Concordance of parent-, teacher- and self-report ratings on the Conners 3 in adolescent survivors of cancer

Attention and executive functioning in children and adolescents treated for high-risk acute lymphoblastic leukemia: A report from the Children's Oncology Group (COG)

OBJECTIVES

Survivors of childhood B-acute lymphoblastic leukemia (B-ALL) are at risk for difficulties with attention and executive functioning (EF) as a late effect of treatment. The present study aimed to identify treatment and demographic factors associated with risk for difficulties with EF in youth treated for high-risk B-ALL.

METHOD

Children and adolescents with B-ALL treated on Children's Oncology Group (COG) protocol AALL0232 were randomized to high-dose or escalating-dose methotrexate (MTX), and either dexamethasone or prednisone during the induction phase. Neuropsychological functioning was evaluated via protocol AALL06N1, including performance-based and parent-report measures, for 177 participants (57% female, 81% white; mean age at diagnosis = 8.4 years; SD = 5.0) 8-24 months following treatment completion.

RESULTS

Mean scores for all attention and EF measures were within the average range, with no significant differences as a function of MTX delivery or steroid treatment (all p > 0.05). In multivariable models, participants with US public insurance exhibited significantly greater parent-reported EF difficulties than those with US private or non-US insurance (p ≤ 0.05). Additionally, participants diagnosed under 10 years of age performed significantly more poorly on measures of attention (i.e., continuous performance task, p ≤ 0.05) and EF (i.e., verbal fluency and tower planning task, p ≤ 0.05).

CONCLUSIONS

For survivors of pediatric B-ALL, treatment-related factors were not associated with attention or EF outcomes. In contrast, outcomes varied by demographic characteristics, including age and insurance type, an indicator of economic hardship. Future research is needed to more directly assess the contribution of socioeconomic status on cognitive outcomes in survivors.

Micronutrients for ADHD in youth (MADDY) study: comparison of results from RCT and open label extension

BACKGROUND

The Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youth (MADDY) study evaluated the efficacy and safety of a multinutrient formula for children with ADHD and emotional dysregulation. The post-RCT open-label extension (OLE) compared the effect of treatment duration (8 weeks vs 16 weeks) on ADHD symptoms, height velocity, and adverse events (AEs).

METHODS

Children aged 6-12 years randomized to multinutrients vs. placebo for 8 weeks (RCT), received an 8-week OLE for a total of 16 weeks. Assessments included the Clinical Global Impression-Improvement (CGI-I), Child and Adolescent Symptom Inventory-5 (CASI-5), Pediatric Adverse Events Rating Scale (PAERS), and anthropometric measures (height and weight).

RESULTS

Of the 126 in the RCT, 103 (81%) continued in the OLE. For those initially assigned to placebo, CGI-I responders increased from 23% in the RCT to 64% in the OLE; those who took multinutrients for 16 weeks increased from 53% (RCT) to 66% responders (OLE). Both groups improved on the CASI-5 composite score and subscales from week 8 to week 16 (all p-values < 0.01). The group taking 16 weeks of multinutrients had marginally greater height growth (2.3 cm) than those with 8 weeks (1.8 cm) (p = 0.07). No difference in AEs between groups was found.

CONCLUSION

The response rate to multinutrients by blinded clinician ratings at 8 weeks was maintained to 16 weeks; the response rate in the group initially assigned to placebo improved significantly with 8 weeks of multinutrients and almost caught up with 16 weeks. Longer time on multinutrients did not result in greater AEs, confirming an acceptable safety profile.

Caregiver and youth inter-rater assessment agreement in autism spectrum disorder, developmental coordination disorder, and typical development

Youth diagnosed with autism spectrum disorder (ASD) and those with developmental coordination disorder (DCD) are at heightened risk for co-occurring mental health diagnoses, especially anxiety and attention-deficit/hyperactivity disorder (ADHD). However, caregiver-child agreement on presence of related symptoms in populations with neurodevelopmental conditions is not well understood. Here, we examine the extent to which 37 ASD, 26 DCD, and 40 typically developing children and their caregivers agree on the degree of the child's symptoms of anxiety and ADHD. All caregiver-child dyads completed the Screen for Child Anxiety Related Emotional Disorders and Conners 3 ADHD Index. Across groups, intraclass correlations indicated generally poor agreement on anxiety and ADHD symptomatology. Although youth generally reported greater internalizing symptoms (i.e., anxiety), caregivers tended to report more observable externalizing behaviors (i.e., ADHD). Together, the results of this study support the need for a multi-informant approach in assessments of anxiety and ADHD in youth with neurodevelopmental disorders.

An Industry-Relevant Metal Mixture, Iron Status, and Reported Attention-Related Behaviors in Italian Adolescents

BACKGROUND

Exposure to environmental metals has been consistently associated with attention and behavioral deficits in children, and these associations may be modified by coexposure to other metals or iron (Fe) status. However, few studies have investigated Fe status as a modifier of a metal mixture, particularly with respect to attention-related behaviors.

METHODS

We used cross-sectional data from the Public Health Impact of Metals Exposure study, which included 707 adolescents (10-14 years of age) from Brescia, Italy. Manganese, chromium, and copper were quantified in hair samples, and lead was quantified in whole blood, using inductively coupled plasma mass spectrometry. Concentrations of Fe status markers (ferritin, hemoglobin, transferrin) were measured using immunoassays or luminescence assays. Attention-related behaviors were assessed using the Conners Rating Scales Self-Report Scale-Long Form, Parent Rating Scales Revised-Short Form, and Teacher Rating Scales Revised-Short Form. We employed Bayesian kernel machine regression to examine associations of the metal mixture with these outcomes and evaluate Fe status as a modifier.

RESULTS

Higher concentrations of the metals and ferritin were jointly associated with worse self-reported attention-related behaviors: metals and ferritin set to their 90th percentiles were associated with 3.0% [β = 0.03 ; 95% credible interval (CrI): - 0.01 , 0.06], 4.1% (β = 0.04 ; 95% CrI: 0.00, 0.08), and 4.1% (β = 0.04 ; 95% CrI: 0.00, 0.08) higher T -scores for self-reported attention deficit/hyperactivity disorder (ADHD) index, inattention, and hyperactivity, respectively, compared with when metals and ferritin were set to their 50th percentiles. These associations were driven by hair manganese, which exhibited nonlinear associations with all self-reported scales. There was no evidence that Fe status modified the neurotoxicity of the metal mixture. The metal mixture was not materially associated with any parent-reported or teacher-reported scale.

CONCLUSIONS

The overall metal mixture, driven by manganese, was adversely associated with self-reported attention-related behavior. These findings suggest that exposure to multiple environmental metals impacts adolescent neurodevelopment, which has significant public health implications. https://doi.org/10.1289/EHP12988.

Concordance of informant and self-reported ratings on the Frontal Systems Behavior Scale in adult survivors of pediatric brain tumor

OBJECTIVE

It has been theorized that pediatric brain tumor survivors may have reduced insight into their executive functioning. Agreement between informants and survivors has been used to probe this theory, but findings have been inconsistent. This study sought to expand on prior work by examining the relationship between participant role and ratings on the Frontal Systems Behavior Scale (FrSBe) among 73 adult survivors and their informants. This study also sought to test whether agreement on scores varied as a function of tumor treatment.

METHOD

Dyadic mixed effects models examined the relationship between participant ratings on FrSBe subscales and the role of a participant (survivor or informant). Intraclass correlations (ICC) were used to calculate reliable change indices to evaluate significant divergence in self and informant agreement.

RESULTS

Dyadic mixed effects models showed an insignificant relationship between participant role and ratings on the FrSBe apathy and executive dysfunction subscales. Participant role was related to ratings on the disinhibition subscale of the FrSBe. The ICC for apathy was ICC = .583, for disinhibition ICC = .420, and for executive dysfunction ICC = .373. Significant divergence in scores did not vary by history of chemoradiation.

CONCLUSIONS

Results demonstrate an effect of role on one FrSBe subscale and weak to moderate agreement between survivor and informant scores, which suggests that agreement between informants and survivors varies by FrSBe domain. The strongest relationship between survivors and informants was seen on apathy, which suggests that apathy is a shared concern for survivors and their families.

Early life manganese exposure and reported attention-related behaviors in Italian adolescents

Background

Manganese (Mn) is an essential nutrient and neurotoxicant, and the neurodevelopmental effects of Mn may depend on exposure timing. Less research has quantitatively compared the impact of Mn exposure on neurodevelopment across exposure periods.

Methods

We used data from 125 Italian adolescents (10-14 years) from the Public Health Impact of Metals Exposure Study to estimate prospective associations of Mn in three early life exposure periods with adolescent attention-related behaviors. Mn was quantified in deciduous teeth using laser ablation-inductively coupled plasma-mass spectrometry to represent prenatal (2nd trimester-birth), postnatal (birth ~1.5 years), and childhood (~1.5-6 years) exposure. Attention-related behavior was evaluated using the Conners Behavior Rating Scales in adolescence. We used multivariable linear regression models to quantify associations between Mn in each exposure period, and multiple informant models to compare associations across exposure periods.

Results

Median tooth Mn levels (normalized to calcium) were 0.4 area under the curve (AUC) 55Mn:43Ca × 104, 0.1 AUC 55Mn:43Ca × 104, and 0.0006 55Mn:43Ca for the prenatal, postnatal, and childhood periods. A doubling in prenatal tooth Mn levels was associated with 5.3% (95% confidence intervals [CI] = -10.3%, 0.0%) lower (i.e., better) teacher-reported inattention scores, whereas a doubling in postnatal tooth Mn levels was associated with 4.5% (95% CI = -9.3%, 0.6%) and 4.6% (95% CI = -9.5%, 0.6%) lower parent-reported inattention and attention deficit/hyperactivity disorder index scores, respectively. Childhood Mn was not beneficially associated with reported attention-related behaviors.

Conclusion

Protective associations in the prenatal and postnatal periods suggest Mn is beneficial for attention-related behavior, but not in the childhood period.

Primary School Children’s Self-Reports of Attention Deficit Hyperactivity Disorder-Related Symptoms and Their Associations With Subjective and Objective Measures of Attention Deficit Hyperactivity Disorder

Background

The diagnosis of Attention deficit hyperactivity disorder (ADHD) is primarily dependent on parents’ and teachers’ reports, while children’s own perspectives on their difficulties and strengths are often overlooked.

Goal

To further increase our insight into children’s ability to reliably report about their ADHD-related symptoms, the current study examined the associations between children’s self-reports, parents’ and teachers’ reports, and standardized continuous performance test (CPT) data. We also examined whether the addition of children’s perceptions of ADHD-symptoms to parents’ and teachers’ reports would be reflected by objective and standardized data.

Methods

The study included 190 children with ADHD, aged 7–10 years, who were referred to a pediatric neurologic clinic. A retrospective analysis was conducted using records of a clinical database. Obtained data included children’s self-reports of their attention level and ADHD-related symptoms, parent, and teacher forms of the Conners ADHD rating scales, Child Behavior Checklist (CBCL), Teacher’s Report Form (TRF), and CPT scores.

Results

Children’s self-evaluations of their functioning were globally associated with their teachers’ and parents’ evaluations, but not uniquely. Children’s self-reports of ADHD symptoms were not uniquely linked to a specific CPT impairment index, but to a general likelihood of having an impaired CPT. The CPT performance successfully distinguished between the group of children who defined themselves as inattentive and those who did not.

Conclusion

Primary school children with ADHD are able to identify their limitations and needs difficulties and that their perspectives should inform clinical practice and research. The clinical and ethical imperative of taking children’s perspectives into account during ADHD diagnosis and treatment is highlighted.

Cognitive and behavioral risk factors for low quality of life in survivors of childhood acute lymphoblastic leukemia

BACKGROUND

With high survival rates for pediatric acute lymphoblastic leukemia (ALL), long-term quality of life is a prominent consideration in treatment. We concurrently evaluated cognition, behavior, and quality of life in child and adolescent ALL survivors and determined associations between them.

METHODS

The sample included 83 controls (mean age: 12.5 years) and 71 ALL survivors (mean age: 11.9 years, mean age at diagnosis: 3.8 years). Participants completed measures of general intellectual abilities, math achievement, and fine motor skills. Parents and teachers completed a survey assessing child participants' cognitive, behavioral, and emotional function. Parents additionally completed a survey about their child's quality of life.

RESULTS

Survivors had lower scores on measures of working memory, processing speed, timed math, and fine motor skills (effect size 0.5-1, p < 0.001). Parents identified more problems with executive function and learning in survivors than controls (effect size > 0.7, p < 0.001), and indicated a lower quality of life in all categories evaluated (effect size > 0.7, p < 10^-4). Reduced quality of life was associated with lower math achievement scores and with inattention and executive function problems.

CONCLUSIONS

ALL survivors experience diffuse cognitive, behavioral, and motor impairments, which are associated with reduced quality of life. These findings underscore the need to address these challenges in ALL survivors.

IMPACT

Compared with cancer-free peers, parents of childhood acute lymphoblastic leukemia survivors treated with chemotherapy only reported reduced quality of life. Math difficulties and behavioral problems increased the risk for reduced quality of life. Reduced quality of life is associated with mild cognitive and behavioral difficulties, suggesting that even relatively mild impairments have broad implications for ALL survivors. Screening and early intervention targeting cognitive and behavioral function may enhance quality of life for ALL survivors.

Who predict ADHD with better diagnostic accuracy?: Parents or teachers?

OBJECTIVE

The objectives of the study were to determine which parents or teachers predict attention-deficit/hyperactivity disorder (ADHD) better in children and adolescents, and to detect both diagnostical and symptomatological agreement levels across informant reports.

METHOD

A total of 417 cases aged 6-14 from a non-referred community sample were assessed by a semi-structured interview, parent- and teacher-rated ADHD Rating Scale-IV. Also, impairment criteria were taken into account to ensure the gold standard diagnosis for ADHD. The measures of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated in each categorical sample. Besides, the agreement between parent and teacher reports of ADHD was investigated.

RESULTS

Parents and teachers had similar diagnostic accuracy for predicting ADHD. Both parents and teachers predicted ADHD in similar accuracy in both boys and girls, separately. However, girls were found to be more predictable by both parents and teachers compared to boys. Parents with lower education levels had worse diagnostic accuracy than both parents with higher education levels and teachers. Low to moderate agreement and correlations between parent and teacher ADHD reports were detected.

CONCLUSION

In general, parents and teachers seem to predict ADHD in similar accuracy. Nevertheless, child gender and parental education level may alter the predictability power for ADHD. The findings can guide for clinicians that how to evaluate observation reports of parents and teachers to make accurate ADHD diagnosis in patients.

Inconsistencies between measures of cognitive dysfunction in childhood acute lymphoblastic leukemia survivors: Description and understanding

OBJECTIVES

The frequency of cognitive difficulties in childhood cancer survivors varies according to the measurement strategy. The goal of this research is to (a) describe agreements and differences between measures of working memory and attention (b) identify contributors of these differences, such as emotional distress, affects, and fatigue.

METHODS

We used data available for 138 adults successfully treated for childhood acute lymphoblastic leukemia (ALL) (PETALE cohort). Working memory and attention were assessed using subtests from the WAIS-IV and self-reported questionnaires (BRIEF-SR and CAARS-S:L). Potential contributors included emotional distress, anxiety, depression (BSI-18), affects (PANAS), and fatigue (PedsQL-MFS). We explored measurement agreements and differences using diagnostic indices and multivariate regression models.

RESULTS

The frequencies of working memory and attention deficits were higher when using cognitive tests (15%-21%) than with self-reports (10%-11%). Self-reported questionnaires showed high specificity (median 0.87) and low sensitivity (median 0.10), suggesting they did not reliably identify positive cases on cognitive tests. We identified negative affectivity as a possible contributor to inconsistencies between self-report and test results.

CONCLUSIONS

When measuring working memory and attention in childhood ALL survivors, cognitive test results and self-reports should not be considered equivalent. At best, self-report may be used for screening (high specificity), but not to assess prevalence in large samples. Self-reported difficulties are also probably influenced by the negative mood in this population.

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.

Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children

Attention deficit hyperactivity disorder (ADHD), one of the most prevalent childhood disorders today, is generally more likely to be diagnosed and treated in boys than in girls. However, gender differences in ADHD are currently poorly understood, partly because previous research included only a limited proportion of girls and relied mainly on subjective measures of ADHD, which are highly vulnerable to reporter's bias. To further examine gender differences in ADHD and to address some of the shortcomings of previous studies, this study examined gender differences in subjective and objective measures of ADHD among clinic-referred children with ADHD. Participants were 204 children aged 6-17 years-old with ADHD (129 boys, 75 girls). A retrospective analysis was conducted using records of a clinical database. Obtained data included parent and teacher forms of the Conners ADHD rating scales, Child Behavior Checklist (CBCL), Teacher's Report Form (TRF), and child's continuous performance test (CPT) scores. Results showed that according to parents' and teachers' reports of ADHD-related symptoms (Conners ADHD rating scales), girls had more inattention problems than boys, but no differences were identified in the level of hyperactivity and impulsivity symptoms. CPT data, however, revealed higher impulsivity among boys. We did not find gender differences in the level of distractibility during CPT performance. Specifically, the effects of distractors type (visual environmental stimuli, auditory stimuli, or a combination of them) and distractors load (one or two distracting stimuli at a time) on CPT performance did not differ between boys and girls with ADHD. These findings suggest that gender effects on ADHD symptoms may differ between subjective and objective measures. Understanding gender differences in ADHD may lead to improved identification of girls with the disorder, helping to reduce the gender gap in diagnosis and treatment.

Monitoring neurocognitive functioning in childhood cancer survivors: evaluation of CogState computerized assessment and the Behavior Rating Inventory of Executive Function (BRIEF)

BACKGROUND

Many childhood cancer survivors develop neurocognitive impairment, negatively affecting education and psychosocial functioning. Recommended comprehensive neuropsychological testing can be time- and cost- intensive for both institutions and patients and their families. It is important to find quick and easily administered surveillance measures to identify those in need of evaluation.

METHODS

We evaluated, individually and in combination, the sensitivity and specificity of the 1) Behavior Rating Inventory of Executive Functioning-Metacognition Index (BRIEF-MCI), and 2) CogState Composite Index (computerized assessment of cognition) in identifying below grade-level performance on state-administered tests of reading and mathematics among childhood cancer survivors.

RESULTS

The 45 participants (39% female) were a mean age of 7.1 ± 4.4 years at diagnosis, 14.0 ± 3.0 at evaluation, with a history of leukemia (58%), lymphoma (9%), central nervous system tumors (20%), and other tumors (13%). Impairment on the BRIEF-MCI was associated with low sensitivity (26% reading, 41% mathematics) but stronger specificity (88% reading, 96% mathematics). We found similar associations for the CogState Composite Index with sensitivity of 26% for reading and 29% for mathematics and specificity of 92% for both reading and mathematics. Combining the two measures did not improve sensitivity appreciably (47% reading, 59% mathematics) while reducing specificity (84% reading, 88% mathematics).

CONCLUSIONS

While individuals identified from the BRIEF-MCI or CogState Composite would likely benefit from a full neuropsychological evaluation given the strong specificity, use of these measures as screening tools is limited. With poor sensitivity, they do not identify many patients with academic difficulties and in need of a full neuropsychological evaluation. Continued effort is required to find screening measures that have both strong sensitivity and specificity.

Correlated Trait-Correlated Method Minus One Analysis of the Convergent and Discriminant Validity of the Conners 3 Short Forms

This study used the correlated trait-correlated method minus one model to examine the convergent and discriminant validity of the scales of the Conners 3 Short [C 3 (S)]. The C 3 (S) scales in the analysis were inattention (IN), hyperactivity/impulsivity (HY), learning problems (LP; learning problems/executive functioning from the teacher version), aggression (AG), and peer relations (PR, only for parent and teacher versions). A total of 529 adolescents and children (75% males, mean age = 11.75 years, SD = 2.97 years) provided self-ratings, and were also rated by their mothers and teachers. The findings indicated no support for the convergence of IN and HY across the three respondents. In contrast, there was convergence for LP, AG, and PR. There was support for the discriminant validity of the traits, except between IN and HY. The findings are discussed in relation to the convergent and discriminant validity of the C 3 (S) measures, and the clinical use of the C 3 (S).