Monitoring and Assessment of Neuropsychological Outcomes as a Standard of Care in Pediatric Oncology

Psychometric evaluation of the pediatric applied cognition scale in pediatric hematology/oncology

Pediatric patients with hematology and oncology conditions often experience disease- and treatment-related neurocognitive deficits. Well-validated screening tools are critical for identifying patients experiencing cognitive impairments. The Pediatric Applied Cognition scale (PAC) Short Form, developed by the National Institutes of Health, assesses attention and memory concerns. The current study is the first to examine the psychometrics of the PAC in pediatric patients with hematology/oncology conditions. Pediatric patients (n = 222) and caregivers completed the PAC and self-report measures of psychosocial and academic functioning. Results revealed strong internal consistency for the Child (α = 0.81-0.89) and Parent (α = 0.92-0.95) PAC. More cognitive concerns on the Child/Parent PAC were associated with greater psychosocial concerns (e.g. anxiety, depression, and fatigue) and lower reported school grades. The Parent PAC incrementally predicted child reported symptoms of depression, mobility concerns, and school grades beyond the Child PAC. Overall, the PAC Short Form may be useful as an indicator of general academic and psychosocial concerns. Further research validating the PAC in relation to performance-based neurocognitive outcomes and academic achievement is needed in children treated for hematology/oncology conditions.

Pediatric oncology provider perspectives and practices: Supporting patients and families in schooling after cancer diagnosis

BACKGROUND

Cognitive limitations are common after childhood cancer and require assessment and support in the medical and school setting. Pediatric oncology providers are tasked with educating families about the side effects of disease/treatment, and supporting families as they navigate the associated challenges. Despite this important role, little is known about the training, practice, and knowledge of providers in the domain of cognitive/school impacts.

METHODS

An online survey was emailed to Children's Oncology Group (COG) member physicians in the United States. The survey consisted of 42 questions about training and practice, and 4 knowledge questions about neurocognitive impacts and school supports.

RESULTS

Surveys were completed by 282 physicians representing 64% of COG institutions and a diverse group of experience and institution size. The pediatric oncologist was reported most frequently (93%) as the person at their institution to provide information to families on this topic, yet 54% reported receiving no specific training in this area and the majority (66%) reported to only "somewhat" understand the issues pediatric oncology patients face when returning to school. A minority reported available institutional guidelines (42%) or screening tools (19%) to assist in making referrals or assessments. Knowledge questions concerning health conditions qualifying children for school supports received the fewest correct answers. The majority (77%) thought more training would be helpful.

CONCLUSIONS

Additional training about cognitive impacts and schooling challenges associated with childhood cancer is needed to prepare providers to support parents/children. In addition, establishing policy guidelines and screening procedures may help support providers in providing care.

The contribution of neurocognitive functions to academic and psychological outcomes in pediatric cancer: A latent profile analysis

This study aimed to identify the impact of neurocognitive functioning on academic and psychological domains using a novel person-centered latent profile analysis approach. We further examined the contribution of identified risk factors (e.g., age at diagnosis, treatment) on latent class membership. 101 pediatric oncology patients and survivors (M age = 11.2, 35.6% female; 47.5% African American; M time since diagnosis = 3.4 years) completed neuropsychological evaluations at a university medical center between February 2004 and June 2017. Neurocognitive, academic, and emotional-behavioral functioning were examined using validated measures. Discreet, homogenous neurocognitive subgroups (latent classes) were identified using latent profile analysis. Demographic and medical factors were evaluated as predictors of latent class. A 3-class model indicated excellent class separation (range: .00-.04) and homogeneity (range: .94-.99). Classes were distinguished by differential cognitive patterns. Class 2 (52%) and Class 3 (25%) displayed overall normative functioning; however, Class 3 displayed significantly poorer attention than the other two classes. Class 1 (23%) demonstrated Borderline neurocognitive, low average academic, and poorer emotional-behavioral and inhibition/executive control functioning. Class membership was predicted by race and whole brain radiation dose. Latent profile analysis identified discrete groups in neurocognitive functioning in this heterogeneous pediatric cancer population. Class membership was predicted by race, whole brain radiation dose, and referral source. Other medical variables (e.g., diagnosis, age at diagnosis) were not significant predictors of neurocognitive function in our sample.

The impact of neuroimaging advancement on neurocognitive evaluation in pediatric brain tumor survivors: A review

Pediatric brain tumors are a type of tumors that are commonly present in children and young adults. With the improvement of treatment, the quality of life, especially the cognitive functioning, is gaining increasingly more attention. Apart from cognitive evaluations, neuroimaging studies begin to play an important part in neurocognitive functioning investigation. In this way, the brain tissue changes caused by tumor variables (including tumor location and tumor size) and treatment variables (including surgery, chemotherapy and radiotherapy) can be detected by neuroimaging. Recent advancement of neuroimaging techniques, such as functional-MRI (fMRI) and diffusion tensor imaging (DTI), made great contributions to understanding cognitive dysfunction and quantifying the effects of tumor variables and treatment variables. In recent years, laminar-fMRI provided a potentially valuable tool for examining the exact origins of neural activity and cognitive function. On the other hand, molecular fMRI might guide diagnosis and treatment of brain disease in the future by using new biomarkers, and DTI can detect white matter changes and obtain some anatomically specific information.

[Formula: see text] Reliable change in pediatric brain tumor: A preliminary investigation

Children treated for brain tumor show evidence of declines in general intellectual abilities (i.e., IQ). Group-level data indicate subtle declines over time on average, but no study has utilized a clinical criterion to identify and describe a reliable change in survivors of pediatric brain tumor (PBT). In this study, we discuss the utility of reliable change index (RCI) methodology to supplement group-level analysis (e.g., repeated measures ANOVA). This pilot sample consisted of 22 children (M age = 10.47 years) treated for PBT who completed initial and follow-up assessments (M interval = 23.58 months). Cognitive data included composite scores from the WISC-IV. An RCI z-score was calculated for each participant on each composite score based on two different test-retest reliability coefficients. As a group, survivors of PBT did not demonstrate a statistically significant change from initial to follow-up on any WISC-IV composite score. When RCI was calculated based on reliability coefficients with shorter test-retest intervals provided by the test publisher, 77% of survivors demonstrated a reliable change in performance on at least one measure. The frequency of RCI decreases in working memory was significantly higher than expected. In contrast, only 32% of survivors showed reliable changes on at least one measure when RCI was based on a reliability coefficient derived from a clinical sample with a longer retest interval. This study demonstrates that highly divergent results may be obtained with RCI and the importance of the source of reliability estimates.

Neurodevelopmental and Mental Health Screening for Patients with Turner Syndrome in Pediatric Endocrine Clinics: Results of a Pediatric Endocrine Society Survey

INTRODUCTION

International Turner syndrome (TS) Clinical Practice Guidelines recommend screening for neurodevelopmental (ND) and mental health (MH) concerns in girls with TS; however, it remains unclear whether this is implemented in current practice. The objective of this mixed methods study was to assess screening practices for ND and MH in girls with TS from the perspective of pediatric endocrinologists.

METHODS

Pediatric Endocrine Society members who provide care for girls with TS were invited to complete an electronic survey on screening practices. Descriptive statistics were used to summarize quantitative results concurrently with thematic analysis of free-text survey responses.

RESULTS

A total of 124 surveys were completed (86% attending pediatric endocrinologists, 81% at academic institutions). Overall, 25% of providers reported their patients with TS received both ND and MH screenings. Only 9 (9%) respondents endorsed screening for ND concerns themselves, while more providers (26%) reported they screen for MH concerns. Multiple barriers to screening for ND and MH concerns within the clinical setting were endorsed. Nearly all providers (>93%) reported they would consider using a short, validated screening tool for ND and MH concerns if such tools were available.

DISCUSSION

A minority of pediatric endocrinologists currently perform ND or MH screening for patients with TS, however, many would be interested in implementing a brief screening tool into their clinical practice. Given almost all girls with a TS diagnosis receive care from pediatric endocrinologists at least annually, this may be an effective method to increase the proportion of girls with TS who receive recommended screenings.

Late effects of pediatric brain tumors

PURPOSE OF REVIEW

Adverse late effects of pediatric brain tumors can be numerous and complex and potentially alter the life trajectories of survivors in a multitude of ways. We review these inter-related late effects that compromise neurocognitive function, general health, social and psychological adjustment, and overall adaptive and vocational outcomes, and threaten to undermine the ability of survivors to transition independently into adulthood and effectively manage their care. Intervention/prevention strategies and advances in treatment that may reduce such late effects are discussed.

RECENT FINDINGS

Studies of neuropsychological late effects have revealed specific deficits in core cognitive functions of attention, working memory and processing speed, with many survivors demonstrating decline in working memory and processing speed over time, irrespective of tumor type or treatment. This in turn affects the ongoing development of higher order neurocognitive skills. Research also highlights the increasing burden of health-related, neuropsychological and psychosocial late effects into adulthood and impact across life outcomes.

SUMMARY

Pediatric brain tumor survivors require coordinated interdisciplinary care, ongoing evaluation and management of late effects, and timely interventions focused on mitigating the impact of late effects. The transition to adulthood can be especially vulnerable and addressing barriers to care is of paramount importance.

Cognitive and Psychosocial Development in Young Children with Brain Tumors: Observations from a Clinical Sample

Survivors of pediatric brain tumor (BT) are known to be at risk for developing cognitive and psychosocial late effects. Young age at treatment (≤6 years) is typically considered to put patients at increased risk. However, there is limited research specifically exploring functioning in these young patients. Cognitive and psychosocial data were retrospectively abstracted from medical charts for 79 young patients (54.4% male) treated for BT with a variety of treatment modalities (e.g., surgery, radiation therapy, chemotherapy). Children were clinically assessed at 4.52 years of age (range = 1.48-5.98) and most were off-therapy (74.4%). Mean performances on developmental (68.3 ± 10.02), cognitive (88.09 ± 18.38), and pre-academic (86.84 ± 19.75) measures were all below average. Parent report of adaptive functioning was also below average (82.10 ± 16.21), but psychosocial functioning was generally within normal limits. Most patients had impaired functioning (scores <10th percentile) in at least one domain assessed. Exploratory analyses revealed that many patients (27.3-60.6%) exhibited a significant discrepancy between domains of cognitive functioning (e.g., verbal and spatial). Young children treated for BT experienced high rates of impairment in cognitive, pre-academic, and adaptive domains. Future work is needed to focus on serial longitudinal assessment of these young patients, as well as dedicated intervention and prevention efforts.

Motor functioning and associated cognitive outcomes in pediatric survivors of acute lymphoblastic leukemia

Pediatric acute lymphoblastic leukemia survivors are at risk for developing neurocognitive late effects following intensive medical treatment. Motor impairments have been highlighted as a common neurocognitive late effect, including fine-, gross-, and visual-motor skills. The severity of these motor deficits is variable in the existing literature, warranting additional investigations with more homogenous samples. In addition, there is an even greater paucity regarding the interrelations between motor deficits and the impact motor challenges may have on other domains of functioning, such as academics. Therefore, the present study aimed to characterize motor functioning in children who were treated for acute lymphoblastic leukemia with chemotherapy (n = 13) in comparison to healthy controls (n = 13). Additionally, this study investigated the relationship between primary (e.g., visual-spatial, fine-motor), secondary (e.g., visual-motor), and tertiary (e.g., academics) skills. The results revealed that oncology survivors had significantly lower fine- and gross-motor skills compared to healthy controls. No significant differences were observed between the groups on visual-perception and visual-motor tasks. Fine-motor functioning was significantly associated with visual-motor functioning in ALL survivors. Motor skills were not related to academic outcomes. The present findings provide evidence for motor impairments in pediatric ALL survivors, along with initial findings highlighting the cascading effect of primary motor impairments on other cognitive domains. This research sheds light on the need for clinical screening and intervention of motor skills in the survivorship population. Future research is warranted to examine the effect of motor deficits on cognitive and psychosocial functioning in pediatric oncology.

Topical Review: Pain in Survivors of Pediatric Cancer: Applying a Prevention Framework

Objective

To apply a biopsychosocial framework to understand factors influencing pain in survivors of pediatric cancer to inform pain prevention efforts and highlight the need for interdisciplinary care.

Method

This topical review draws from both pediatric cancer survivorship research and chronic noncancer pain research to illustrate how components of a preventative model can be applied to pain in survivorship.

Results

Pain is a common experience among long-term survivors of pediatric cancer. The pain experience in survivorship can be conceptualized in terms of biological disease and treatment factors, cognitive and affective factors, and social and contextual factors. We review literature pertinent to each of these biopsychosocial factors and tailor an existing public health prevention framework for pain in survivors of pediatric cancer.

Conclusions

Classifying survivors of pediatric cancer into pain risk categories based on their daily experiences of pain, pain-related functional impairment, and distress could help guide the implementation of pain-related prevention and intervention strategies in this population. Future research is needed to establish the efficacy of screening measures to identify patients in need of psychosocial pain and pain-related fear management services, and interdisciplinary pediatric chronic pain management programs in survivors of pediatric cancer.

Brain morphology and information processing at the completion of chemotherapy-only treatment for pediatric acute lymphoblastic leukemia

Background: Approximately 50% of survivors of childhood acute lymphoblastic leukemia (ALL) demonstrate cognitive impairments. However, the trajectory of change and contributing neuropathology is unclear, limiting our ability to tailor intervention content and timing. This study aimed to explore information processing abilities and brain morphology early post-treatment for pediatric ALL. Procedure: Twenty-one children at the end of ALL treatment and 18 controls underwent neuropsychological assessment. A subset also completed structural magnetic resonance imaging. Results: A principal component analysis generated two cognitive factors: information processing capacity and information processing speed. Compared to control group, the ALL group displayed deficits in capacity, but not speed. No group differences were identified in morphology. No relationship was identified between capacity or speed and morphology. Conclusion: Early cognitive intervention should target information processing abilities using a system-wide approach. Future studies should employ alternative imaging techniques sensitive to white-matter microstructure when exploring pathology underlying information processing deficits.

Using the Patient-Reported Outcomes Measurement Information System (PROMIS) to measure symptom burden reported by patients with brain tumors

BACKGROUND

Children with brain tumors can experience symptom burden throughout their disease continuum. The aim of the study was to evaluate symptom burden reported by children with brain tumors and factors that potentially were associated with their symptoms.

METHODS

Data from 199 children with brain tumors aged 7-22 (mean age = 14 years; 52% males; 76% white) were analyzed. Symptom burden was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) via computerized adaptive testing (CAT)-anxiety, depression, fatigue, mobility, upper extremity function, peer relationship, and cognition. Patients and parents completed Symptom Distress Scales (SDS). Test statistics and ANOVA were used to evaluate relationships between PROMIS measures and potentially influential variables.

RESULTS

Significant results (P < 0.01) showing impact of symptom burden included: PROMIS measures correlated with SDSs reported by patients and parents on all comparisons. Fatigue, mobility, and upper extremity function were associated with Karnofsky functional performance status, number of treatment modalities (0-3), and time since last treatment (≤1 year, >1 year). Fatigue and cognition were associated with educational program (regular classroom without an individualized education plan vs those that had an individualized education plan); mobility and upper extremity function were associated with time since last radiation. Mobility, upper extremity function, and anxiety were associated with time since last chemotherapy.

CONCLUSIONS

Significant associations were found between PROMIS and SDS as well as clinical and demographic characteristics. Brief-yet-precise PROMIS CATs can be used to systematically assess symptom burden experienced by children with brain tumors.

Attention-mediated neurocognitive profiles in survivors of pediatric brain tumors: comparison to children with neurodevelopmental ADHD

Background

Attention and working memory symptoms are among the most common late effects in survivors of pediatric brain tumors, and are often associated with academic and psychosocial difficulties. Diagnostic and treatment approaches derived from the literature on attention-deficit hyperactivity disorder (ADHD) have frequently been applied to survivors, yet the extent of overlap in cognitive profiles between these groups is unclear. The objective of the present study is to compare neurocognition in survivors of brain tumors and children with neurodevelopmental ADHD.

Methods

Neuropsychological data were abstracted from clinically referred brain tumor survivors (n = 105, Mage = 12.0 y, 52.4% male) and children with ADHD (n = 178, Mage = 11.1 y, 64.0% male). Data consist of a battery of parent-report questionnaires and performance-based neuropsychological measures.

Results

Twenty-five survivors (23.8%) of pediatric brain tumors met symptom criteria for ADHD. Participants with neurodevelopmental ADHD and survivors who met ADHD criteria had significantly greater parent- (P < 0.001) and teacher-reported (P < 0.001) working memory and behavior regulation difficulties than survivors of tumor who did not meet criteria. Children with ADHD symptoms also performed worse on measures of sustained attention than survivors without ADHD symptoms (P < 0.001). Additionally, survivors with ADHD symptoms had greater performance-based working memory difficulties than either survivors without attention problems or children with neurodevelopmental ADHD (P = 0.002).

Conclusions

Nearly a quarter of survivors with attention symptoms have functional profiles that are similar to children with neurodevelopmental ADHD. They also experience more neurocognitive impairments than survivors without attentional difficulties, particularly in working memory. Screening for ADHD symptoms may help providers triage a subset of individuals in need of earlier or additional neuropsychological assessment.

Maternal stress and pediatric brain cancer: A French study

BACKGROUND

Despite evidence that pediatric cancer induces a trajectory of parental stress, studies including mothers of children with malignant brain tumors remain scarce. The present work aims to add to the scientific literature by evaluating maternal stress with a French translation of the Pediatric Inventory for Parents (PIP) in a population of mothers whose children have been diagnosed with a brain tumor.

PROCEDURE

The mothers of 35 children with malignant brain tumors completed the Pediatric Inventory for Parents (PIP), the State-Trait Anxiety Inventory (STAI) and the Family Assessment Device (FAD) at a mean time since diagnosis of 2.3 years.

RESULTS

The PIP showed good internal consistency and correlated significantly with the STAI and the FAD. Maternal stress scores were higher in younger mothers and in mothers of younger children. Emotional functioning was the most affected domain.

CONCLUSIONS

Emotional stress as assessed by the PIP in mothers of children with malignant brain tumors is considerable, and should be routinely assessed, in order to implement appropriate specific psychosocial interventions when needed.

Neurocognitive and Psychosocial Outcomes in Pediatric Brain Tumor Survivors

The late neurocognitive and psychosocial effects of treatment for pediatric brain tumor (PBT) represent important areas of clinical focus and ongoing research. Neurocognitive sequelae and associated problems with learning and socioemotional development negatively impact PBT survivors' overall health-related quality of life, educational attainment and employment rates. Multiple factors including tumor features and associated complications, treatment methods, individual protective and vulnerability factors and accessibility of environmental supports contribute to the neurocognitive and psychosocial outcomes in PBT survivors. Declines in overall measured intelligence are common and may persist years after treatment. Core deficits in attention, processing speed and working memory are postulated to underlie problems with overall intellectual development, academic achievement and career attainment. Additionally, psychological problems after PBT can include depression, anxiety and psychosocial adjustment issues. Several intervention paradigms are briefly described, though to date research on innovative, specific and effective interventions for neurocognitive late effects is still in its early stages. This article reviews the existing research for understanding PBT late effects and highlights the need for innovative research to enhance neurocognitive and psychosocial outcomes in PBT survivors.

Neurocognitive deficits in children with chronic health conditions

Over 4 million children in the United States suffer from chronic health conditions, including cancer, sickle cell disease, and diabetes. Because of major advances in the early identification and treatment of these conditions, survival rates for these children continue to rise, and the majority now lives into adulthood. However, increases in survival have come with costs related to long-term effects of disease processes and treatments. Foremost among these consequences is impairment in brain development and neurocognitive function that may affect a substantial portion of children with chronic health conditions and follow many into adulthood. Impaired cognitive function may contribute to impairment in educational and occupational attainment, mental health, and quality of life for children with chronic conditions. Despite the significance and scope of this problem, advances in the identification and understanding of neurocognitive problems and the delivery of effective clinical care have been hindered in part because research has been "siloed"-conducted on each chronic condition in isolation. This review examines, for the first time, neurocognitive problems in a selected set of 6 chronic pediatric health conditions-leukemia, brain tumors, sickle cell disease, congenital heart disease, Type 1 diabetes, and traumatic brain injury-to define the magnitude of the problem and identify directions for future research and clinical care. Psychologists from many areas of specialization, including pediatric psychology, educational and school psychology, neuropsychology, behavioral medicine, and adult primary care, are uniquely positioned to contribute to every phase of this work, including research, identification, and intervention. (PsycINFO Database Record

Delivery of care consistent with the psychosocial standards in pediatric cancer: Current practices in the United States

BACKGROUND

With published evidence-based Standards for Psychosocial Care for Children with Cancer and their Families, it is important to know the current status of their implementation. This paper presents data on delivery of psychosocial care related to the Standards in the United States.

PROCEDURE

Pediatric oncologists, psychosocial leaders, and administrators in pediatric oncology from 144 programs completed an online survey. Participants reported on the extent to which psychosocial care consistent with the Standards was implemented and was comprehensive and state of the art. They also reported on specific practices and services for each Standard and the extent to which psychosocial care was integrated into broader medical care.

RESULTS

Participants indicated that psychosocial care consistent with the Standards was usually or always provided at their center for most of the Standards. However, only half of the oncologists (55.6%) and psychosocial leaders (45.6%) agreed or strongly agreed that their psychosocial care was comprehensive and state of the art. Types of psychosocial care provided included evidence-based and less established approaches but were most often provided when problems were identified, rather than proactively. The perception of state of the art care was associated with practices indicative of integrated psychosocial care and the extent to which the Standards are currently implemented.

CONCLUSION

Many oncologists and psychosocial leaders perceive that the delivery of psychosocial care at their center is consistent with the Standards. However, care is quite variable, with evidence for the value of more integrated models of psychosocial services.

Cognitive outcomes among Latino survivors of childhood acute lymphoblastic leukemia and lymphoma: A cross-sectional cohort study using culturally competent, performance-based assessment

BACKGROUND

This study sought to characterize cognitive outcomes among Latino survivors of childhood acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LL).

PROCEDURE

In this cross-sectional cohort study, Latino survivors of ALL (n = 57) and LL (n = 5) aged 6-16 years were pooled and evaluated using validated measures of cognitive, academic, and behavioral function and English language proficiency. Performance was compared with norms using single-sample t-tests.

RESULTS

In this cohort (n = 62, 50% male), mean ages at diagnosis and testing were 4.5 and 10.8 years, respectively; mean time off treatment was 44.7 months. All participants spoke English and over half (57%) identified Spanish as the primary language in the home. Forty-two families (68%) placed in the two lowest Hollingshead socioeconomic status categories. Participants were below average for working memory (P < 0.001). Overall, participants were in the average range, but significantly lower than published norms on domain-specific measures of verbal comprehension (P < 0.001); perceptual reasoning (P = 0.033); processing speed (P = 0.003); visual memory (P < 0.001); visuomotor attention, scanning, and sequencing (P = 0.005); and reading comprehension (P = 0.001). Parents reported concerns with working memory (P < 0.001) and metacognition (P = 0.014).

CONCLUSIONS

Similar to other childhood ALL/LL survivors, overall cognitive function in this Latino sample was relatively preserved but selected deficits were observed. Routine cognitive screening is indicated in this population.

Implementing the psychosocial standards in pediatric cancer: Current staffing and services available

BACKGROUND

Fifteen evidence-based Standards for Psychosocial Care for Children with Cancer and Their Families (Standards) were published in 2015. The Standards cover a broad range of topics and circumstances and require qualified multidisciplinary staff to be implemented. This paper presents data on the availability of psychosocial staff and existing practices at pediatric oncology programs in the United States, providing data that can be used to advocate for expanded services and prepare for implementation of the Standards.

PROCEDURE

Up to three healthcare professionals from 144 programs (72% response rate) participated in an online survey conducted June-December 2016. There were 99 pediatric oncologists with clinical leadership responsibility (Medical Director/Clinical Director), 132 psychosocial leaders in pediatric oncology (Director of Psychosocial Services/Manager/most senior staff member), and 58 administrators in pediatric oncology (Administrative Director/Business Administrator/Director of Operations). The primary outcomes were number and type of psychosocial staff, psychosocial practices, and identified challenges in the delivery of psychosocial care.

RESULTS

Over 90% of programs have social workers and child life specialists who provide care to children with cancer and their families. Fewer programs have psychologists (60%), neuropsychologists (31%), or psychiatrists (19%). Challenges in psychosocial care are primarily based on pragmatic issues related to funding and reimbursement.

CONCLUSION

Most participating pediatric oncology programs appear to have at least the basic level of staffing necessary to implement of some of the Standards. However, the lack of a more comprehensive multidisciplinary team is a likely barrier in the implementation of the full set of Standards.

Parent perspectives on the educational barriers and unmet needs of children with cancer

Childhood cancer challenges academic success and school engagement, yet little research has described these hardships. This study documented parental perspectives of the educational barriers and unmet needs of youth treated for cancer (n = 102). Treatment-related physical sequelae were noted as common problems interfering with school attendance and engagement. One-fourth of parents reported worse academic performance since diagnosis; however, many never had their child evaluated (63.3%) or enacted formalized educational accommodations (55%). Findings reflect educational challenges across the continuum of cancer care and survivorship, and highlight the importance of education of school staff on both acute and long-term effects of cancer treatment.

Family estimates of risk for neurocognitive late effects following pediatric cancer: From diagnosis through the first three years of survivorship

BACKGROUND

Families often express a need for additional information about neurocognitive late effects (NCLE) after a pediatric cancer diagnosis. Therefore, we examined: (i) differences in parent, child, and oncologist estimates of risk for NCLE; (ii) whether the estimates of parents and/or children change over time; and (iii) whether estimates are different for children treated with central nervous system (CNS) directed therapies.

PROCEDURE

Mothers, fathers, and children (initial age: 5-17, self-report: >10) from 258 families reported their perceived likelihood of the child developing "thinking/learning problems" on a visual analog scale (0-100%) at 2 months (T1), 1 year (T2), and 3 years (T3) following cancer diagnosis/relapse. Oncologists estimated the likelihood of NCLE at T1. Children were separated into groups based on CNS-directed treatment (n = 137; neurosurgery, intrathecal chemotherapy, and/or craniospinal radiation) or no CNS treatment.

RESULTS

Mother, father, and child estimates of risk for NCLE were similar to oncologists and to one another around diagnosis (T1). Although there were no significant mean differences, a considerable subset of family members either underestimated their child's risk for NCLE (>40%) or overestimated the risk for NCLE (20%) in comparison to oncologists. At T2 and T3, the estimates of mothers were significantly higher than children. Linear growth curves indicated that mothers' estimates for children with CNS-directed treatment significantly increased throughout the first 3 years of survivorship.

CONCLUSIONS

Considering that accurate understanding of NCLE is essential to seeking appropriate assessment and intervention, healthcare providers should focus on implementing family-based education early in treatment and throughout survivorship care.

Implementing guidelines: Proposed definitions of neuropsychology services in pediatric oncology

Several organizations have published guidelines for the neuropsychological care of survivors of childhood cancer. However, there is limited consensus in how these guidelines are applied. The model of neuropsychology service delivery is further complicated by the variable terminology used to describe recommended services. In an important first step to translate published guidelines into clinical practice, this paper proposes definitions for specific neuropsychological processes and services, with the goal of facilitating consistency across sites to foster future clinical program development and to clarify clinical practice guidelines.

Psychosexual development and satisfaction in long-term survivors of childhood cancer: Neurotoxic treatment intensity as a risk indicator

BACKGROUND

Risk factors for impairment in psychosexual development and satisfaction among adult survivors of childhood cancer are poorly understood. The authors compared psychosexual outcomes between survivors and healthy controls, and tested whether at-risk survivors can be identified by 1) treatment neurotoxicity or 2) diagnosis.

METHODS

A total of 144 young adult survivors of childhood cancer and 144 matched controls completed questionnaires regarding psychosexual development, sexual satisfaction, and satisfaction with relationship status. Survivors were aged 20 to 40 years and were 5 to 34 years after diagnosis. Using medical chart data, survivors were divided into non-neurotoxic (48 survivors), low-dose (36 survivors), and high-dose (58 survivors) neurotoxic treatment groups.

RESULTS

Apart from having fewer lifetime sex partners, survivors did not appear to differ from controls. However, survivors of brain tumors and any survivor who received high-dose neurotoxic treatment reported the lowest rates of achieving milestones of psychosexual development, whereas sexual and relationship status satisfaction were found to be related to relationship status. Neurotoxic treatment intensity further distinguished between survivors of brain tumors with and without psychosexual impairment.

CONCLUSIONS

The intensity of neurotoxic treatment may be a valuable indicator of risk for psychosexual impairment relative to diagnosis alone. Health care providers should assess romantic/sexual problems among survivors at risk and make referrals if needed. Cancer 2017;123:1869-1876. © 2017 American Cancer Society.

Applying the International Classification of Functioning-Children and Youth Version to Pediatric Neuro-oncology

Given the increased survival rates in patients with pediatric central nervous system tumors, late effects such as treatment- and/or illness-related neurologic sequelae as well as neuropsychological deficits and social difficulties have moved into focus in follow-up care. In order to provide personalized treatment recommendations for pediatric brain tumor survivors, it is crucial not only to assess cognitive impairments but also to measure a patient's functional deficiencies, for example, restricted participation in everyday social activities. Thus, this article introduces the International Classification of Functioning-Children and Youth version (ICF-CY) as a conceptual framework for quantifying functional limitations and informing long-term care in pediatric neuro-oncology. A standardized self-report and proxy-report questionnaire for measuring participation is briefly discussed and specific recommendations based on so-called core sets for clinical practice in pediatric neuro-oncology are provided.

Measurement of neurodevelopmental changes in children treated with radiation for brain tumors: what is a true 'baseline?'

OBJECTIVE

To review the various ways in which baseline neuropsychological functioning is measured in the extant literature on pediatric brain tumors, describe the pros and cons of each approach, and increase the awareness of researchers as to the implications of each.

METHOD

We reviewed the literature from 1993 to 2013, and classified studies by baseline approach and explicitness of selection of approach.

RESULTS

There are multiple approaches to operationalizing baseline levels of ability and to assess change from baseline. Each approach has strengths and weaknesses, and selection may depend on the question under investigation. Approaches to baseline estimation varied widely with a trend over time toward reliance on statistical modeling. Researchers were often insufficiently explicit about the reasons for adopting a particular approach. The common use of standardized scores requires caution as they obscure critical inferential limitations about change and magnitude of change. Some viable approaches were infrequently used, such as actuarial prediction formulas. Multiple simultaneous methods akin to theory testing and formal methods of construct validation could enhance scientific yield since all approaches are fallible.

CONCLUSIONS

Estimating baseline neuropsychological functioning is very challenging, particularly when it concerns children in the preschool years. Nevertheless, it is a crucial methodological decision with important implications for the interpretation of research findings that needs to be dealt with explicitly.

Psychosocial Follow-Up in Survivorship as a Standard of Care in Pediatric Oncology

Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory.

Communication, Documentation, and Training Standards in Pediatric Psychosocial Oncology

As part of a larger effort to create standards for psychosocial care of children with cancer, we document consensus and evidence-based data on interprofessional communication, documentation, and training for professionals providing psycho-oncology services. Six databases were searched. Sixty-five articles and six guidelines and consensus-based documents were identified; 35 met inclusion criteria. Data support strong recommendations for standards of care in communication/collaboration, documentation of patient information, and training in pediatric psycho-oncology. These are areas where extensive research is unlikely to be conducted; however, professional expectations and qualifications may be further clarified and strengthened with time.

Standards for the Psychosocial Care of Children With Cancer and Their Families: An Introduction to the Special Issue

Pediatric oncology psychosocial professionals collaborated with an interdisciplinary group of experts and stakeholders and developed evidence-based standards for pediatric psychosocial care. Given the breadth of research evidence and traditions of clinical care, 15 standards were derived. Each standard is based on a systematic review of relevant literature and used the AGREE II process to evaluate the quality of the evidence. This article describes the methods used to develop the standards and introduces the 15 articles included in this special issue. Established standards help ensure that all children with cancer and their families receive essential psychosocial care.