Executive function late effects in survivors of pediatric brain tumors and acute lymphoblastic leukemia

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.

Internal Consistency and Floor/Ceiling Effects of the Gross Motor Function Measure for Use with Children Affected by Cancer: A Cross-Sectional Study

Children/adolescents with cancer can develop adverse effects impacting gross motor function. There is a lack of gross motor function assessment tools that have been validated for this population. The aim of this multicenter cross-sectional study was to preliminary validate the 88-item Gross Motor Function Measure (GMFM-88) for use in children/adolescents with cancer, exploring internal consistency and floor/ceiling effect. Inclusion criteria regarded children/adolescents diagnosed with cancer on treatment or <1 year off therapy. The internal consistency was assessed using Cronbach's α, and the floor-ceiling effects were calculated through percentage. This study involved 217 participants with heterogeneous neoplasm conditions. Internal consistency was good, with a Cronbach's α of 0.989. Floor-ceiling effect analysis reveals that several items obtained a dichotomous scoring distribution in each of the five sub-scales of the GMFM-88. This can be explained by the heterogeneous clinical characteristics of the target population. The preliminary validation of GMFM-88 in a group of children/adolescents affected by cancer suggests that some items are not able to discriminate between different gross motor function levels, and therefore it does not represent an informative tool to measure gross motor function in children with cancer. Future research is needed to define which ones could be more useful for clinical practice.

Relationships between cognitive flexibility performance and adaptive behavior outcomes in survivors of pediatric brain tumor

Objective: Survivors of pediatric brain tumors are at increased risk of executive function (EF) and adaptive behavior difficulties. While previous research suggests that executive dysfunction impacts suboptimal adaptive outcomes, the specific elements of EF influencing this relationship remain unexplored. This study examines the relationship between cognitive flexibility and adaptive behavior in survivors compared to healthy controls. Methods: 86 survivors (Mage(SD)=23.41(4.24), 44 females) and 86 controls (Mage(SD)=23.09(4.50), 44 females) completed the Delis-Kaplan Executive Function System Trail Making Test (TMT) and Verbal Fluency Test (VFT). The Letter-Number Sequencing (LNS) and Category Switching (CS) conditions were isolated as measures of cognitive flexibility. Informants provided responses to obtain adaptive behavior ratings using the Scales of Independent Behavior-Revised (SIB-R). Linear regressions explored relationships between cognitive flexibility and SIB-R scores in survivors compared to controls. Results: For both TMT and VFT, the relationship between cognitive flexibility and adaptive behavior was significantly different between survivors and controls for SIB-R scores in Social Communication, Community Living, and Personal Living Skills (p<.0125). Survivors' better LNS performance predicted greater SIB-R scores across the same 3 domains (all p= <.001, r2semipartial=.08). Similarly, survivors' better CS performance predicted greater SIB-R scores across the same 3 domains (p = 0.002 to .02, r2semipartial =.03 to .04). No significant relationships were found in controls (all p >.05). After adjusting for working memory and inhibitory control, most relationships remained significant in survivors (p= <.001 to .046, r2semipartial=.02 to .08). Conclusion: These findings reveal a robust, positive relationship between cognitive flexibility performance and adaptive behaviors specific to survivors.

Long term neuropsychological outcomes of a pediatric ETANTR brain tumor: A case study

Survivors of pediatric brain tumors are at high risk for long-term neuropsychological difficulties. In the current case study, we present longitudinal neuropsychological data spanning 10 years (from age 9 to 19 years) of a patient with a rare, very large, bifrontal, embryonal tumor with abundant neuropil and true rosettes (ETANTR), which is typically associated with poor survivorship and significant neurological impact. Results demonstrated that the patient had largely intact cognitive functioning with specific difficulties in executive functioning, fine motor skills, and adaptive functioning at her most recent neuropsychology 10-year follow-up. These results highlight outcomes for a patient with remarkable resiliency in the context of numerous risk factors (a very large tumor size, multi-modal treatment, and seizure history). Patient protective factors (a high level of cognitive reserve, family support, and appropriate comprehensive educational services) likely contributed to the patient's favorable neuropsychological outcome. The patient's age at brain tumor diagnosis (9 years) and associated treatment was at a critical period of development for emerging higher order cognitive functions which likely impacted acquisition of executive functioning skills and secondarily adaptive skill outcomes. Consequently, pediatric brain tumor survivors with ETANTR or other frontal tumors require targeted screening of executive functions and proactive interventions.

Impaired neurocognitive functioning 3 months following diagnosis of high-risk acute lymphoblastic leukemia: A report from the Children's Oncology Group

PURPOSE

Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer diagnosis. Cognitive late effects develop in 20%-40% of ALL survivors, but the course of declines is unclear. The aim of this paper is to characterize cognitive functioning, and its association with patient-reported outcomes, early in treatment.

PATIENTS AND METHODS

A total of 483 children with high-risk ALL, aged 6-12 years at diagnosis, consented to the neurocognitive study embedded in a prospective therapeutic trial, Children's Oncology Group (COG) AALL1131. A computerized neurocognitive battery (Cogstate) was administered 3 months post diagnosis assessing reaction time, visual attention, working memory, visual learning, and executive functioning. Parent-reported executive functioning and patient-reported physical symptoms were also collected.

RESULTS

Data from 390 participants (mean age at diagnosis = 9.2 years, 55.4% male) were obtained. Relatively few patients reported pain (16.0%) or nausea (22.6%), but a majority (68.5%) reported feeling at least some fatigue at testing. Mean Cogstate Z-scores were within normal limits across tasks; however, rates of impairment (Z-scores ≤ -1.5) for reaction time, working memory, visual learning, and visual attention were all higher than expected compared to the standardization sample. Patients reporting fatigue were significantly more likely to have impaired reaction time and visual attention compared to those reporting no fatigue.

CONCLUSION

Findings support feasibility of computerized cognitive assessments and suggest higher-than-expected rates of impaired cognitive performance early during treatment for pediatric ALL, notably within 3 months of diagnosis, suggesting intervention efforts may be indicated. These results also highlight acute factors that may impact reliability of "baseline" assessments conducted soon after diagnosis.

The Role of Speech-Language Pathologists in Expanding Delivery of Teen Online Problem Solving for Adolescents With Acquired Brain Injury: A Quality Improvement Project

PURPOSE

Teen Online Problem Solving (TOPS) is an evidence-based teletherapy program designed to promote neurocognitive, behavioral, and psychosocial recovery following brain injury through family-centered training. To date, TOPS has been primarily administered by neuropsychologists and clinical psychologists. This clinical focus article discusses a quality improvement project to adapt the TOPS training and manual for use by speech-language pathologists (SLPs) and reports feedback from SLPs following TOPS training and after delivering the program with adolescents who experienced neurological insults.

METHOD

SLPs were invited to participate in TOPS training. Trainees were asked to complete posttraining surveys, active therapist questionnaires, and follow-up surveys directed to SLPs who had completed the intervention with at least one patient.

RESULTS

To date, a total of 38 SLPs completed TOPS training, 13 have implemented TOPS with at least one adolescent. Eight SLPs and 16 psychologists/trainees responded to follow-up surveys to share their perspectives on the program. Perceptions of clinicians delivering the program did not differ significantly in most respects. SLPs rated the ease of understanding nonverbal communication higher than psychologists. Seven SLPs responded to an SLP-specific survey about their experiences administering TOPS, noting a range of advantages and some limitations in their open-ended responses.

CONCLUSION

Training SLPs to deliver TOPS has the potential to increase service provision to adolescents with acquired brain injury who have cognitive communication difficulties and their families.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22357327.

Processing efficiency in pediatric cancer survivors: A review and operationalization for outcomes research and clinical utility

OBJECTIVE

Childhood cancer and cancer-related treatments disrupt brain development and maturation, placing survivors at risk for cognitive late effects. Given that assessment tools vary widely across researchers and clinicians, it has been daunting to identify distinct patterns in outcomes across diverse cancer types and to implement systematic neurocognitive screening tools. This review aims to operationalize processing efficiency skill impairment-or inefficient neural processing as measured by working memory and processing speed abilities-as a worthwhile avenue for continued study within the context of childhood cancer.

METHODS

A comprehensive literature review was conducted to examine the existing research on cognitive late effects and biopsychosocial risk factors in order to conceptualize processing efficiency skill trends in childhood cancer survivors.

RESULTS

While a frequently reported pattern of neurobiological (white matter) and cognitive (working memory and processing speed) disruption is consistent with processing efficiency skill impairment, these weaknesses have not yet been fully operationalized in this population. We offer a theoretical model that highlights the impacts of a host of biological and environmental factors on the underlying neurobiological substrates of cancer survivors that precede and may even predict long-term cognitive outcomes and functional abilities following treatment.

CONCLUSION

The unified construct of processing efficiency may be useful in assessing and communicating neurocognitive skills in both outcomes research and clinical practice. Deficits in processing efficiency may serve as a possible indicator of cognitive late effects and functional outcomes due to the unique relationship between processing efficiency skills and neurobiological disruption following cancer treatment. Continued research along these lines is crucial for advancing childhood cancer outcomes research and improving quality of life for survivors.

Preserved executive functioning and low stress symptoms in children treated for acute lymphoblastic leukemia

Pediatric cancer treatment can negatively impact cognitive and psychosocial development, although it has been suggested that these adverse effects may be minimized when children have higher resilience and better executive functioning. We aimed to evaluate the impact of pediatric Acute Lymphoblastic Leukemia (ALL) treatment on executive function, resilience and stress in survivors and to investigate correlations between executive functioning and resilience and between executive functioning and stress. The neuropsychological assessment was performed in 32 ALL survivors aged 7-17 years and 28 age-, sex- and socioeconomic status matched controls. Executive functioning was assessed by inhibitory control, mental flexibility and working memory tasks. Children's self-report scales were used to assess stress symptoms and resilience. Results revealed no executive function impairment nor stress symptom differences between ALL survivors and control group. In the ALL group, executive function and resilience were positively correlated, whereas executive function and stress were negatively correlated. We concluded that ALL treatment was not associated with impairment in executive functioning nor to increased stress symptoms in our sample. ALL survivors with better performance in mental flexibility and inhibition tasks reported fewer stress symptoms and more resilience, indicating a possible relationship between these variables.

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.

Social Problem Solving in Survivors of Pediatric Brain Tumor

OBJECTIVES

Psychosocial late effects among survivors of pediatric brain tumors are common. For school-aged survivors, social skills deficits and isolation present a particular challenge. Social problem-solving is a social skill that is an important determinant of social outcomes and may yield a potential target for intervention.

METHODS

School-aged youth (N = 65) 8-12 years of age (10.59 ± 1.36 years; 55.4% female, 86.2% white) who were 5.23 (SD = 2.44, range 2-10.9) years post-treatment for a brain tumor completed the Attributions and Coping Questionnaire, a measure of social problem-solving that uses vignettes to assess attribution of intent, subsequent emotional response, and imagined behavioral response to an interpersonal problem. Youth also completed self-reports of social functioning (PROMIS Peer Relationships, Self-Perception Profile). A caregiver completed additional measures of child social functioning (NIH Toolbox-Emotion Measures).

RESULTS

Survivors attributed unpleasant situations to accidental causes (neutral attribution) and responded in ways that prioritized the friendship (appeasement) or relied on adult intervention. Self-reported social functioning was higher among those who were less likely to avoid challenging social problem-solving situations.

CONCLUSIONS

Findings identified characteristic social problem-solving approaches among survivors, including a tendency to attribute ambiguous situations to accidental causes and to request adult assistance and/or maintain social relationships. This may indicate a possible avenue for intervention, with a focus on increasing survivors' understanding of the causes of potentially negative peer interactions and reducing their reliance on adults.

Support for Community School Personnel Working with Pediatric Cancer Patients: A Quality Improvement Initiative

Improved therapies and increased survival rates are sending more pediatric cancer patients and survivors back to their classrooms; however, most community school personnel lack training or experience in working with these students. The aim of this quality improvement project was twofold: (a) to evaluate community school personnel's perceptions of their preparedness to work with patients and childhood cancer survivors who have reentered the classroom; and (b) to standardize school reentry supports to improve community school personnel preparedness. Twenty community school personnel, prekindergarten through 12-grade teachers, guidance counselors, and administrators, who had previously worked with a pediatric cancer patient were surveyed regarding their experiences with the patient's school reentry. Responses were coded and analyzed, and a thematic map was created. School personnel reported concerns related to student functioning, such as academic readiness, cognitive impacts of treatment, social-emotional adjustment, physical ability to participate in school, and medical fragility. They also reported concerns related to their own ability to accommodate the student's needs. These results were used to design educational guides for community personnel consisting of information and resources to support them in managing the unique academic, social-emotional, physical, and medical needs of pediatric cancer patients and survivors in the classroom.

The assessment of executive functioning in pediatric patients with posterior fossa tumors: A recommendation to combine caregiver-based ratings and performance-based tests

OBJECTIVE

This study addresses the issue of drawing valid conclusions about the assessment of executive functioning (EF) in long-term survivors of pediatric posterior fossa tumors (PPFT).

METHOD

All 44 patients (females = 18, mean age = 11 years) were treated consecutively at our department for PPFTs (medulloblastomas, ependymomas, low-grade-gliomas). Four years after diagnosis, their EF was investigated, considering age at diagnosis and treatment type. The validity, sensitivity, and specificity of different EF measures (TMT-B, Number Repetition, WCST, BRIEF) were compared and Strengths-and-Difficulties-Questionnaire was incorporated as a potential screening for EF issues.

RESULTS

EF impairments were found, especially in patients with chemo-/radiotherapy. Caregiver-ratings and performance-based-EF-tests identified different patients as below average. Sensitivity was highest in TMT-B. Strengths-and-Difficulties-Questionnaire was not an adequate screening for EF.

CONCLUSION

It is essential to assess patients with PPFT with performance-based-tests as well as caregiver-questionnaires, since EF impairments are not always visible at the behavioral level but may still influence everyday life.

Educational Pain Points for Pediatric Brain Tumor Survivors: Review of Risks and Remedies

Evolving treatment paradigms have led to increased survival rates for children diagnosed with a brain tumor, and this has increasingly shifted clinical and research focus to morbidity and quality of life among survivors. Among unfavorable outcomes, survivors of pediatric brain tumors are at risk for academic failure and low educational attainment, which may then contribute to lower health related quality of life, lower income and vocational status, and a greater likelihood of dependence on others in adulthood. Several specific risk factors for lower educational performance and attainment have been investigated. These are typically examined in isolation from one another which clouds understanding of the full range and potential interplay of contributors to educational difficulties. This review integrates and summarizes what is known about the direct and indirect barriers to educational success and performance (i.e., educational pain points) to enhance clinician knowledge of factors to consider when working with pediatric brain tumor survivors. Specific barriers to educational success include neurocognitive difficulties, school absences, psychosocial challenges, challenges to knowledge and communication, and physical and sensory difficulties. Finally, we discuss the current state of educational interventions and supports and offer recommendations for future research to improve educational outcomes for pediatric brain tumor survivors.

Effects of chemotherapy for acute lymphoblastic leukemia on cognitive function in animal models of contemporary protocols: A systematic literature review

Survival rates of childhood acute lymphoblastic leukemia (ALL) have improved greatly due to advanced therapies and supportive care. Intrathecal chemotherapy replaced cranial radiation due to radiation-induced neurotoxicity and late-effects. Survivors treated with chemotherapy-only experience neurologic and cognitive problems following cessation of treatment. Very long-term cognitive outcomes remain unclear. Animal models are being generated to assess late-effects of chemotherapy on cognitive function. Although, few address juvenile models of chemotherapy-induced cognitive impairment (CICI) and developing brain, results of this review outline neurocognitive effects of chemotherapy consistent with childhood ALL therapy. Studies demonstrate deficits across cognitive domains including spatial memory, executive function, short-term memory, anxiety and depression. Inflammation, oxidative stress, excitotoxity, and other metabolic disruptions may lead to neurodegeneration associated with cognitive impairment observed in ALL survivors. Interventions directly targeting these mechanisms may prevent and/or promote recovery of cognitive function and improve long-term outcomes. Evidence suggests success of anti-inflammatory and antioxidant treatments in reducing cognitive decline. Animal models provide basis for assessing effects of chemotherapy on neurologic processes to guide future clinical investigations.

Impact of executive functioning on health-related quality of life of pediatric brain tumor survivors

BACKGROUND

Brain tumor survivors are at risk for significant late effects following treatment completion that may adversely impact health-related quality of life (HRQOL). The current study examines the relationship between executive functioning (EF) and HRQOL in pediatric brain tumor survivors within a longitudinal framework. We hypothesized that early deficits in EF would be related to less optimal HRQOL in this population.

PROCEDURE

The current study utilized retrospective medical chart review to identify neurocognitive correlates of HRQOL in 137 youth previously treated for a pediatric brain tumor. Participants completed the Pediatric Quality of Life Inventory (PedsQL) and neuropsychological assessment, including a well-validated measure of executive functioning (Behavior Rating Inventory of Executive Function; BRIEF). General linear regression and multivariate models were utilized to examine the relationship between child executive functioning and HRQOL.

RESULTS

Multiple domains of child executive functioning, as reported by parents on the BRIEF, significantly predicted parent-proxy reported HRQOL after controlling for demographic and medical covariates, including child intellectual functioning (IF). Similarly, after controlling for covariates, the BRIEF Cognitive Regulation Index was a significant predictor of self-reported physical and school functioning domains of HRQOL.

CONCLUSION

Current data demonstrate EF is a significant predictor of HRQOL during survivorship for youth previously diagnosed with a pediatric brain tumor. Results suggest that opportunities may exist to intervene and improve HRQOL of pediatric brain tumor survivors by targeting EF.

Neuropsychological assessment in pediatric oncology survivorship care: utilization of services, results of evaluation, and educational and behavioral health outcomes

PURPOSE

Neuropsychological evaluation has become a standard component of long-term follow-up care for survivors of pediatric cancer. The purpose of the present study was to examine access to, and benefits of, neuropsychological evaluation for survivors.

METHODS

A retrospective chart review was conducted on cancer survivors who were referred for neuropsychological evaluation from a multidisciplinary long-term follow-up (LTFU) clinic approximately 5 years following treatment cessation. Descriptive statistics were calculated, and t-tests and chi-square analyses were utilized to examine variables that may impact survivors' access to neuropsychological services.

RESULTS

One hundred seven survivors between 6 and 26 years old were referred for a neuropsychological evaluation. Referred male patients were less likely than female patients to schedule an evaluation. Consultation with a neuropsychologist in the LTFU clinic was related to more referrals but did not improve attrition rates (55%). Twenty-four percent of evaluated patients displayed severe cognitive impairment and 75% were diagnosed with a psychological disorder. Utilization of educational and behavioral health services did not significantly change following evaluation.

CONCLUSION

Survivors' utilization of neuropsychological services is lower for males than females. The presence of a neuropsychologist in a multidisciplinary team clinic can improve identification of survivors that may benefit from neuropsychological evaluation. Many survivors did not receive recommended services, suggesting patients and families may need additional supports following evaluation. Future research should focus on improving survivors' access to neuropsychological services and identifying barriers to receiving recommended services.

Linguistic-Cognitive Outcomes in Children with Acute Lymphoid Leukemia: An Exploratory Study

Background

Acute lymphoid leukemia (ALL) is the most prevalent cancer of childhood. Impairment in linguistic and memory skills is a possible late sequela in cancer survivors that can limit their quality of life and the overall performance of the individual in society. There is evidence that survivors of ALL treated exclusively with chemotherapy demonstrate significant differences in long-term linguistic and memory functions and also changes in neuroanatomical integrity. However, most studies described do not count on a speech-language pathologist in their team, which we consider important to discuss. Thus, the objective of the present study was to assess memory and vocabulary skills in the pediatric population diagnosed with acute lymphoid leukemia during chemotherapy treatment.

Materials and Methods

An observational cohort study was conducted over a 1.8-year period. Participants of this research were children diagnosed with ALL. All participants were assessed on their linguistic-cognitive skills (ie, vocabulary, short-term memory and lexical access). All data underwent statistical analyses.

Results

The results of the current study found no major significant difference in the linguistic-cognitive performance of children with ALL and their healthy controls. Regarding the linguistic variables, we believe that there should be a differentiation between the effects of the drugs and the effects of social communication skills on performance.

Conclusion

This first characterization of the linguistic-cognitive abilities of children with ALL did not identify differences between these children and their healthy peers, although we were able to identify variables regarding the multidisciplinary team and social communication that should be considered in future studies.

The Influence of Early Childhood Temperament on Later Social-Emotional Functioning in Youth with Cancer

OBJECTIVE

One of the peak incidences of childhood cancer is during the early childhood years. This is also an important time for psychosocial and personality development, and it is well known that early childhood temperament influences later psychosocial functioning. However, this association has not been examined in young children with cancer.

METHODS

Parents of children with cancer (N = 39) and healthy comparisons (N = 35) completed an indicator of temperament (Children's Behavior Questionnaire) when children were young (Mage=4.99 ± 1.05 years). Five years later, parents and youth completed measures of psychosocial functioning (Mage=10.15 ± 1.10 years; Behavior Assessment Scale for Children, 2nd edition and Social Emotional Assets and Resilience Scale).

RESULTS

Parents of healthy comparisons reported that their children demonstrated greater surgency than youth with cancer; there were no differences in negative affect or effortful control. Children with cancer and healthy comparisons were rated similarly on measures of psychosocial functioning. Health status was not a significant predictor of later functioning, but socioeconomic status and temperament were. The influence of temperament was stronger for strengths-based functioning (e.g., social competence, adaptive functioning) versus distress (internalizing and externalizing problems).

CONCLUSIONS

Early childhood temperament is a strong predictor of later psychosocial functioning, regardless of health status. Findings highlight the need to consider temperament in the clinical assessment of psychosocial functioning in children with cancer. Additional research is needed to specifically assess how a diagnosis of cancer in early childhood influences temperament over time.

Executive Function and Psychosocial Adjustment in Adolescent Survivors of Pediatric Brain Tumor

Adolescent survivors of pediatric brain tumor (PBT) are a sparsely studied subset of childhood cancer survivors. Sustaining a PBT may complicate the development of executive functions (EFs), which play a vital role in long-term psychosocial adjustment. In this study, 48 adolescent survivors and their parents completed questionnaires assessing EF, psychological symptoms, fatigue, and adaptive functioning, and 26 survivors underwent neuropsychological assessment. Survivors reported significantly more problems with adaptive functioning than a healthy control group, and this was most strongly associated to executive dysfunction, compared to psychological symptoms and fatigue. The findings have important implications for long-term follow-ups.

Self- and Parent-Reported Psychological Symptoms in Young Cancer Survivors and Control Peers: Results from a Clinical Center

Pediatric cancer survivors are at increased risk for psychological distress. We sought to understand the severity and symptoms' co-occurrence among pediatric survivors compared to controls by rating both self- and parent-reported symptomatology. Forty survivors (22 males; mean age at study time: 12.9 years) participated in the study. Most survivors (85%) had a diagnosis of acute lymphoblastic leukemia. Seventy-nine healthy controls with the same age and gender distribution as the patients were included. A standardized assessment of psychological functioning was conducted by self- and parent-reported symptoms evaluations. The self-reported anxious symptom severity was significantly higher in survivors. A significantly higher proportion of survivors compared to controls had clinically significant anxiety, depression, and combined anxiety symptoms (i.e., social anxiety, separation anxiety, or physical symptoms). In both study groups, the self-reported emotional and somatic symptoms were significantly associated. The multi-informant assessments of the psychological symptoms revealed distinct associations between the child- and parent-reported symptoms in the survivors' group: the survivors' self-reports of depressive symptoms, somatic symptoms, and functional impairment were significantly correlated with the parent reports of child behavioral concerns, somatic complaints, and functional impairment, respectively. Conclusion: Self-reported symptoms showed similar comorbidity profiles in survivors and control peers. The multi-informant assessments detected differences in the association of self- and parent-reported symptoms between the survivor and control groups. The present study showed that multi-informant assessment is critical to understanding symptom profiles and to informing intervention with particular regard to parental participation and support.

Assessment of Executive Functions after Treatment of Childhood Acute Lymphoid Leukemia: a Systematic Review

Individuals treated for childhood acute lymphoblastic leukemia (ALL) have a high survival rate. This fact, however, may lead to neurocognitive impairments in survivors, as shown in some studies. The prefrontal cortex and executive functions seem to be particularly vulnerable due to the late maturation in the development process. Executive impairments have been associated with poorer quality of life in childhood cancer survivors. A systematic review was carried out with studies that assessed executive functions in childhood ALL survivors.\ Studies were collected from five electronic databases: MEDLINE (PubMed); PsycInfo; WebOfScience; LILACS and IBECS. Eighty-four studies were retrieved from the database search, of which 50 were read in full and 26 met the inclusion criteria. The studies were heterogeneous as to the instruments used to assess executive function, the skills assessed and the comparison methods. Despite some discrepancies, ALL survivors seem to exhibit poorer executive functioning than typical controls, but this result did not hold true when subjects were compared to normative mean. Changes in brain structure and dynamics resulting from the disease itself, the toxicity of the treatment and difficulties in coping with the stress during treatment may be related to executive impairments in ALL survivors. Discussion proposed standardized methods and measures for assessing executive functioning in children during and after ALL treatment.

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

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

High occurrence of sleep problems in survivors of a childhood brain tumor with neurocognitive complaints: The association with psychosocial and behavioral executive functioning

BACKGROUND

Survivors of childhood brain tumors are prone to sleep and neurocognitive problems. Effective interventions to improve neurocognitive functioning are largely lacking. In general, sleep problems are negatively related to neurocognitive functioning, but this relationship is unclear in survivors of childhood brain tumors. Therefore, the occurrence of sleep problems, potential risk factors, and the relation between sleep and executive functioning were evaluated.

PROCEDURE

Baseline data of a randomized controlled trial on the effectiveness of neurofeedback were used. Childhood brain tumor survivors 8-18 years of age with parent-reported neurocognitive complaints ≥2 years after treatment were eligible. Parents completed the Sleep Disturbance Scale for Children. Executive functioning was assessed by parents and teachers (Behavior Rating Inventory of Executive Functioning). Multiple linear regression analyses were used to examine sociodemographic and medical characteristics and emotional difficulties and hyperactivity/inattention (Strength and Difficulties Questionnaire) as potential risk factors for sleep problems, and to assess the association between sleep and executive functioning.

RESULTS

Forty-eight percent of survivors (n = 82, 7.0 ± 3.6 years post diagnosis, age 13.8 ± 3.2 years) had sleep problems and scored significantly worse than the norm on the subscales Initiating and Maintaining Sleep, Excessive Somnolence, and the total scale (effect sizes 0.58-0.92). Emotional problems and/or hyperactivity/inattention were independent potential risk factors. Sleep problems were associated with worse parent-reported executive functioning.

CONCLUSIONS

Sleep problems occur among half of childhood brain tumor survivors with neurocognitive problems, and are associated with worse executive functioning. Future studies should focus on the development of sleep interventions for this population, to improve sleep as well as executive functioning.

Association Between Executive Functioning and Functional Impairment Among Pediatric Cancer Survivors and Controls

OBJECTIVE

To examine the impact of cancer treatment upon neurocognitive and functional impairment; and to explore the relationship between these constructs in pediatric cancer survivors compared to controls.

METHOD

A cross-sectional cohort of survivors (n = 26) and controls (n = 53) was included. Survivors were off treatment an average of 6.35 years (SD = 5.38; range 1-15 years) and demonstrated an average "medium" Central Nervous System (CNS) treatment intensity score. Participants completed measures of neurocognitive functions including intellectual assessment (RIST) and executive functions (NIH Examiner), while parents reported on children's functional impairment (BIS).

RESULTS

Survivors were similar to controls in neurocognitive ability, including intellectual and executive functions, and functional impairment. Regardless of group membership, NIH Examiner performance and functional impairment increased with age. Increased impairment was associated with different neurocognitive variables for survivors versus controls.

CONCLUSIONS

Research regarding functional impairment of cancer survivors and the association between neurocognitive deficits and functional impairment has been limited. Our results demonstrate that, while low treatment intensity may confer relative sparing of neurocognitive and executive functioning among survivors, functional impairment continues to be a potential risk. In conclusion, pediatric cancer survivors should be screened for functional difficulties, particularly in the areas of interpersonal relations and self-care.

Associations among diffusion tensor imaging and neurocognitive function in survivors of pediatric brain tumor: A pilot study

The purpose of this study was to determine associations among neurocognitive outcomes and white matter integrity in the inferior fronto-occipital fasciculus (IFOF), uncinate fasciculus (UF), and genu of the corpus callosum (gCC) in survivors of pediatric brain tumor and healthy controls (HCs). Eleven survivors (ages 8-16; >2 years post-treatment) and 14 HCs underwent MRI; diffusion tensor imaging tractography (DSI Studio) was used to assess white matter integrity. Participants completed neuropsychological assessment of overall cognitive ability, executive function, processing speed, divided attention, and memory. As previously reported, survivors performed significantly worse than HCs on measures of overall IQ, working memory, processing speed, and executive function (ps < .01), but not on measures of long-delay memory. Mean fractional anisotropy was significantly lower in survivors than HC in the right IFOF, left UF, and gCC (ps < .05). Correlations with the total sample revealed a number of significant positive associations among white matter tracts and scores on neurocognitive measures. Survivors show deficits on measures of cognitive function and decreased white matter integrity compared to HCs. Results revealed a more general pattern of associations among white matter pathways and neurocognitive outcomes than initially hypothesized. It is possible that survivors with diffuse pathology from treatment effects (i.e., hydrocephalus or posterior fossa syndrome) show more general decreases in cognitive functioning and white matter integrity. Additional research with a larger and more diverse group of survivors is needed to better understand white matter integrity and neurocognitive outcome associations in this population.

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

Background

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

Methods

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

Results

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

Conclusions

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

Automated respiratory sinus arrhythmia measurement: Demonstration using executive function assessment

Respiratory sinus arrhythmia (RSA) is a quantitative metric that reflects autonomic nervous system regulation and provides a physiological marker of attentional engagement that supports cognitive and affective regulatory processes. RSA can be added to executive function (EF) assessments with minimal participant burden because of the commercial availability of lightweight, wearable electrocardiogram (ECG) sensors. However, the inclusion of RSA data in large data collection efforts has been hindered by the time-intensive processing of RSA. In this study we evaluated the performance of an automated RSA-scoring method in the context of an EF study in preschool-aged children. The absolute differences in RSA across both scoring methods were small (mean RSA differences = -0.02-0.10), with little to no evidence of bias for the automated relative to the hand-scoring approach. Moreover, the relative rank-ordering of RSA across both scoring methods was strong (rs = .96-.99). Reliable changes in RSA from baseline to the EF task were highly similar across both scoring methods (96%-100% absolute agreement; Kappa = .83-1.0). On the basis of these findings, the automated RSA algorithm appears to be a suitable substitute for hand-scoring in the context of EF assessment.

Early adolescent language development following intrathecal chemotherapy for acute lymphoblastic leukaemia

PURPOSE

Central nervous system (CNS) prophylaxis in the treatment of childhood acute lymphoblastic leukaemia (ALL) is routinely achieved through intrathecal chemotherapy (ITC). The presence of high level language deficits in older children who received CNS-directed ITC for ALL in early childhood is yet to be elucidated, with previous research suggesting that high level language deficits may appear later in ALL survivors' development at an age when these skills typically emerge.

METHOD

A test battery covering foundational language skills and higher-order language skills was administered to five participants (aged 10-15 years) with a history of ITC for ALL. Conversion of each child's language performance scores to z scores allowed for clinical interpretation of data across the language areas tested.

RESULT

Foundational language skills were, in general, of no clinical concern. Three of the five children presented with clinically impaired language skills in areas including resolving ambiguity, making inferences and composing novel sentences. Performance variation between the participants and within the individual participants was noted.

CONCLUSION

Given the importance of early adolescent language abilities to academic and social development in late primary and secondary schooling, these preliminary findings suggest further research into emerging adolescent language abilities following ITC for ALL is warranted.

Late effects in survivors of childhood acute lymphoblastic leukemia in the context of selected gene polymorphisms

BACKGROUND

It has been shown that approximately half of survivors of childhood acute lymphoblastic leukemia (ALL) have symptomatic late effects (LE) that may be severe or life-threatening. The aim of our study was to assess the health status of childhood ALL survivors after over 10 years of follow-up and to assess its relationships with gene polymorphisms, numbers and types of LEs, as well as with intensity of chemotherapy and cranial radiotherapy (CRT).

METHODS

We conducted a telephone survey in 125 ALL survivors (median time from completion of treatment was 12 years) and compared the results with those obtained in our previous study. Most of the patients were followed-up by local providers.

RESULTS

The prevalence of LEs of approximately 50% was similar in both study groups. More than one LE was found in almost 25% of patients. Endocrine LEs were less frequent than in our previous study (44% vs 22%), probably due to underdiagnosis. The prevalence of hepatitis B/C decreased from 30%/50 to 18% (counted together), and prevalence of neurologic LEs decreased from 18 to 6%. The increase in the rate of second malignancies was not significant (2% vs. 3%). Sixty four percent of patients continued their education at the time of the study. Approximately 51% of ALL survivors who have completed their education by the time of the study had no permanent employment, including 4 mothers of infants and 3 persons qualified for a disability living allowance. These employment problems may have been due to cognitive impairment. The offspring of the ALL survivors included 11 children, all of them healthy. Further analysis showed higher prevalence of hepatitis in patients treated with CRT (p = 0.0001). Genetic studies revealed higher prevalence of hepatitis in patients homozygous for the rs9939609A variant of the FTO gene compared with other patients (p = 0.03). Moreover, wild-type rs1137101 polymorphism (Q223R) of the and leptin receptor gene was more frequent in patients with psychological LEs (p = 0.03).

CONCLUSIONS

The prevalence of LEs in ALL survivors is of key importance. The transition of childhood ALL survivors from pediatric to adult care should be urgently improved to maintain continued follow-up provide high-quality care.

TRIAL REGISTRATION

Bioethics Committee of the Jagiellonian University approved the study protocol. Registration number: KBET/113/B/2006.

Factors influencing risk-based care of the childhood cancer survivor in the 21st century

The population of adult survivors of childhood cancer continues to grow as survival rates improve. Although it is well established that these survivors experience various complications and comorbidities related to their malignancy and treatment, this risk is modified by many factors that are not directly linked to their cancer history. Research evaluating the influence of patient-specific demographic and genetic factors, premorbid and comorbid conditions, health behaviors, and aging has identified additional risk factors that influence cancer treatment-related toxicity and possible targets for intervention in this population. Furthermore, although current long-term follow-up guidelines comprehensively address specific therapy-related risks and provide screening recommendations, the risk profile of the population continues to evolve with ongoing modification of treatment strategies and the emergence of novel therapeutics. To address the multifactorial modifiers of cancer treatment-related health risk and evolving treatment approaches, a patient-centered and risk-adapted approach to care that often requires a multidisciplinary team approach, including medical and behavioral providers, is necessary for this population. CA Cancer J Clin 2018;68:133-152. © 2018 American Cancer Society.

The efficacy of cognitive interventions for improving cognitive performance and academic achievement in children after cancer treatment: A systematic review

Academic decline has been reported in children after cancer treatment, believed to be as a result of cognitive impairment. Cognitive interventions may improve both the present and future outcomes for children after cancer treatment by improving cognitive and/or academic performance. This review aimed to examine the efficacy of cognitive interventions in children who had received cancer treatment. A systematic search of the PsycInfo and PubMed databases was conducted in May 2015 to identify studies in which cognitive interventions were conducted with children who had undergone cancer treatment and were under the age of 21. Cognitive or academic outcomes needed to be reported pre- and post-intervention to meet the inclusion criteria. Eleven studies were included in this review. Computerized and home-based cognitive interventions were found to be most successful at improving cognitive skills. However, few cognitive interventions assessed academic achievement specifically. Future cognitive intervention research studies should include measures of academic achievement outcomes, because academic achievement and cognitive outcomes may differ. Future research regarding the effectiveness of early, home-based and computerized intervention is warranted.

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.

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

Survivors of childhood cancer are at risk for attention problems. The objectives of this study were to assess concordance between parent-, teacher-, and self-report ratings on a measure of attention (Conners Rating Scales, 3rd ed.; Conners, 2008) in adolescent survivors of childhood cancer and to examine associations with a performance-based task. The Conners 3 was completed by 80 survivors of pediatric cancer (39 brain tumor, 41 acute lymphoblastic leukemia; ages 12–17; at least 1 year posttreatment; 51.3% male) as well as their parents and 1 teacher. In addition, survivors completed a continuous performance test. Parents and teachers demonstrated moderate agreement on most subscales; however, agreement was weaker than would be expected based on the normative sample. Agreement between self- and proxy ratings was more variable. The strongest associations for all raters were observed on the Learning Problems subscale. There were significant mean differences between parent and teacher ratings, with parents reporting more problems across subscales. Only self-ratings of Inattention were significantly associated with the continuous performance test (omission errors). Agreement across raters in assessment of attentional functioning in adolescent survivors of childhood cancer is modest. Findings support the need to obtain multiple ratings of behavior, including both proxy- and self-report, when assessing youth with cancer, particularly adolescents.

Development of a web-based executive functioning intervention for adolescents with epilepsy: The Epilepsy Journey

INTRODUCTION

Youth with epilepsy exhibit significant deficits in executive functioning (EF), yet there are few interventions to improve EF for adolescents. The aims of the current study were to develop an individually-tailored intervention, called Epilepsy Journey, to improve aspects of EF through an iterative, patient-centered process including focus groups and usability testing.

METHODS

Five adolescents and caregivers participated in focus groups. This input was used to develop ten learning modules based on subscales of the Behavioral Rating Inventory of Executive Functions and key issues that may impact EF in adolescents. Six adolescents participated in usability testing and a usability expert conducted a heuristic evaluation. Demographic information, chart reviews and measures of EF were also completed.

RESULTS

Focus group participants and their parents reported difficulties with memory, attention, organization, monitoring, initiation, impulsivity, emotional control, sleep, awareness in schools and managing stress. They also identified successful strategies to address memory and organizational difficulties. Usability testing of the resultant Epilepsy Journey modules revealed problems with navigation and identified features that promoted usability, including progress bars and interactive modules. Program modifications were made after each usability trial resulting in a relatively brief, interactive and readily navigable program. Perceived utility was high with all but one participant. Participants rated the content as helpful and indicated they would recommend Epilepsy Journey to others.

CONCLUSIONS

Feedback from the focus group and usability testing yielded a feasible, acceptable, relevant and user-friendly web-based intervention for adolescents with epilepsy. The Epilepsy Journey program will be further tested in an open pilot with adolescents with epilepsy and associated EF deficits.

Attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy

BACKGROUND AND PURPOSE

This study examines attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy (PBRT).

MATERIAL AND METHODS

We examined 39 survivors (age 6-19years) who were 3.61years post-PBRT on average. Craniospinal (CSI; n=21) and focal (n=18) subgroups were analyzed. Attention, processing speed, and executive functioning scores were compared to population norms, and clinical/demographic risk factors were examined.

RESULTS

As a group, survivors treated with focal PBRT exhibited attention, processing speed, and executive functioning that did not differ from population norms (all p>0.05). Performance in the CSI group across attention scales was normative (all p>0.05), but areas of relative weakness were identified on one executive functioning subtest and several processing speed subtests (all p<0.01).

CONCLUSIONS

Survivors treated with PBRT may exhibit relative resilience in cognitive domains traditionally associated with radiation late effects. Attention, processing speed, and executive functioning remained intact and within normal limits for survivors treated with focal PBRT. Among survivors treated with CSI, a score pattern emerged that was suggestive of difficulties in underlying component skills (i.e., processing speed) rather than true executive dysfunction. No evidence of profound cognitive impairment was found in either group.

The Behavior Rating Inventory of Executive Function (BRIEF) to Identify Pediatric Acute Lymphoblastic Leukemia (ALL) Survivors At Risk for Neurocognitive Impairment

Neurocognitive problems, including executive dysfunction, are potential late effects of pediatric acute lymphoblastic leukemia treatment. Surveillance for neurocognitive impairment in a timely and efficient manner is imperative to ongoing clinical care. We sought to determine if the Behavior Rating Inventory of Executive Function (BRIEF) Parent Form identified leukemia survivors with cognitive impairment. In this 28-site cross-sectional study, parents of 256 children, a mean of 8.9±2.2 years after treatment for standard-risk precursor-B acute lymphoblastic leukemia and in first remission, completed the BRIEF. We used a multivariate logistic regression to calculate the association between elevated scores on 3 composite BRIEF indices (Behavioral Regulation Index, Metacognition Index, Global Executive Composite [GEC]) and special education and attention-deficit/hyperactivity disorder (ADHD) outcomes. All BRIEF index scores were significantly associated with receipt of special education services or ADHD. The BRI was most strongly associated with ADHD (odds ratios=4.33; 95% confidence interval, 1.72-10.9). The GEC was most strongly associated with ADHD (odds ratios=4.46; 95% confidence interval, 1.77-11.22). Elevated scores on the BRIEF GEC were associated with low sensitivity (24.1 to 39.1) for detecting the outcomes but better specificity (range, 87.7 to 89.3). These results suggest that the parent-completed BRIEF is associated with clinical outcomes but is not a sensitive tool to identify leukemia survivors that require a comprehensive neuropsychological assessment.

Behavioral, Social, and Emotional Symptom Comorbidities and Profiles in Adolescent Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

In the general population, psychological symptoms frequently co-occur; however, profiles of symptom comorbidities have not been examined among adolescent survivors of childhood cancer.

PATIENTS AND METHODS

Parents of 3,893 5-year survivors of childhood cancer who were treated between 1970 and 1999 and who were assessed in adolescence (age 12 to 17 years) completed the Behavior Problems Index. Age- and sex-standardized z scores were calculated for symptom domains by using the Childhood Cancer Survivor Study sibling cohort. Latent profile analysis identified profiles of comorbid symptoms, and multivariable multinomial logistic regression modeling examined associations between cancer treatment exposures and physical late effects and identified symptom profiles. Odds ratios (ORs) and 95% CIs for latent class membership were estimated and analyses were stratified by cranial radiation therapy (CRT; CRT or no CRT).

RESULTS

Four symptoms profiles were identified: no significant symptoms (CRT, 63%; no CRT, 70%); elevated anxiety and/or depression, social withdrawal, and attention problems (internalizing; CRT, 31%; no CRT, 16%); elevated headstrong behavior and attention problems (externalizing; CRT, no observed; no CRT, 9%); and elevated internalizing and externalizing symptoms (global symptoms; CRT, 6%; no CRT, 5%). Treatment with ≥ 30 Gy CRT conferred greater risk of internalizing (OR, 1.7; 95% CI, 1.0 to 2.8) and global symptoms (OR, 3.2; 95% CI, 1.2 to 8.4). Among the no CRT group, corticosteroid treatment was associated with externalizing symptoms (OR, 1.9; 95% CI, 1.2 to 2.8) and ≥ 4.3 g/m(2) intravenous methotrexate exposure was associated with global symptoms (OR, 1.5; 95% CI, 0.9 to 2.4). Treatment late effects, including obesity, cancer-related pain, and sensory impairments, were significantly associated with increased risk of comorbid symptoms.

CONCLUSION

Behavioral, emotional, and social symptoms frequently co-occur in adolescent survivors of childhood cancer and are associated with treatment exposures and physical late effects. Assessment and consideration of symptom profiles are essential for directing appropriate mental health treatment for adolescent survivors.

Executive dysfunction is associated with poorer health-related quality of life in pediatric brain tumor survivors

Children with a brain tumor (BT) are at risk for a number of physical and cognitive problems that may lower their health-related quality of life (HRQoL). Executive functioning (EF) and intellectual ability are hypothesized to associate with HRQoL and deficits in these areas may be amenable to interventions. This study aimed to investigate intellectual function, EF, and HRQoL following conformal radiation therapy (CRT) for pediatric BT. Forty-five BT survivors (age 12.68 ± 2.56) treated with CRT participated. Thirty-six siblings of BT patients (age 12.36 ± 2.13) and 33 survivors of non-CNS solid tumors (ST; age 12.18 ± 2.88) were comparison groups. IQ estimate (Wechsler Abbreviated Scale of Intelligence; WASI), EF ratings (Behavior Rating Inventory of Executive Function; BRIEF), and HRQoL ratings (KINDL-R) were obtained. BT survivors reported lower overall HRQoL than ST survivors (p = .012). Parents reported lower overall HRQoL for BT survivors than siblings (p = .014). Parent-report on individual areas of HRQoL was higher than self-report for most subscales. IQ and HRQoL ratings were not related (Parent r = .17, p = .27; Child r = .11, p = .49). EF ratings correlated with Parent (r = -.15 to -.73) but not Child HRQoL ratings. Children with BT experienced poorer HRQoL than controls. Children's HRQoL was consistently rated higher by parent- than self-report across all domains. HRQoL was associated with EF, but not with IQ. These findings identify interventions targeting EF (e.g., cognitive rehabilitation, medication) as a possible avenue for improving HRQoL in childhood BT survivors.

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

Central nervous system cancers or exposure to CNS-directed therapies increase risk for neuropsychological deficits. There are no accepted guidelines for assessment of neuropsychological functioning in this population. A multifaceted literature search was conducted and relevant literature reviewed to inform the guidelines. Studies of neuropsychological outcomes are widely documented in the pediatric oncology literature. There is strong evidence of need for neuropsychological assessment, but insufficient evidence to guide the timing of assessment, nor to recommend specific interventions. Children with brain tumors and others at high risk for neuropsychological deficits should be monitored and assessed for neuropsychological deficits.

Executive functioning profiles from the BRIEF across pediatric medical disorders: Age and diagnosis factors

The objective of the study was to compare executive functioning (EF) profiles across several pediatric medical conditions and explore the influence of age of diagnosis and evaluation. A retrospective, cross-sectional study of 734 children aged 5 to 18 years was conducted across five medical groups (brain tumor, leukemia [ALL], epilepsy [EPI], neurofibromatosis type 1 [NF1], and ornithine transcarbamylase deficiency [OTC-D]), attention deficit hyperactivity disorder (ADHD) controls, and matched healthy controls. We compared groups across the scales of a parent-completed Behavior Rating Inventory of Executive Functioning (BRIEF) using a repeated measures analysis of variance (ANOVA). Separate ANOVAs were conducted to look at age factors. The results showed that the ADHD group differed from all other groups and had the highest level of reported EF problems. The NF1 and OTC-D groups differed significantly from the healthy comparison group for overall EF problems, while the EPI and cancer groups did not. Working memory was the most elevated scale across medical groups, followed by plan/organize. Children with medical disorders were two to four times more likely than healthy controls to have clinically significant problems in several EF domains. There was a main effect for age at diagnosis and age at evaluation. A subset of children with medical disorders were found to have parent-reported EF difficulties, with particular vulnerability noted in working memory and organizational/planning skills. This has relevance for the development of interventions that may be helpful across disorders. Children with particular diagnoses and earlier age of diagnosis and evaluation had greater reported EF problems.