factor, such as the disease itself or systemic and IT chemotherapy.

Psychologic and neurologic function following treatment for childhood temporal lobe astrocytoma

Seven school-aged children treated for temporal lobe astrocytomas with surgical resection and irradiation were prospectively tested to evaluate their intellectual, academic, personality, and neurologic status after therapy. At their most recent follow-up examination, neuropsychologic functioning was adequate in only two patients. The other five children manifested either intellectual deterioration, learning disability, mental retardation, or psychopathology. These deficits were associated with poor postoperative performance status, inadequate seizure control, tumor recurrence, and younger age at diagnosis. No pattern of intellectual, academic, or personality dysfunction emerged in association with left- versus right-hemisphere tumors.

Intellectual and academic achievement status after CNS relapse: a retrospective analysis of 40 children treated for acute lymphoblastic leukemia

We determined the intellectual and academic status of 40 children with acute lymphoblastic leukemia who had experienced a primary isolated relapse in the CNS by analyzing the results of psychoeducational tests administered a median of 6.1 years after the relapse. Mean scores for full-scale IQ (87.5), verbal IQ (86.7), performance IQ (90.3), as well as academic achievement in reading (89.8), spelling (83.9), and mathematics (83.5) were significantly below normal expectations for age. Twenty percent of the group were mentally retarded and were receiving special educational assistance. The best clinical predictors of full-scale IQ were the number of radiation therapy courses, age, and the presence or absence of cerebral pathology as measured by computed tomography (CT). Children who were younger at the time of treatment, who received two courses of radiation therapy, and who had clinical seizures and structural abnormalities of the brain as detected by CT had the poorest psychological outcome. Although the psychoeducational consequences of CNS relapse and its attendant treatment are significant, these must be balanced by consideration of the relatively low probability of long-term survival without aggressive therapy. Recognition of this type of delayed morbidity with systematic surveillance and prompt attempts at rehabilitation may decrease or at least minimize these sequelae.

Serial neuropsychological studies of a child with acute lymphoblastic leukemia and subsequent glioblastoma multiforme

A 10-year-old boy had a right posterior parietal glioblastoma 5 years after completing treatment for acute lymphoblastic leukemia. Interim findings included seizures, leukoencephalopathy, diffuse mineralizing microangiopathy, and abnormal changes in neuropsychological test performance, which, in retrospect, provided information about the location of the tumor. This case highlights unusual sequelae of childhood leukemia and its treatment, as well as the value of neuropsychological procedures in assessing functional status and integrity of the brain.

The subacute effects of CNS prophylaxis for acute lymphoblastic leukemia on neuropsychological performance: a comparison of four protocols

We report an assessment of the intellectual functioning after one year of therapy of 117 children treated for acute lymphoblastic leukemia (ALL) who were assigned to one of four protocols for central nervous systems (CNS) prophylaxis. These protocols were (a) 2400 rad cranial irradiation plus concurrent intrathecal methotrexate (i.t. MTX), (b)i.t. MTX alone, (c) 1800 rad cranial irradiation plus concurrent i.t. MTX, and (d) a protocol for high-risk patients that included intensive systemic chemotherapy plus 2400 rad delayed irradiation. Neuropsychological evaluation consisted of the Wechsler intelligence scales, the Wide Range Achievement Test, and selected tests from the Halstead-Reitan Neuropsychological Battery administered one year after diagnosis. All patients performed in the average range on measures, although the high-risk patients performed marginally worse than did the others. In general, our results do not support previous reports that cranial irradiation results in early adverse neuropsychological sequelae.

Neuropsychologic function in children with brain tumors: III. Interval changes in the six months following treatment

Twenty-six children with primary brain tumors were studied prospectively with regard to their sensorimotor, intellectual, academic, and emotional status. Serial evaluations were conducted after surgery (pre-irradiation) and six months after the completion of radiation therapy. The timing of the second evaluation was chosen so as to antedate the late effects of irradiation. Children over 6 years old displayed significant improvement of intellectual function over time, with only 11% exhibiting deterioration on one or more cognitive parameters. In contrast, 68% of younger children clinically deteriorated in one or more areas of intellectual functioning, with prominent difficulties in memory and selective attention for age. Children under 6 years old with supratentorial tumors were less likely than those with posterior fossa tumors to improve their cognitive performance. At the second evaluation, 23% of the patients were functioning below normal (IQ less than 80) intellectually, with 50% of the younger children and 11% of the older children receiving special educational assistance. Approximately 40-50% of the patients manifested emotional adjustment problems at each evaluation. The results are discussed in terms of the clinical need to follow similar patient populations with formal psychological assessments over time, and in terms of the difficulties involved in defining factors that determine the functional status of children surviving brain tumors.

Treatment of meningeal relapse in childhood acute lymphoblastic leukemia. I. Results of craniospinal irradiation

Fourteen children were treated for isolated meningeal relapse occurring seven to 44 months (median, 14 months) after prophylactic cranial irradiation (2,400 rad/12 fractions) and intrathecal methotrexate (IT MTX, 12 mg/m2 for four doses during cranial irradiation). Eight had "high-risk" acute lymphocytic leukemia with age less than 2 years, white blood cell counts greater than 20,000, or T cell markers. Treatment for central nervous system leukemia included IT MTX (12 mg/m2 twice weekly until clearance of spinal fluid cytology) followed by craniospinal irradiation (CSI, 3,000 rad/20 fractions to the cranium and 1,800 rad/12 fractions to the spine). No maintenance IT MTX was given. Systemic chemotherapy was continued or reinstituted for a minimum of one year after CSI. No instance of second meningeal relapse has occurred. Five patients remain in secondary complete remission 66+, 54+, 36+, 26+, and 24+ months after meningeal relapse. Disease-free survival was limited by marrow relapse in eight patients (2-20 months after CSI) and testicular relapse in one. No acute toxicities were noted with CSI. Myelosuppression occurred in seven patients. Infections within two months of CSI were noted in five. No neurologic sequelae are apparent. Serial neuropsychometric studies in 10 patients revealed a significant decline in mean values on Global IQ scales. Long-term survival with acceptable toxicity is possible following aggressive, prompt treatment of meningeal relapse occurring after prophylactic cranial irradiation. Hematologic relapse remains the major obstacle to long-term disease-free survival.

Neuropsychologic function in children with brain tumors: II. Serial studies of intellect and time after treatment

Serial neuropsychologic studies were performed in 18 children following surgery and irradiation for brain tumors. Initial evaluations (#1) 3-70 months post therapy (median 22 months) revealed subnormal full scale IQ (FSIQ less than 90) in nine. Time elapsed since treatment did not significantly correlate with IQ or memory scores. Second evaluations (#2) 10-23 months after #1 showed FSIQ stability in 12 (67%) and improvement (FSIQ greater than or equal to 10 points higher) in three. Deterioration (FSIQ greater than or equal to 10 points lower) was noted in three, in each case associated with clinically significant neurologic events. Serial memory scores improved in two, remained stable in 10, and declined in six. Third evaluations (#3), 6-23 months after #2, documented FSIQ stability in 8/9 studied and significant, late improvement in one. The effect of age is suggested primarily in memory-oriented functions. Selective attending is abnormal at #1 in 6/9 less than 6 years old at diagnosis, and 1/9 greater than or equal to 6 years. Interval decline in memory scores between #1 and #2 occurred in 5/9 less than 6 years old at diagnosis, and 1/9 greater than or equal to 6 years. The findings support earlier observations of relative declines in intellectual function in this population. Identification of intellectual delays requiring special educational assistance permits learning intervention early in the child's course. Substantial interval improvement apparent in 4/18 children indicates some degree of repair or adaptation with time, likely affected by directed educational programs.