Social competence in childhood brain tumor survivors: a comprehensive review

Cognitive disengagement syndrome (sluggish cognitive tempo) and medical conditions: a systematic review and call for future research

Cognitive disengagement syndrome (CDS, previously referred to as sluggish cognitive tempo) is a unique set of symptoms distinct from ADHD inattentive symptoms that appear to be independently associated with neuropsychological and psychosocial outcomes in community and ADHD-specific samples of youth. However, our understanding of CDS in individuals with chronic or complex medical conditions is limited. The current systematic review is the first to summarize the literature on CDS prevalence rates and associations with neurocognitive and functional outcomes in youth with medical conditions, and to discuss areas of future research to guide clinical intervention. We conducted literature searches across four major databases and included studies assessing prevalence estimates, associations with neuropsychological and/or psychosocial functioning, or predictors of CDS in individuals with chronic or complex medical conditions. Twenty-five studies were identified and retained. Fifteen of sixteen studies reported elevations in CDS symptoms, though findings were mixed in studies comparing mean differences to typically developing youth. Seven studies provided inconsistent evidence for CDS being associated with neuropsychological or academic functioning, with six studies demonstrating consistent effects on psychosocial functioning. Finally, nine studies identified biological and sociodemographic factors associated with CDS, though almost all await replication. CDS symptoms are significantly elevated in youth with medical conditions and appear to be particularly linked with psychosocial functioning. Future research is needed to identify prevalence of CDS across a range of medical conditions, examine associations with neuropsychological and psychosocial functioning, and examine whether CDS impacts self-management.

A systematic review of the efficacy of group social skills interventions on social functioning and social participation in children with acquired brain injury or cerebral palsy

AIM

The aim of this study was to evaluate the efficacy of Group social skills interventions (GSSIs) versus any comparator on social functioning in children aged 5-12 years with acquired brain injury or cerebral palsy.

BACKGROUND

GSSIs are an evidence-based approach to foster social skills development in children with autism spectrum disorder. Currently, limited literature exploring GSSIs in children with acquired brain injury and cerebral palsy is available.

RESULTS

MEDLINE, SCOPUS, Embase, CINAHL, Cochrane Library, PsycINFO, clinicaltrials.gov, ICTRP and ProQuest Dissertations and Theses were systematically searched. Study screening, risk-of-bias, Grading of Recommendations Assessment, Development and Evaluation and data extraction were performed in duplicate. Six studies were included in the narrative synthesis (one randomised controlled trial and five nonrandomised studies). Results indicate that GSSIs may increase children's social skills as measured on the Social Skills Rating System and Social Skills Questionnaire. Very low certainty evidence was found for improvements in social functioning and competence.

CONCLUSIONS

There is low certainty evidence that participation in GSSI may lead to gains in social functioning for children with acquired brain injury or cerebral palsy. Given the certainty of the evidence, these results must be interpreted with caution. Only one randomised controlled trial of GSSIs for children with acquired brain injury was identified, underscoring the need for additional high-quality studies.

Adolescents and Young Adults With Cancer: CNS Tumors

Tumors of CNS are common in adolescents and young adults (AYAs). As the second leading cause of cancer-related death, CNS tumors in AYAs require improved clinical management. In this review, we discussed the current diagnostic approaches and recommended management strategies for malignant tumors in adult-type (IDH-mutant gliomas) and pediatric-type gliomas (pediatric high-grade gliomas), ependymoma and medulloblastoma, which commonly occur in AYAs. The impact of advanced molecular diagnostic approaches on the understanding of tumor biology of AYA CNS tumors is emphasized. To enhance participation in clinical trials, which poses a unique challenge in AYAs with CNS tumors, we propose encouraging referrals to neuro-oncology specialty care and improving collaboration between oncologists who care for both pediatric and adult patients. This will ensure better representation of AYA patients in research studies. Finally, we discussed the importance of considering neurocognitive and psychological function in AYAs with CNS tumor.

Social affective outcomes and brain injury in children and adolescents treated for brain tumours

In this Review we critically evaluate the empirical literature investigating the effect of paediatric brain tumours and their treatment on social affective function. We focus specifically on relations between social affective function and compromised brain structure and function associated with treatment for a paediatric brain tumour. We concentrate on emotion recognition and regulation, because these are core components of social affective function. First, we provide an overview of the literature in typically developing children and discuss the underlying brain networks thought to subserve emotion (ie, limbic system and supporting white matter microstructure). We then focus on how damage to brain structure and function after treatment for a paediatric brain tumour might be related to compromised emotion recognition and regulation-as well as broader social affective outcomes. On the basis of our review of the literature across typically developing children and those with a paediatric brain tumour, we suggest that structural changes to fronto-limbic tracts might interrupt social network neural communication in children and adolescents treated for brain tumours. A critical analysis of the reviewed literature suggests a relationship between social affective dysfunction and childhood-acquired injury to white matter microstructure. We argue that the knowledge synthesised regarding paediatric brain tumours could extend to other neurological disorders. Finally, we identify considerations for future investigation and recommend research practices to be adopted in forthcoming studies to establish causal links between brain structure and function to social affective processes.

Psychosexual Development and Sexual Functioning in Young Adult Survivors of Childhood Cancer

BACKGROUND

Childhood cancer and its treatment can impair survivors' development throughout life, particularly psychosexual development, which can be affected in complex ways and is crucial for survivors' well-being. Yet, research is scarce.

AIM

This study assessed psychosexual development (milestone attainment, age at attainment, perceived timing) in young adult survivors of childhood cancer. It further examined sexual satisfaction and sexual functioning, and whether survivors' perceived timing of sexual debut was related to satisfaction or functioning.

METHODS

A registry-based nationwide survey was completed by N = 492 German survivors of childhood cancer (age 21-26 years, 6-26 years postdiagnosis). They completed standardized measures of psychosexual milestones (eg, first kiss, sexual debut), sexual satisfaction, and sexual functioning. Psychosexual development was compared to normative data (N = 1,533).

OUTCOMES

Psychosexual development, sexual satisfaction, and sexual functioning were the primary outcome measures. Psychosexual development was characterized in three ways: milestone attainment (yes/no), age at attainment, perceived timing ("right" time, too early/late).

RESULTS

Milestone attainment was comparable to normative data, except for sexual debut: Survivors were less often experienced (82.5% vs 88%; P = .002) and older at sexual debut (17.4 vs 16.2 years; g = 0.55), but most survivors (58.3%) perceived their timing as "right." Survivors of brain tumors were least likely to have had their sexual debut, but if experienced age at sexual debut was similar to other survivors. Female survivors were somewhat more experienced than males (eg, first kiss, first relationship; <10% difference), but they were somewhat older when they first kissed (g = 0.26). Age at diagnosis was unrelated to milestone attainment. Perceived early/late sexual debut was related to lower satisfaction in female survivors (P = .026), but unrelated to sexual dysfunction. Instead, partnered men reported particularly low dysfunction whereas women reported similar levels of sexual dysfunction irrespective of their relationship status (P = .049). Overall, sexual functioning was favorable (60.2%: not/barely problematic).

CLINICAL IMPLICATIONS

Most survivors reported favorable sexual satisfaction and functioning, but a minority of survivors may need supportive services.

STRENGTHS & LIMITATIONS

This project represents one of few large-scale studies on psychosexual development in childhood cancer survivors relative to normative data, and is the first to link development to sexual satisfaction/functioning. Assessing satisfaction/functioning with validated, but brief measures limits detailed insights, but was inclusive of any sexual orientation. Medical background information based on registry data was limited.

CONCLUSION

Results showed normative psychosexual development (except for sexual debut) in most survivors. A self-determined attitude toward sexuality (ie, engaging in sexual activities at the "right" time) may generally determine positive sexual experiences.

The Influence of Socioeconomic Status (SES) and Processing Speed on the Psychological Adjustment and Wellbeing of Pediatric Brain Tumor Survivors

Simple Summary

Processing speed (PS) is one of the most impaired functions in pediatric brain tumor survivors (PBTSs) and it has been linked to difficulties in their psychological functioning, together with other non-insult-related risk factors, such as socio-economic status (SES). Given the psychological adjustment difficulties observed in PBTS, the aim of the current study was to explore the relationship between SES and psychological functioning, measured with the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire, and considering the contribution of PS as a mediator. The results demonstrated that the influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the SES–internalizing problems relationship but not on the SES–externalizing problems relationship. These findings suggest that PS may be a rehabilitation target to prevent psychological distress and should be addressed, especially for PBTSs who live in a disadvantaged situation.

Abstract

(1) Background: The relationship between processing speed (PS) and psychological adjustment in the healthy population is well established, as is that between low socio-economic status (SES) and psychological distress. While PS is one of the most impaired functions in pediatric brain tumor survivors (PBTSs), previous research has demonstrated that low SES may be a predictor of increased psychosocial risk in PBTSs. Given the psychological adjustment difficulties observed in PBTS, in the current study we aimed to explore the relationship between SES and psychological functioning, considering the contribution of PS as a mediator. (2) Methods: demographic and clinical data of 80 children (age range: 4–17 y.o.) were retrospectively collected. Psychological measures were the parent-compiled versions of the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire (SDQ). Mediation analysis models were performed on psychological measures with and without the inclusion of covariates. (3) Results: The influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the relationship between SES and internalizing problems but not on the relationship between SES and externalizing problems. (4) Conclusions: The results suggest that PS may be a rehabilitation target for the prevention of psychological distress and should be addressed especially for PBTSs who live in a disadvantaged situation.

Cognitive predictors of social adjustment in pediatric brain tumor survivors treated with photon versus proton radiation therapy

BACKGROUND

Pediatric brain tumor survivors are at risk for poor social outcomes. It remains unknown whether cognitive sparing with proton radiotherapy (PRT) supports better social outcomes relative to photon radiotherapy (XRT). We hypothesized that survivors treated with PRT would outperform those treated with XRT on measures of cognitive and social outcomes. Further, we hypothesized that cognitive performance would predict survivor social outcomes.

PROCEDURE

Survivors who underwent PRT (n = 38) or XRT (n = 20) participated in a neurocognitive evaluation >1 year post radiotherapy. Group differences in cognitive and social functioning were assessed using analysis of covariance (ANCOVA). Regression analyses examined predictors of peer relations and social skills.

RESULTS

Age at evaluation, radiation dose, tumor diameter, and sex did not differ between groups (all p > .05). XRT participants were younger at diagnosis (XRT M = 5.0 years, PRT M = 7.6 years) and further out from radiotherapy (XRT M = 8.7 years, PRT M = 4.6 years). The XRT group performed worse than the PRT group on measures of processing speed (p = .01) and verbal memory (p < .01); however, social outcomes did not differ by radiation type. The proportion of survivors with impairment in peer relations and social skills exceeded expectation; χ² (1) = 38.67, p < .001; χ² (1) = 5.63, p < .05. Household poverty predicted peer relation difficulties (t = 2.18, p < .05), and verbal memory approached significance (t = -1.99, p = .05). Tumor diameter predicted social skills (t = -2.07, p < .05).

CONCLUSIONS

Regardless of radiation modality, survivors are at risk for social challenges. Deficits in verbal memory may place survivors at particular risk. Results support monitoring of cognitive and social functioning throughout survivorship, as well as consideration of sociodemographic risk factors.

Pediatric Brain Tumor Survivors' Understanding of Friendships: A Qualitative Analysis of ADOS-2 Interview Responses

BACKGROUND

Pediatric brain tumor survivors (PBTS) are at risk of experiencing social competence challenges, but only a limited number of studies have used a qualitative approach to understand their social relationships. We examined PBTS responses to social interview questions within the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2), which includes questions related to their understanding of their own relationships, as well as the construct of friendship more generally.

METHODS

Twenty-four PBTS (ages 9-17 years; M = 14.2 years from diagnosis; 50% male; 42% received radiation treatment) completed the ADOS-2. ADOS-2 social interview responses were recorded and transcribed verbatim. Themes were derived using an inductive thematic analysis approach.

RESULTS

PBTS reported that they considered trust, acceptance, respect, emotional support, and spending time together to be important aspects of friendships in general. When describing their own social relationships, some PBTS noted a lack of intimacy or closeness, spending time with their friends almost exclusively at school, with structured activities outside of school being an additional basis for friendship. Challenges to their social relationships included loneliness and reliance on family for social support, experiences of teasing and bullying, social skills deficits, and lack of insight into social situations.

CONCLUSION

Although PBTS were able to acknowledge many important qualities of friendships in general (e.g., trust, emotional support), these were not necessarily reported in their own friendships. PBTS also appeared to have difficulty identifying whether someone was their friend. These findings offer potential opportunities for supporting PBTS in achieving friendships consistent with their conception of this important relationship.

Psychiatric disorders in childhood cancer survivors in Denmark, Finland, and Sweden: a register-based cohort study from the SALiCCS research programme

BACKGROUND

A childhood cancer diagnosis and treatment-induced somatic late effects can affect the long-term mental health of survivors. We aimed to explore whether childhood cancer survivors are at higher risk of psychiatric disorders later in life than their siblings and the general population.

METHODS

In this register-based cohort study (part of the Socioeconomic Consequences in Adult Life after Childhood Cancer [SALiCCS] research programme), we included 5-year survivors of childhood cancer diagnosed before 20 years of age between Jan 1, 1974 and Dec 31, 2011, in Denmark, Finland, and Sweden. In Denmark and Sweden, 94·7% of individuals were born in a Nordic country (ie, Denmark, Finland, Iceland, Norway, or Sweden); similar information was not available in Finland. Data on ethnicity were not collected. Survivors were compared with their siblings and randomly selected individuals from the general population who were matched to the survivors by year of birth, sex, and geographical region. We followed up our study population from 5 years after the childhood cancer diagnosis or corresponding calendar date for matched individuals (the index date) until Aug 11, 2017, and assessed information on hospital contacts for any and specific psychiatric disorders. For siblings, the index date was defined as 5 years from the date on which they were of the same age as their sibling survivor when diagnosed with cancer.

FINDINGS

The study population included 18 621 childhood cancer survivors (9934 [53·3%] males and 8687 [46·7%] females), 24 775 siblings (12 594 [50·8%] males and 12 181 [49·2%] females), and 88 630 matched individuals (47 300 [53·4%] males and 41 330 [46·6%] females). The cumulative incidence proportion of having had a psychiatric hospital contact by 30 years of age between Jan 1, 1979, and Aug 11, 2017, was 15·9% (95% CI 15·3-16·5) for childhood cancer survivors, 14·0% (13·5-14·5) for siblings, and 12·7% (12·4-12·9) for matched individuals. Despite a small absolute difference, survivors were at higher relative risk of any psychiatric hospital contact than their siblings (1·39, 1·31-1·48) and matched individuals (hazard ratio 1·34, 95% CI 1·28-1·39). The higher risk persisted at the age of 50 years. Survivors had a higher burden of recurrent psychiatric hospital contacts and had more hospital contacts for different psychiatric disorders than their siblings and the matched individuals.

INTERPRETATION

Childhood cancer survivors are at higher long-term risk of psychiatric disorders than their siblings and matched individuals from the general population. To improve mental health and the overall quality of life after childhood cancer, survivorship care should include a focus on early signs of mental health problems, especially among high-risk groups of survivors.

FUNDING

NordForsk, Aarhus University, Swedish Childhood Cancer Foundation, Danish Health Foundation, and Swiss National Science Foundation.

Health-related quality of life in long-term survivors of childhood brain tumors: a population-based cohort study

PURPOSE

Survivors of childhood brain tumors (BT) are at high risk for long-term physical and psychological sequelae. Still, knowledge about health-related quality of life (HRQL) and associated factors in this population is sparse. This study investigated HRQL and its predictors in long-term survivors of childhood BT.

METHODS

Survivors of childhood BT (mean age = 28.1 years, SD = 6.8, n = 60) underwent clinical examination and neurocognitive examination, and completed self-rating questionnaires assessing HRQL (RAND-36) and depressive symptoms (Beck Depression Inventory-II). Socio-demographic information was gathered via a questionnaire. Tumor- and treatment-related information was collected from medical records. Control group data were collected from age-matched controls (n = 146) without a history of cancer, randomly selected from the local population registry. Multiple linear regression models were used to investigate predictors of HRQL; separate models were fitted for each domain of the RAND-36.

RESULTS

Male survivors (mean age = 27.0, SD = 6.0, n = 39) reported significantly lower HRQL than male controls in the domains of physical functioning, general health, vitality, social functioning, and role limitations-emotional. Female survivors (mean age = 30.2 years, SD = 7.6, n = 21) reported comparable levels as female controls in all domains except physical functioning. A higher burden of late effects, not working/studying, being diagnosed with BT during adolescence, and reporting current depressive symptoms were significant predictors of lower HRQL.

CONCLUSION

Our results highlight that male survivors of childhood BT are at particular risk of impaired HRQL. Also, results point to the close relation between symptoms of depression and impaired HRQL in survivors of childhood BT which should be acknowledged by long-term follow-up care.

"I'm With my People!": Perceived Benefits of Participation in a Group Social Skills Intervention for Children and Adolescent Survivors of Brain Tumors

BACKGROUND

Children and adolescent survivors of brain tumors may experience impairments in social competence.

OBJECTIVE

This qualitative randomized controlled substudy aimed to investigate the outcomes of a social skills intervention group by interviewing these children and adolescents and their caregivers following group participation.

INTERVENTIONS/METHODS

Children and adolescents were randomized to the Social Skills Intervention Program or the attention control group. Using purposive sampling, 12 patients (average age, 11.42 years) and 12 caregivers were interviewed following group participation. The Social Skills Intervention Program consists of eight 2-hour manualized sessions delivered weekly; each session was structured around a social skill (eg, making friends, bullying) through arts and crafts and cognitive-behavioral strategies. The sessions in the control group were structured around daily themes (eg, summer activities) doing arts and crafts. Interviews were analyzed using content analysis.

RESULTS

Themes unique to the intervention program included improved self-control and self-acceptance, reduced feelings of sadness, and improved problem solving. Themes common to both groups included group bonding over similar experiences, increased social confidence with peers and family, and reduced acting out.

CONCLUSIONS

This study uncovered additional unique intervention effects not captured by quantitative measures: improved self-control and problem solving and benefits of the group experience in general.

IMPLICATIONS FOR PRACTICE

Findings support the need for group socialization opportunities for children with brain tumors. Nurses can promote socializing opportunities for children and adolescent survivors of brain tumors during and after medical treatment ends to prevent social competence deterioration.

Bridging the Gap: Exploring the Impact of Hospital Isolation on Peer Relationships Among Children and Adolescents with a Malignant Brain Tumor

Children and adolescents with complex medical conditions are often uprooted from their environments and isolated in hospital while undergoing treatment. Little is known about how they perceive this isolation and its subsequent impact on their relationships with peers, both during and after isolation for treatment. This study describes the experience of hospital isolation from the perspectives of children and adolescents with a malignant brain tumor. The use and impact of information and communication technologies (ICT) as a possible bridge for contact is also explored. Following a qualitative approach utilizing interpretive phenomenological analysis, in-depth interviews were conducted with eight youth participants who had undergone treatment for medulloblastoma. Data analysis generated three main themes: (1) transforming children and relationships, (2) hospitalization in a digital world, and (3) ICTs as a promising bridge back to school. Study findings provide insight into the experience of hospital isolation for children and adolescents, while highlighting the positive social as well as academic outcomes of frequent, open ended ICT use throughout hospital isolation. This is timely, given the context of the COVID-19 pandemic and its resulting isolation. Considerations for hospital social workers to promote relationships and connection, while facilitating a smooth transition as these children return to school are included.

Assessing neuropsychological phenotypes of pediatric brain tumor survivors

INTRODUCTION

Pediatric brain tumor survivors (PBTS) are at risk for both neurocognitive impairments and psychological difficulties, yet these two domains have historically been discretely examined, with assessment of psychosocial outcomes rarely included in studies of cognitive outcomes. Taking a person-centered approach, the current study aimed to more comprehensively evaluate PBTS late effect profiles, including both neurocognitive and psychological sequelae, and predictors of these profiles.

METHOD

PBTS (N = 89) were assessed in a pediatric neuropsychological clinic between May 2009 and May 2018, diagnosed at least 1 year prior, and off-treatment for at least 3 months (M_age  = 6.57 years, SD = 4.53; 46.1% female). Parent- and teacher-report of psychological symptoms, and performance-based measures of neurocognitive functioning were examined using latent profile analysis. The R3STEP procedure identified predictors of class membership.

RESULTS

The optimal model identified four classes characterized by: (1) average functioning across all measures ("Average," n = 47), (2) average psychosocial functioning and impaired neurocognitive functioning ("Cognitive Deficit," n = 25), (3) elevated social problems and significant neurocognitive impairments ("Social/Cognitive Deficit," n = 9), and (4) impaired visual planning and problem-solving and elevated parent-reported psychosocial problems, but average processing speed, working memory, and teacher-reported psychosocial outcomes ("Discrepant," n = 8). Ethnicity, race, radiation treatment, and diagnoses of neurofibromatosis 1, hydrocephalus, and cerebellar mutism syndrome were significant predictors of class membership (ps < 0.05).

CONCLUSION

The present study identified distinct phenotypes with unique patterns of relations among neurocognitive and psychological domains. These findings are a vital first step toward identifying those at highest risk for poor outcomes and informing interventions that effectively address interrelated treatment targets for specific groups.

Return to play after brain tumor surgery in children

PURPOSE

Children with a history of brain tumors do not appear to be at a significantly higher risk of sports-related injuries. Nevertheless, according to the systematic review and survey conducted by Perreault et al., 75% of healthcare professionals restrict their patients' participation in physical activities after brain tumor surgery. The aim of our study was to verify whether children after brain tumor surgery return to physical education (PE) classes. It was also an attempt to explore factors limiting return to physical activity.

METHODS

Patients after brain tumor surgery, ≤ 18 years old on admission with ≥ 1 year follow-up were included in the analysis. Data concerning the disease were collected and summarized in search of factors limiting return to physical activity. Meticulous information about return to sports and physical education at school was gathered during follow-up visits.

RESULTS

71.43% of patients returned to school sports activities. Children who did not return to PE had markedly higher neoplasm WHO grade. Significant differences were also found between the groups in terms of hydrocephalus occurrence and need for additional oncological treatment. In univariate analysis, we identified neoplasm WHO grade, tumor location, presence of neurological deficit after the procedure, additional oncological treatment, and occurrence of hydrocephalus needing shunting as the risk factors for not returning to school physical education.

CONCLUSIONS

The majority of pediatric brain tumor survivors return safely to physical education. Higher neoplasm WHO grade, presence of neurological deficit after the procedure, additional oncological treatment, and occurrence of hydrocephalus are risk factors for not returning to physical education.

A Novel Approach to Understanding Social Behaviors in Pediatric Brain Tumor Survivors: A Pilot Study

BACKGROUND/OBJECTIVES

Pediatric brain tumor survivors (PBTS) are at risk of experiencing challenges in social adjustment. However, the specific social behaviors of PBTS have rarely been directly assessed. This pilot study explores the first novel use of the Autism Diagnostic Observation Schedule, second edition (ADOS-2), to evaluate the social behaviors of PBTS.

METHODS

Twenty-six PBTS (ages 9-17 years; M = 7.8 years from diagnosis; 52% male; 41% received radiation treatment) completed the ADOS-2. The proportion of the sample experiencing impairment was examined descriptively across all items of the ADOS-2, as well as by a summary "overall score" created for this study, and using the ADOS-2 "diagnostic algorithm" scores for autism. Social adjustment, cognitive, medical, and demographic variables were explored as correlates of the ADOS-2 "overall score".

RESULTS

Study recruitment was 34%, impeded by distance from the tertiary-care center. The percentage of PBTS experiencing detectable impairments ranged from 0% to 50% across ADOS-2 items. Cranial radiation treatment, lower IQ, and slower cognitive processing were associated with higher impairment on the ADOS-2 "overall score".

CONCLUSION

The ADOS-2 can be used to assess the discrete social behaviors of PBTS. This study provides a foundation for future investigations using the ADOS-2 to assess social behaviors in this population. Identifying specific social behavior difficulties in PBTS is key to refining much needed targeted social skills interventions for this population.

Parents' perception of their children's process of reintegration after childhood cancer treatment

Our objective was to further the understanding of the process of reintegration of childhood cancer patients after treatment and to identify factors influencing that process. Using a qualitative approach, we conducted 49 interviews with parents (n = 29 mothers, n = 20 fathers) from 31 families with a child (<18 years) with leukemia or CNS tumor. Interviews were conducted about 16 to 24 months after the end of the treatment. We used a semi-structured interview guideline and analyzed the data using content analysis. Average age of pediatric cancer patients was 5.5 years at the time of diagnosis; mean time since diagnosis was 3.5 years. Parents reported immediate impact of the disease on their children. Reintegration had gone along with delayed nursery/school enrollment or social challenges. In most cases reintegration was organized with a gradual increase of attendance. Due to exhaustion by obligatory activities, reintegration in leisure time activities was demanding and parents reported a gradual increase of activity level for their children. Parents described several barriers and facilitators influencing the reintegration process into nursery/school and leisure time activities (structural support, social support, health status, intrapersonal aspects). Although many children reintegrate well, the process takes lots of effort from parents and children. Childhood cancer survivors and their families should be supported after the end of intensive treatment to facilitate reintegration.

Psychological adjustment outcomes among pediatric brain tumor survivors: A meta-analysis

BACKGROUND

Pediatric brain tumor survivors (PBTS) are at significant risk for psychological adjustment difficulties, including greater depressive and anxious symptomology. Systematic reviews have identified this heightened risk among youth with medical conditions, but these reviews have not been specific to PBTS. Therefore, the current study aimed to directly examine the psychological adjustment of PBTS as compared to healthy peers.

PROCEDURE

A systematic review and meta-analysis was conducted using PubMed, PsychInfo, and Academic Search Premier databases. The search yielded 2833 articles, with 22 articles meeting inclusion criteria.

RESULTS

A statistically significant overall medium effect size (Hedge's g = 0.32) indicated that PBTS exhibited poorer overall psychological adjustment relative to healthy comparison groups. Studies that included younger children were associated with larger between-group differences. When evaluating specific outcomes, PBTS had relatively higher levels of depressive symptoms (Hedge's g = 0.36), anxious symptoms (Hedge's g = 0.11), and general distress (Hedge's g = 0.22), but not more externalizing problems.

CONCLUSIONS

The present study confirmed that PBTS are indeed at greater risk for psychological adjustment difficulties relative to healthy comparison groups. These findings highlight the importance of psychosocial screening among this population. Given that depressive symptoms were the most elevated relative to healthy peers, investigation of such symptomatology among PBTS is particularly important.

Symptom burden trajectories experienced by patients with brain tumors

BACKGROUND

Survivors of childhood brain tumors experience persistent health concerns across their lifespan. In the current study, the authors evaluated changes in symptom burden over the course of 12 months using pediatric Patient-Reported Outcomes Measurement Information System (PROMIS) measures.

METHODS

Data from 202 survivors aged 8 to 21 years and 262 parents of survivors who were aged 5 to 21 years were analyzed. All completed a PROMIS Cognition short form and computerized adaptive tests of pediatric Anxiety, Depressive Symptoms, Fatigue, Mobility, Upper Extremity Function, and Peer Relationships. Approximately one-half of participants (223 participants: 97 survivors of childhood brain tumors and 126 parents) completed the 12-month follow-up. Linear mixed-effects models evaluated group-level symptoms over time. Cox proportional hazard models explored whether symptoms predicted survival, and latent class growth analysis investigated patterns of individual-level symptom changes over time.

RESULTS

Linear mixed-effects models demonstrated that patient-reported Cognition and parent-reported Anxiety worsened over time. Latent class growth analysis results indicated that patient and parent reports diverged, both with regard to the number of classes identified and in the trends of these classes. Parents and patients reported similar patterns of depression over time. For the other areas, parents either were more likely to observe different patterns (Peer Relationships and Mobility) or less likely to observe different patterns (Upper Extremity Function, Cognition, Anxiety, and Fatigue). Baseline patient-reported Mobility and Upper Extremity Function were found to be associated with survival.

CONCLUSIONS

Survivors of childhood brain tumors demonstrated different trajectory patterns of symptom burden. Along with baseline functioning status and days since treatment, patient-reported Mobility and Upper Extremity Function were associated with survival, suggesting a possible role for patient-reported outcomes in clinical care, especially individualized, tailored assessments such as PROMIS.

Profiles of perceived social functioning in adolescent and young adult survivors of childhood cancer

OBJECTIVES

Social interaction and peer relationships are critical for development, especially for adolescents and young adults (AYA). Cancer treatment may disrupt social functioning and impact quality of life. Prior research into AYA social functioning has primarily been qualitative in nature or assessed via broad measures of functioning. Given the multi-dimensional nature of social functioning, and its importance for AYA, a person-centered approach to analyses is needed.

METHODS

AYA survivors of childhood cancer, ages 13 to 23 (n = 192, 51% male) and at least 1 year post-treatment (M = 7.35 ± 4.18 years post), completed measures to assess perceived social functioning, social support, and positive and negative affect. Caregivers also completed a measure of social functioning. Latent profile analysis was used to empirically derive profiles of perceived social functioning using the self-perception profile for adolescents (SPPA).

RESULTS

A 3-class solution provided the best fit to the data: 58.9% average, 33.7% high, and 7.5% low functioning. The average group reported mean scores that were similar to normative values available in the SPPA manual. Demographic and medical factors were unrelated to class membership. Social support and positive/negative affect differed significantly by class; caregiver-report of social functioning did not.

CONCLUSIONS

Overall, the majority of AYA survivors of childhood cancer are doing well socially, with perceived adequate social functioning associated with both high levels of social support as well as greater perceptions of positive affect. Future work is needed to elucidate longitudinal trajectories of social functioning, as well as to identify and intervene with those survivors who are struggling.

Behavioral outcome among survivors of childhood brain tumor: a case control study

BACKGROUND

Advances in the treatment of childhood brain tumors have significantly improved survival rates. With improved survival rates, long-term treatment-related toxicities have become important, and the resulting complications can affect patients' emotion and behavior. This study aimed to 1) evaluate behavioral outcomes among survivors of childhood brain tumors, 2) compare behavioral outcomes among survivors of childhood brain tumors with survivors of childhood leukemia and healthy children, and 3) determine any demographic, disease, and/or treatment-related factors that could affect the behavioral outcomes of survivors of childhood brain tumors.

METHODS

A comparative cross-sectional study was conducted over a period of 1 year (June 1st, 2018-May 31st, 2019) in two tertiary referral centers in Kuala Lumpur, Malaysia. Thirty-eight survivors of childhood brain tumors aged 6 to 18 years old who had been off-treatment for at least 1 year and were in remission, 38 age- and gender-matched survivors of childhood leukemia who had been off-treatment for at least 1 year and were in remission, and 38 age- and gender-matched unrelated healthy children were recruited. The Child Behaviour Checklist (CBCL) parent report and Youth Self-Report (YSR) questionnaires were used to assess behavioral outcomes.

RESULTS

Survivors of childhood brain tumors showed statistically significantly worse behavioral outcomes than healthy children for social problems and attention problems (p < 0.05, respectively). A significantly worse outcome was found for "social problems" (p < 0.05) in survivors of childhood brain tumors compared to survivors of childhood leukemia. Significant associations were also found between physical disability, visual impairment, education level of survivors, and father's occupation and behavioral outcomes among survivors of childhood brain tumors.

CONCLUSIONS

Survivors of childhood brain tumors in our center showed poor behavioral outcomes for social problems and attention problems. Thus, effective psychosocial support interventions tailored to individual patients as soon as treatment is completed are important to prevent potentially debilitating emotional problems.

Social competence in newly diagnosed pediatric brain tumor patients

Brain tumors (BTs) are a common pediatric malignancy. Improved treatment has resulted in higher survival rates. There is, however, increasing concern about adverse effects of the disease and its treatment, including effects on social competence (i.e. effective social functioning in everyday life). The aim of this study is to examine multiple levels of social competence (i.e. social skills and social adjustment) in newly diagnosed pediatric BT patients. Thirty newly diagnosed BT patients aged 5-12 years were assessed shortly after diagnosis with a neuropsychological test battery focusing on social competence, including tests for IQ, social skills (i.e. social-affective and executive functioning) and social adjustment (rated by parents and teachers). Their performance was compared to 95 healthy controls who completed the same assessment. Patients and healthy controls were largely comparable with regard to demographic and environmental factors and did not differ on measures of IQ, social skills and social adjustment. Furthermore, age was found to have a positive significant effect on social skills independent of group. Shortly after diagnosis, pediatric BT patients did not perform different from healthy controls on IQ and measures of social skills and social adjustment. This is an encouraging finding. However, because of potentially neurotoxic adjuvant therapy and the ongoing development of social skills, longitudinal follow-up studies are needed to investigate long-term outcome regarding social competence in BT survivors.

Diminished social attention in pediatric brain tumor survivors: Using eye tracking technology during naturalistic social perception

OBJECTIVE

The etiology of pediatric brain tumor survivor (PBTSs) social difficulties is not well understood. A model of social competence for youth with brain disorder and evidence from youth with autism spectrum disorder (ASD) suggests that diminished social attention may underlie social deficits in PBTSs. This study used eye tracking technology to compare visual social attention in PBTSs, youth with ASD, and typically developing (TD) youth.

METHODS

Participants included 90 age-, gender-, and IQ-matched youth (N = 30 per group). PBTSs were at least 5 years from diagnosis and 2 years from the completion of tumor-directed therapy. Participants' eye gaze patterns were recorded while watching an established social play paradigm that presented videos of children engaging in either interactive or parallel play. Group differences in proportional gaze duration toward social versus nonsocial areas of interest were compared. Medical correlates of social attention in PBTSs were evaluated.

RESULTS

Groups significantly differed in gaze preference across conditions, with PBTSs looking less at social areas of interest than TD youth and in a manner comparable to youth with ASD. Among PBTSs, multimodal tumor-directed therapy was associated with reduced gaze preference for faces.

CONCLUSIONS

This study provides the first evidence of disrupted social attention in PBTSs, with parallels to the social attention deficits observed in ASD. Findings offer a new way to conceptualize the social difficulties of PBTSs and could guide interventions aimed at improving PBTS social adjustment by increasing visual attention to socially relevant information during social interactions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

PROMIS Peer Relationships Short Form: How Well Does Self-Report Correlate With Data From Peers?

Objective

To examine the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS®) peer relationships short form (PR-SF), including association with peer-reported friendships, likeability, and social reputation.

Method

203 children (Mage = 10.12 years, SD = 2.37, range = 6-14) in Grades 1-8 completed the 8-item PR-SF and friendship nominations, like ratings, and social reputation measures about their peers during 2 classroom visits approximately 4 months apart, as part of a larger study. A confirmatory factor analysis, followed by an exploratory factor analysis, was conducted to examine the factor structure of the PR-SF. Spearman correlations between the PR-SF and peer-reported outcomes evaluated construct validity.

Results

For the PR-SF, a 2-factor solution demonstrated better fit than a 1-factor solution. The 2 factors appear to assess friendship quality (3 items) and peer acceptance (5 items). Reliability was marginal for the friendship quality factor (.66) but adequate for the acceptance factor (.85); stability was .34 for the PR-SF over 4 months. The PR-SF (8 items) and acceptance factor (5 items) both had modest but significant correlations with measures of friendship (rs = .25-.27), likeability (rs = .21-.22), and social reputation (rs = .29-.44).

Conclusions

The PR-SF appears to be measuring two distinct aspects of social functioning. The 5-item peer acceptance scale is modestly associated with peer-reported friendship, likeability, and social reputation. Although not a replacement for peer-reported outcomes, the PR-SF is a promising patient-reported outcome for peer relationships in youth.

Social attainment in survivors of pediatric central nervous system tumors: a systematic review and meta-analysis from the Children's Oncology Group

PURPOSE

Improved therapies for pediatric central nervous system (CNS) tumors have increased survival rates; however, many survivors experience significant long-term functional limitations. Survivors of pediatric CNS tumors can experience deficits in social attainment. The aim of this review was to systematically amalgamate findings pertaining to social attainment (i.e., educational attainment, marriage, employment outcomes) in survivors of pediatric CNS tumors.

METHODS

PubMed (web-based), PsycINFO (EBSCO), EMBASE (Ovid), and Web of Science (Thomson Reuters) were used to identify articles published between January 2011 and September 2018. Eligible studies reported outcomes for survivors of pediatric CNS tumors diagnosed before age 21 years and > 5 years from diagnosis and/or > 2 years off therapy. All data were independently abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0.

RESULTS

The search yielded 7021 unique publications. Forty-six were included in the current review. Meta-analyses revealed survivors of CNS tumors were significantly more likely to have completed compulsory education only (OR = 1.87, 95% CI = 1.66, 2.12, p < 0.00001), less likely to be married (OR = 4.70, 95% CI = 3.89, 5.68, p < 0.00001), and more likely to be unemployed (OR = 2.84, 95% CI = 2.62, 3.08, p < 0.00001) compared to non-cancer controls. Cranial radiation therapy, neurocognitive deficits, and younger age at diagnosis were associated with poorer outcomes. Hearing loss and bilateral blindness were also related to poorer outcomes. Sex did not impact social attainment outcomes.

CONCLUSIONS

Survivors of pediatric CNS tumors are at elevated risk for poor attainment of key adult social outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

There is a critical need to develop interventions to support survivors in becoming independent and productive adults.

Social attainment in physically well-functioning long-term survivors of pediatric brain tumour; the role of executive dysfunction, fatigue, and psychological and emotional symptoms

The purpose of this cross-sectional study was to investigate long-term social attainment in physically well-functioning adult survivors of pediatric brain tumour (PBT) and identify demographic, medical, and psychological factors related to poor social outcomes, with a special focus on the significance of executive dysfunction. One hundred and fourteen PBT survivors and a healthy control group provided personal data on social outcomes, i.e., education, work, and government benefits, and completed questionnaires on executive function (EF), psychological and emotional difficulties, and fatigue. A significantly higher number of survivors compared to healthy controls reported having received educational adjustments and substantial government benefits, and significantly more survivors than controls were currently not engaged in regular employment/training. PBT survivors and healthy controls did not differ on educational level or living situation. The factors most strongly associated with poor social outcomes were self-reported executive dysfunction, difficulties with adaptive functioning, and fatigue. The findings show that physically well-functioning PBT survivors are at risk of poorer social outcomes and financial dependence in adulthood compared to their healthy peers, and underline the importance of investigating EF in short- and long-term follow-ups. Future rehabilitation efforts should focus more on compensatory strategies for executive dysfunction and improving EF skills.

Social Functioning of Childhood Cancer Survivors after Computerized Cognitive Training: A Randomized Controlled Trial

Childhood cancer survivors are at risk for cognitive and social deficits. Previous findings indicate computerized cognitive training can result in an improvement of cognitive skills. The current objective was to investigate whether these cognitive gains generalize to social functioning benefits. Sixty-eight survivors of childhood cancer were randomly assigned to a computerized cognitive intervention (mean age 12.21 ± 2.47 years, 4.97 ± 3.02 years off-treatment) or waitlist control group (mean age 11.82 ± 2.42 years, 5.04 ± 2.41 years off-treatment). Conners 3 Parent and Self-Report forms were completed pre-intervention, immediately post-intervention and six-months post-intervention. Piecewise linear mixed-effects models indicated no significant differences in Peer Relations between groups at baseline and no difference in change between groups from pre- to immediate post-intervention or post- to six-months post-intervention (ps > 0.40). Baseline Family Relations problems were significantly elevated in the control group relative to the intervention group (p < 0.01), with a significantly greater decline from pre- to immediate post-intervention (p < 0.05) and no difference in change between groups from post- to six-months post-intervention (p > 0.80). The study results suggest cognitive gains from computerized training do not generalize to social functioning. Training focused on skill-based social processing (e.g., affect recognition) may be more efficacious.

Reintegration Into School After Treatment for a Brain Tumor: The Child's Perspective

This multiple case study investigated perspectives of childhood brain tumor survivors on reintegration into school over a 2-year period. Semistructured interviews were conducted with 5 children at 3 times to obtain an extensive view of their overall school experience. Thematic analysis of data resulted in 4 themes: “school life and participation,” “peer relations and friendships,” “performance and difficulties,” and “support and follow-up.” Childhood brain tumor survivors consider school attendance as part of a normal disease-free life. Social contact and friendships represent their main motivating factors for returning to school. Attitudes and feelings regarding performance, difficulties, and support vary among survivors and change over time. In conclusion, continuity in learning and social contact established before the return facilitate the reintegration process. A comprehensive assessment of their academic and psychosocial functioning should be organized on reentry. Systematic follow-up by parents, school staff, and health professionals throughout the child’s school career is required.

Meaning Making and Religious Engagement Among Survivors of Childhood Brain Tumors and Their Caregivers

PURPOSE

To describe how adolescent and young adult survivors and their mother-caregivers ascribe meaning to their post-brain tumor survivorship experience, with a focus on sense making and benefit findings and intersections with religious engagement.

PARTICIPANTS & SETTING

Adolescent and young adult survivors of childhood brain tumors and their families, living in their community settings.

METHODOLOGIC APPROACH

Secondary analysis of simultaneous and separate individual, semistructured interviews of the 40 matched dyads (80 total interviews) occurred using conventional content analysis across and within dyads. Meaning is interpreted through narrative profiles of expectations for function and independence.

FINDINGS

Participants made sense of the brain tumor diagnosis by finding benefits and nonbenefits unique to their experiences. Meaning was framed in either nonreligious or religious terms.

IMPLICATIONS FOR NURSING

Acknowledging positive meaning alongside negative or neutral meaning could enhance interactions with survivors, caregivers, and their families. Exploring the meaning of their experiences may help them to reconstruct meaning and reframe post-tumor realities through being heard and validated.

The impact of connectedness on social functioning in youth with brain tumors

PURPOSE

Children with brain tumors (BT) are at risk for difficulties with social functioning. Research to date has focused on deficits, with no studies identifying areas of strength or resilience. Our objective was to assess the potential influence of connectedness on social functioning in youth with BT as compared with children with other cancers.

METHODS

Children with cancer (20 with BT, 33 with other diagnoses) were enrolled on a longitudinal study of psychosocial functioning. The current study included measures from time 2 (+1 year after enrollment; M_age  = 13.11 ± 2.31, M_{timesincediagnosis}  = 4.95 ± 3.74 years) and time 3 (+3 years after enrollment; M_age  = 14.98 ± 2.36, M_{timesincediagnosis}  = 6.82 ± 3.81 years). Youth completed the Hemingway Measure of Adolescent Connectedness (HMAC) at time 2. Two years later, social functioning was assessed by the self- and proxy-report versions of the Social-Emotional Assets and Resilience Scale (SEARS).

RESULTS

Youth with BT perceived that they were less connected to friends (t(50) = -2.13, P = 0.04), but similarly connected to peers as youth with other cancers. Youth with BT also demonstrated lower social functioning by self- and parent report. Connectedness to friends significantly mediated the relationship between diagnostic category and self-reported social functioning, such that youth with BT who reported being more connected to friends also indicated greater social functioning. Analyses using connectedness to peers and/or parent-reported social functioning were nonsignificant.

CONCLUSIONS

Perceiving a connection to a friend may be a protective factor that could mitigate deficits in social functioning in youth with BT. Additional research is needed to further assess the potential benefits of this construct.

Are we friends? Best friend nominations in pediatric brain tumor survivors and associated factors

BACKGROUND

Pediatric brain tumor survivors (PBTSs) are at risk of impairments in social competence. Limited information is available regarding nominations and reciprocated nominations of PBTSs as best friends and factors which may predict these.

PROCEDURE

Caregivers of children (n = 32) aged 8-16 (38% low-grade glioma, 34% medulloblastoma, 28% other) completed ratings of child adjustment at baseline (T1) and PBTSs and classmates completed the Three Best Friends measure approximately 12 months later (T2). Sociometric data yielded ratings of best friend nominations and reciprocated best friend nominations.

RESULTS

Nominations of PBTSs as best friends were not significantly different than controls, but PBTSs had fewer reciprocated best friend nominations than controls. Approximately half of PBTSs in this study did not have any reciprocated best friend nominations and 25% were not nominated by any peer as a best friend. Greater symptoms of depression and lower social skills in PBTSs were associated with fewer nominations as a best friend by peers and a greater likelihood of no reciprocal best friend nominations. Greater difficulties in emotional control were associated with fewer nominations as a best friend by peers.

CONCLUSIONS

The discrepancy between reciprocated best friend nominations and best friend nominations highlights a need to attend to reciprocal friendships in PBTSs and further understand social information processes in this population. Longitudinal analyses illustrate the impact of emotional adjustment on PBTS friendships.

Social adjustment of adolescent cancer patients transitioning off active treatment: A short-term prospective mixed methods study

BACKGROUND

Psychosocial follow-up in survivorship is a standard of care in pediatric oncology; however, little is known about patients' psychosocial functioning during the transition off active treatment, a unique time in the cancer journey. This study examined the social adjustment of adolescent cancer patients during this transition period, which has been understudied to date.

PROCEDURE

Participants were 21 patients (ages 12-18 years; age M = 14.71 years; 62% female, 81% White) with various cancer diagnoses. Patients and their parents completed the Social Competence subscale of the Youth Self-Report (YSR) and Child Behavior Checklist (CBCL), respectively, PedsQL Social Functioning subscale, and a semistructured interview 1-2 months prior to ending treatment (time 1) and 3-7 months after ending treatment (time 2).

RESULTS

YSR and CBCL social competence scores were within the normal range at both time points. PedsQL social functioning scores were more consistent with norms for pediatric cancer samples at time 1 and norms for healthy children at time 2, with self-reported scores significantly improving from time 1 to time 2. A subset of patients had elevated social concerns at time 1, a number that decreased by time 2. Interviews revealed both positive and negative themes related to peer relationships and support, quantity of friends, and socialization.

CONCLUSIONS

Most adolescent cancer patients are socially well adjusted as they transition off treatment, although a subset have elevated concerns. Interviews provide insight into complex social experiences not captured on questionnaires. Patients may benefit from screening and support during this unique time.

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.

Social skills interventions for survivors of pediatric brain tumors: A review and reformulation

Youth with brain tumors are at risk for late effects. Families report that survivors' difficulties with peer relationships are among the most distressing and impactful on quality of life. As such, interventions have been designed to improve social functioning. The objective was to review the nine published social skills intervention studies for survivors of brain tumors with regard to study design, participation rates, skills targeted, assessment measures, and outcomes. Results of this review were used to discuss future directions, with a focus on alternative approaches to inclusion criteria (including developmental considerations and screening for weaknesses), intervention timing and modality.

Executive functions and social skills in pediatric brain tumor survivors

Pediatric brain tumor survivors (PBTSs) may experience impairment in executive functions and social competence, but their interrelation is not well understood. This study aimed to address the specificity of this relationship. PBTSs (n = 91) were on average 11.21 years old, 5 years from diagnosis, and 48.4% female. One parent and PBTS completed the Social Skills Rating System (subscales: Cooperation, Assertiveness, Empathy, Self-Control, and Total), and parents also completed the Behavior Rating Inventory of Executive Function (General Executive Composite [GEC], Metacognition [MI], and Behavioral Regulation [BRI] indices) and the (Withdrawal scale). Based on proxy reports, more PBTSs had deficits in Cooperation, Assertiveness and Responsibility skills relative to normative data. MI was more consistently associated with parent reported social skills deficits than BRI. PBTSs reported fewer deficits in social skills relative to normative data across all scales; none of the correlations between PBTSs reported social skills and executive functions were significant. Time since diagnosis and proxy reported lower total social skills predicted greater withdrawal. These findings highlight the importance of assessing differential perspectives of PBTSs social competence, and that metacognitive strategies may bear particular importance for the social skills of PBTSs.

Social adjustment in adolescent survivors of pediatric central nervous system tumors: A report from the Childhood Cancer Survivor Study

BACKGROUND

The purpose of this study was to examine the prevalence and predictors of social difficulties in adolescent survivors of central nervous system (CNS) tumors.

METHODS

Six hundred sixty-five survivors of CNS tumors (53.8% male and 51.7% treated with cranial radiation therapy [CRT]), who had a current median age of 15.0 years (range, 2.0-17.0 years) and were a median of 12.1 years (range, 8.0-17.7 years) from their diagnosis, were compared with 1376 survivors of solid tumors (50.4% male), who had a median age of 15.0 years (range, 12.0-17.0 years) and were a median of 13.2 years (range, 8.3-17.9 years) from their diagnosis, and 726 siblings (52.2% male), who had a median age of 15.0 years (range, 12.0-17.0 years). Social adjustment was measured with parent-proxy responses to the Behavior Problems Index. Latent profile analysis defined social classes. Multinomial logistic regression, adjusted for age, sex, and age at diagnosis, identified predictors of class membership. Path analyses tested mediating effects of physical limitations, sensory loss, and cognitive impairment on social outcomes.

RESULTS

Caregivers reported that survivors of CNS tumors were more likely to have 0 friends (15.3%) and to interact with friends less than once per week (41.0%) in comparison with survivors of solid tumors (2.9% and 13.6%, respectively) and siblings (2.3% and 8.7%, respectively). Latent profile analysis identified 3 social classes for survivors of CNS tumors: well-adjusted (53.4%), social deficits (16.2%), and poor peer relationships (30.4%). However, 2 classes were identified for survivors of solid tumors and siblings: well-adjusted (86.2% and 91.1%, respectively) and social deficits (13.8% and 8.9%, respectively). CRT predicted class membership for CNS survivors (odds ratio [OR] for poor peer relationships, 1.16/10 Gy; 95% confidence interval [CI], 1.08-1.25; OR for social deficits 1.14/10 Gy; 95% CI, 1.04-1.25; reference, well-adjusted). Cognitive impairment mediated the association between all social outcomes and CRT (P values < .001).

CONCLUSION

Almost 50% of survivors of CNS tumors experience social difficulties; the pattern is unique in comparison with solid tumor and sibling groups. Cognitive impairment is associated with increased risk, and this highlights the need for multitargeted interventions.

Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes

Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.

Development of the functional social network index for adolescent and young adult cancer survivors

BACKGROUND

To the authors' knowledge, social network status in adolescent and young adult (AYA) cancer survivors has not been adequately studied to date. The authors developed and validated a functional social network index (FSNI) for AYA survivors, and compared its performance with that of 2 traditional indices (density and betweenness centrality).

METHODS

A total of 102 AYA survivors and 102 noncancer controls who were matched for age, sex, and race were recruited from an Internet panel. Each participant reported relationships with up to 25 close friends and/or relatives. The authors developed a FSNI with reported marital status, contact frequency with friends/relatives, available resources for emotional and tangible support, and available resources for physical activity and weight management advice. Linear regression was used to analyze associations between the FSNI and cancer diagnoses, treatments, and coping skills.

RESULTS

Based on the FSNI, survivors were found to have more available resources for emotional support (beta [b] = 3.02; P = .003), tangible support (b = 4.17; P<.001), physical activity advice (b = 3.94; P<.001), and weight management advice (b = 4.10; P<.001) compared with noncancer controls. Survivors of lymphoma had the largest FSNI, whereas survivors of central nervous system malignancies had the smallest (b = 2.77; P = .02). A higher FSNI was associated with better coping skills: less denial (b = 0.10; P = .01), using emotional support (b = 0.08; P = .04), using instrumental support (b = 0.12; P<.001), less behavioral disengagement (b = 0.08; P = .04), venting of emotions (b = 0.10; P = .004), positive reframing (b = 0.12; P = .003), planning for the future (b = 0.08; P = .03), and religious engagement (b = 0.16; P<.001). Density and betweenness centrality indices demonstrated neither significant differences in social networks between cancer survivors and controls (all P values >.05) nor significant associations with coping skills (all P values >.05).

CONCLUSIONS

The FSNI appears to provide a better social network assessment for AYA cancer survivors than traditional indices. Cancer 2018;124:2220-7. © 2018 American Cancer Society.

Neuropsychological consequences of childhood medulloblastoma and possible interventions: A review

BACKGROUND

Children who have been treated for a medulloblastoma often suffer long-term cognitive impairments that often negatively affect their academic performance and quality of life. In this article, we will review the neuropsychological consequences of childhood medulloblastoma and discuss the risk factors known to influence the presence and severity of these cognitive impairments and possible interventions to improve their quality of life.

METHODS

This narrative review was based on electronic searches of PubMed to identify all relevant studies.

RESULTS

Although many types of cognitive impairments often emerge during a child's subsequent development, the core cognitive domains that are most often affected in children treated for a medulloblastoma are processing speed, attention and working memory. The emergence and magnitude of these deficits varies greatly among patients. They are influenced by demographic (age at diagnosis, parental education), medical and treatment-related factors (perioperative complications, including posterior fossa syndrome, radiation therapy dose, etc.), and the quality of interventions such as school adaptations provided to the child or rehabilitation programs that focus on cognitive skills, behavior and psychosocial functioning.

CONCLUSION

These patients require specialized and coordinated multidisciplinary rehabilitation follow-up that provides timely and adapted assessments and culminates in personalized intervention goals being set with the patient and the family. Follow-up should be continued until referral to adult services.

Unequal Cumulative Incidence and Mortality Outcome in Childhood Brain and Central Nervous System Malignancy in the USA

BACKGROUND

While survival in overall pediatric malignancy has improved during recent decades, brain/central nervous system (CNS) tumors has not demonstrated comparable survival advantage. Incidence and mortality data in this malignancy continue to illustrate race and sex differences; however, there are few data in the pediatric setting. This study sought to characterize brain/CNS tumors by socio-demographic and assess racial and sex variances in both cumulative incidence and mortality.

METHODS

A retrospective cohort design with Surveillance, Epidemiology and End Results (SEER) 1973-2014 was used for the assessment of children aged < 1-19 years diagnosed with brain/CNS tumors. The age-adjusted incidence rates were used for temporal trends, percent change, and annual percent change. We utilized binomial regression model to determine the exposure effect of race and sex on cancer mortality, adjusting for potential confounders.

RESULTS

Childhood brain/CNS tumor cumulative incidence (CmI) continues to rise in annual percent change, and mortality varied by race, sex, and year of diagnosis. The CmI was highest among whites, intermediate among blacks, and lowest among Asians, as well as lower in females relative to that in males. Compared to whites, blacks were 21% more likely to die from brain/CNS tumors [risk ratio (RR) 1.21, 95% confidence interval (C.I.) 1.13-1.28], while males were 4% more likely to die relative to females (RR 1.04, 95% C.I. 1.00-1.08). After controlling for age, sex, and tumor grade, racial disparities persisted, with 16% increased risk of dying among blacks relative to whites [adjusted risk ratio 1.16, (99% C.I.) 1.08-1.25, p < 0.001].

CONCLUSION

The cumulative incidence of brain/CNS malignancy is higher among whites relative to that in blacks; however, blacks experienced survival disadvantage even after adjustment for potential tumor prognostic and predisposing factors.

Social adjustment and repressive adaptive style in survivors of pediatric cancer

PURPOSE

The aim of the study was to explore the relationship between repressive adaptive style and self-reports of social adjustment in survivors of pediatric cancer compared to their siblings. We hypothesized that there would be a greater proportion of repressors among survivors of pediatric cancer compared to siblings, and that repressive adaptive style would be significantly associated with more positive self-reports of social adjustment.

METHODS

We utilized a cross-sectional approach. Seventy-seven families participated. Survivors of pediatric cancer (n = 77, 48% male; 8-18 years of age) and one sibling (n = 50, 48% male; 8-18 years of age) completed measures assessing repressive adaptive style and social adjustment. As well, one parent from each family completed a socio-demographic questionnaire. Questionnaire packages were mailed to eligible families who agreed to participate, and were mailed back to investigators in a pre-addressed, pre-stamped envelope.

RESULTS

Chi-square analyses revealed there was no significant difference in the proportion of repressors among survivors and siblings. Social adjustment scores were subjected to a two (group: survivor, sibling) by two (repressor, nonrepressor) ANCOVA with gender and age as covariates. There was a significant main effect of repressive adaptive style (F = 5.69, p < .05, η² = 0.05) with a modest effect. Survivors and siblings with a repressive style reported significantly higher social adjustment scores (M = 106.91, SD = 11.69) compared to nonrepressors (M = 99.57, SD = 13.45).

CONCLUSIONS

Repressive adaptive style explains some of the variance in survivors and siblings' self-reports of social adjustment. Future research should aim to better understand the role of the repressive adaptive style in survivors and siblings of children with cancer.

Impact of attention on social functioning in pediatric medulloblastoma survivors

BACKGROUND

Parent-reported attention problems have been associated with social functioning in a broad sample of pediatric cancer survivors.

OBJECTIVE

The present study focused on a more homogeneous sample (pediatric medulloblastoma survivors), with the novel inclusion of self-reported attention ratings.

PARTICIPANTS/METHODS

Thirty-three pediatric medulloblastoma survivors, ages 7-18 years, completed a brief IQ measure and self-report of attentional and social functioning. Parents rated patients' attentional and social functioning.

RESULTS

Mean attention ratings were average based on both parent- and self-report, though parent ratings were significantly discrepant from normative means. No significant demographic or treatment-related predictors of self-reported attention problems were identified, whereas female gender was associated with greater parent-reported attention problems. Canonical correlation analysis revealed a significant association between parent-reported attention difficulties and social functioning in pediatric medulloblastoma survivors, but there was no association between self-reported attention problems and measures of social functioning.

CONCLUSIONS

Consistent with existing literature in broader samples of pediatric cancer survivors, the present study further affirms attention deficits as an underlying contributor to social deficits in pediatric medulloblastoma survivors while also finding little relationship between self-reports of attention and social performance. Notably, present findings provide additional support suggesting that attention functioning is a more significant contributor to social outcomes for pediatric medulloblastoma survivors than the level of cognitive ability.

Quality of Life Among Parents of Adolescent and Young Adult Brain Tumor Survivors

We aimed to describe the quality of life (QOL) among parents of adolescent and young adult brain tumor survivors as well as parent, survivor, and diagnosis/treatment-related factors associated with adverse QOL. A cross-sectional study of 28 parents of adolescent and young adult brain tumor survivors (who were on average 10 y postdiagnosis) was used to assess QOL. Parent QOL was measured using the Patient-Reported Outcomes Measurement Information System Global Health measure. Factors associated with adverse parent QOL were explored using logistic regression including: parent, survivor, and diagnosis/treatment-related factors. Parent QOL was within the normal range; however, 40% scored below the clinical threshold of 0.5 SD below the mean for physical and mental health. Parent perceptions of greater family impact, survivor emotional/behavioral health problems, improved cognitive function, and recurrence were associated with adverse parent physical health. Parent anger/sorrow, uncertainty, survivor emotional/behavioral health problems, speech/language problems, and recurrence were associated with adverse parent mental health. Parental emotional resources and perceptions of improved survivor peer relationships were associated with greater parent physical and mental health. The impact of a brain tumor diagnosis and treatment on the QOL of parents may be significant. Interventions are needed to ensure that the needs of parents are met.

Cognitive and Psychosocial Functioning of Preschool-Aged Children with Cancer

OBJECTIVE

Most children with cancer are diagnosed in early childhood, potentially resulting in missed developmental opportunities. The most common diagnoses-brain tumors, leukemia-are also associated with increased risk of neurocognitive deficits. Unfortunately, research regarding the functioning of preschool-aged children with cancer is limited. Our objective is to describe the cognitive and psychosocial functioning of preschool-aged children with cancer who completed a clinical evaluation at a hospital-based psychology clinic.

METHODS

Assessment data from 98 preschool-aged children with cancer (M = 5.17 years old, SD = 0.54; 54.1% male) who completed clinically referred evaluations from 2011 to 2015 were abstracted. Because of variability in assessment measures used across clinicians, indicators of cognitive, adaptive, preacademic, and emotional/behavioral functioning were collapsed before analyses.

RESULTS

Children were 2.56 years from diagnosis (SD = 1.46, range 0-5.25 years) and most were off therapy (79.6%). Primary diagnostic categories were represented: brain tumor (68.4%), solid tumor (15.3%), and leukemia (16.3%). Mean IQ scores were significantly below expectations (t[80] = -7.95, p < .001). There were no differences based on diagnostic category, treatment status, or sex. Adaptive functioning (t[73] = -8.42, p < .001) and preacademic skills (t[77] = -6.20, p < .001) were also significantly below expectations. Mean scores on a measure of parent-reported emotional/behavioral functioning were in the average range.

CONCLUSION

Young children with cancer may be at significant risk of deficits in intellectual, adaptive, and preacademic functioning. Although our sample is biased by those who were referred for clinical evaluations, the severity of deficits highlights the potential vulnerability of young patients, even before most have entered formal school. Interventions-such as hospital-based preschool programs to increase preacademic skills-should be designed that explicitly target preschool-aged children and focus on a wide range of domains.

Determinants of quality of life outcomes for survivors of pediatric brain tumors

INTRODUCTION

To describe the quality of life (QOL) of pediatric brain tumor survivors (PBTSs) prospectively and to identify potential medical, personal and family contextual factors associated with QOL.

METHODS

Ninety-one PBTSs (8-16 years) who were off treatment and attending a regular classroom participated. Self- and caregiver-proxy-reported on QOL at baseline, 2 and 8 months. At baseline, cognitive, executive function, attention and memory, medical and demographics information were attained.

RESULTS

Significant improvements over time in PBTS's emotional QOL were self- and proxy-reported (P < 0.01) and global QOL proxy-reported (P = 0.04). Receiving cranial irradiation therapy (CIT) and poor behavioral regulation predicted poor global QOL scores reported by both informants (P < 0.017). Poor behavioral regulation also predicted poor self-reported school functioning, and poor proxy-reported emotional and social QOL (P < 0.037). Boys reported better emotional QOL (P = 0.029), and PBTSs over 11 years old were reported to have better emotion and school-related QOL. Finally, being non-White and having low income predicted poor self-reported global and emotional QOL (P = 0.041).

CONCLUSIONS

Receiving CIT, having poor behavioral regulation, being a female, under 11 years old and coming from low-income, non-White families place PBTSs at risk for poor QOL.

Computerized Adaptive Testing in Pediatric Brain Tumor Clinics

CONTEXT

Monitoring of health-related quality of life and symptoms of patients with brain tumors is needed yet not always feasible. This is partially due to lack of brief-yet-precise assessments with minimal administration burden that are easily incorporated into clinics. Dynamic computerized adaptive testing (CAT) or static fixed-length short forms, derived from psychometrically sound item banks, are designed to fill this void.

OBJECTIVE

This study evaluated the comparability of scores obtained from CATs and short forms.

METHODS

Patients (ages 7-22 years) were recruited from brain tumor clinics and completed Patient-Reported Outcome Measurement Information System CATs and short forms (Fatigue, Mobility, Upper Extremity, Depressive Symptoms, Anxiety, and Peer Relationships). Pearson correlations, paired t-tests, and Cohen's d were used to evaluate the relationship, significant differences, and the magnitude of the difference between these two scores, respectively.

RESULTS

Data from 161 patients with brain tumors were analyzed. Patients completed each CAT within 2 minutes. Scores obtained from CATs and short forms were highly correlated (r = 0.95-0.98). Significantly different CAT vs. short-form scores were found on 4 (of 6) domains yet with negligible effect sizes (|d| < 0.09). These relationships varied across patients with different levels of reported symptoms, with the strongest association at the worst or best symptom scores.

CONCLUSIONS

This study demonstrated the comparability of scores from CATs and short forms. Yet the agreement between these two varied across degrees of symptom severity which was a result of the ceiling effects of static short forms. We recommend CATs to enable individualized assessment for longitudinal monitoring.

Systematic review and meta-analysis of health-related quality of life in pediatric CNS tumor survivors

BACKGROUND

Pediatric central nervous system (CNS) tumor survivors are at high risk for numerous late effects including decreased health-related quality of life (HRQOL). Our objective was to summarize studies describing HRQOL in pediatric CNS tumor survivors and compare HRQOL outcomes in studies that included a comparison group.

PROCEDURE

EMBASE, MEDLINE, and PsychINFO were used to identify relevant articles published until August, 2016. Eligible studies reported outcomes for pediatric CNS tumor survivors diagnosed before age 21, at least 5 years from diagnosis and/or 2 years off therapy and used a standardized measure of HRQOL. All data were abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0.

RESULTS

Of 1,912 unique articles identified, 74 were included in this review. Papers described 29 different HRQOL tools. Meta-analyses compared pediatric CNS tumor survivors to healthy comparisons and other pediatric cancer survivors separately. HRQOL was significantly lower for CNS (n = 797) than healthy comparisons (n = 1,397) (mean difference = -0.54, 95% confidence interval [CI] = -0.72 to -0.35, P < 0.001, I² = 35%). HRQOL was also significantly lower for CNS (n = 244) than non-CNS survivors (n = 414) (mean difference = -0.56, 95% CI = -0.73 to -0.38, P < 0.00001, I² = 0%).

CONCLUSIONS

Pediatric CNS tumor survivors experience worse HRQOL than healthy comparisons and non-CNS cancer survivors. Future HRQOL work should be longitudinal, and/or multisite studies that examine HRQOL by diagnosis and treatment modalities.