Assessment of proxy-reported responses as predictors of motor and sensory peripheral neuropathy in children with B-lymphoblastic leukemia

Chemotherapy-induced peripheral neuropathy (CIPN), a common condition in children with acute lymphoblastic leukemia, can be challenging to diagnose. Using data from Children's Oncology Group AALL0932 physical function study, we sought to determine if parent/guardian proxy-reported responses from the Pediatric Outcomes Data Collection Instrument could identify children with motor or sensory CIPN diagnosed by physical/occupational therapists (PT/OT). Four variables moderately discriminated between children with and without motor CIPN (c-index 0.76, 95% confidence interval [CI]: 0.64-0.84), but sensory and optimism-corrected models had weak discrimination (c-index sensory models 0.65, 95% CI: 0.54-0.74). New proxy-report measures are needed to identify children with PT/OT diagnosed CIPN.

Persistence of Chemotherapy-Induced Peripheral Neuropathy Despite Vincristine Reduction in Childhood B-Acute Lymphoblastic Leukemia

BACKGROUND

Children with B-acute lymphoblastic leukemia (B-ALL) are at risk for chemotherapy-induced peripheral neuropathy (CIPN). Children's Oncology Group AALL0932 randomized reduction in vincristine and dexamethasone (every 4 weeks vs 12 weeks during maintenance in the average-risk subset of National Cancer Institute standard-B-ALL (SR AR B-ALL). We longitudinally measured CIPN, overall and by treatment group.

METHODS

AALL0932 standard-B-ALL patients aged 3 years and older were evaluated at T1-T4 (end consolidation, maintenance month 1, maintenance month 18, 12 months posttherapy). Physical and occupational therapists (PT/OT) measured motor CIPN (hand and ankle strength, dorsiflexion and plantarflexion range of motion), sensory CIPN (finger and toe vibration and touch), function (dexterity [Purdue Pegboard], and walking efficiency [Six-Minute Walk]). Proxy-reported function (Pediatric Outcome Data Collection Instrument) and quality of life (Pediatric Quality of Life Inventory) were assessed. Age- and sex-matched z scores and proportion impaired were measured longitudinally and compared between groups.

RESULTS

Consent and data were obtained from 150 participants (mean age = 5.1 years [SD = 1.7], 48.7% female). Among participants with completed evaluations, 81.8% had CIPN at T1 (74.5% motor, 34.1% sensory). When examining severity of PT/OT outcomes, only handgrip strength (P < .001) and walking efficiency (P = .02) improved from T1-T4, and only dorsiflexion range of motion (46.7% vs 14.7%; P = .008) and handgrip strength (22.2% vs 37.1%; P = .03) differed in vincristine and dexamethasone every 4 weeks vs vincristine and dexamethasone 12 weeks at T4. Proxy-reported outcomes improved from T1 to T4 (P < .001), and most did not differ between groups.

CONCLUSIONS

CIPN is prevalent early in B-ALL therapy and persists at least 12 months posttherapy. Most outcomes did not differ between treatment groups despite reduction in vincristine frequency. Children with B-ALL should be monitored for CIPN, even with reduced vincristine frequency.

Longitudinal analysis of quality of life outcomes in children during treatment for acute lymphoblastic leukemia: A report from the Children’s Oncology Group (COG) AALL0932

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Background: 5-year event-free survival for average-risk acute lymphoblastic leukemia (AR-ALL) in children is ~95%. However, therapy involves multi-agent chemotherapy, frequent hospital visits (duration of therapy is 26 months for girls and 38 months for boys) and painful procedures that can adversely affect quality of life (QOL). Methods: AR-ALL patients enrolled on COG AALL0932 were offered participation if ≥4 years old at diagnosis with an English-speaking parent. At ~2, 8, 17, 26, and 38 (boys only) months after diagnosis, parents completed the PedsQL4.0 and the Family Assessment Device instruments for QOL (assessing physical and emotional functioning) and family functioning, respectively. The proportions of individuals scoring in the impaired range (i.e. 2 SD below population mean) were calculated at each timepoint. Patterns of impairment over time and potential predictors were examined. Results: 594 participants with AR-ALL (48% female, 68% white) were diagnosed at a median age of 5.6 (IQR: 4.6–7.1) years. At 2 months, a significant percentage of participants had impaired scores compared to population norms for physical (36.5 vs. 2.3; 95% CI 32.3-40.8) and emotional functioning (26.2 vs. 2.3; 95% CI 22.5-30.2). Although scores improved over time, elevations persisted at 26 months for physical (11.9 vs. 2.3; 95% CI 8.4-16.1) and emotional (9.8 vs. 2.3; 95% CI 2.0-6.7) functioning. In repeated measures analysis with multivariate modeling, emotional impairment at 2 months (OR 3.7; 95% CI 1.5-7.7) and abnormal family functioning (OR 1.5; 95% CI 1.1-2.1) significantly predicted emotional impairment. QOL outcomes were similar for girls at 26 months and boys at 38 months. Conclusions: Many children with AR-ALL experience severe impairment in both physical and emotional functioning that begins early in treatment and persists. Family functioning is a modifiable risk factor that may be targeted for early screening and intervention.

Comorbidity, case complexity, and effects of evidence-based treatment for children referred for disruptive behavior

Comorbidity and complexity of cases seen in clinical work form a basis for discounting the applicability and generality of evidence-based treatments (EBTs). The authors evaluated treatment outcomes in 2 samples of clinically referred children who met criteria for oppositional defiant disorder (n = 183; 42 girls, 141 boys; ages 3-14) or conduct disorder (n = 132; 35 girls, 97 boys; ages 7-14) but varied in comorbidity (up to 5 additional disorders). In addition to comorbidity, 4 domains of case complexity were evaluated: scope and severity of child dysfunction, socioeconomic disadvantage, parent and family functioning, and barriers that emerged during treatment. Comorbidity was associated with greater therapeutic change. Children who varied in comorbidity did not differ on outcome measures at the end of treatment. Complexity was either unrelated or positively related to therapeutic change. As an exception, perceived barriers were associated with less child improvement, but, even with high barriers, effect sizes for these children were large. The findings suggest that comorbidity or complexity of cases does not necessarily influence outcome or limit the applicability of EBTs.

Pretreatment social relations, therapeutic alliance, and improvements in parenting practices in parent management training

The authors examined the parent-therapist alliance in parent management training for children (N = 218; 53 girls and 165 boys, ages 2-14) referred clinically for oppositional, aggressive, and antisocial behavior. The interrelations of pretreatment parent social relationships, the parent-therapist alliance over the course of treatment, and improvements in parenting practices at the end of treatment were evaluated by different raters. As expected, the better the quality of the parent-therapist alliance, the greater the improvements in parenting practices by the end of treatment. Social relations of the parents prior to treatment were associated with the parent-therapist alliance during treatment and parental improvements at the end of treatment. The relation between the therapeutic alliance and improvement in parenting practices was partially explained by pretreatment parent social relations.

The therapeutic alliance in cognitive-behavioral treatment of children referred for oppositional, aggressive, and antisocial behavior

The authors examined the therapeutic alliance in evidence-based treatment for children (N = 185, 47 girls, 138 boys; ages 3-14 years) referred clinically for oppositional, aggressive, and antisocial behavior. Different alliances (child-therapist, parent-therapist) were assessed from each participant's perspective at 2 points over the course of treatment. As predicted, both child-therapist and parent-therapist alliances related to therapeutic change, family experience of barriers to participation in treatment, and treatment acceptability. Greater alliance was associated with greater therapeutic change, fewer perceived barriers, and greater treatment acceptability. The findings could not be attributed to the influence of socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction or to rater effects (common rater variance in the predictors and criteria).

The therapeutic alliance in cognitive-behavioral treatment of children referred for oppositional, aggressive, and antisocial behavior

The authors examined the therapeutic alliance in evidence-based treatment for children (N = 185, 47 girls, 138 boys; ages 3-14 years) referred clinically for oppositional, aggressive, and antisocial behavior. Different alliances (child-therapist, parent-therapist) were assessed from each participant's perspective at 2 points over the course of treatment. As predicted, both child-therapist and parent-therapist alliances related to therapeutic change, family experience of barriers to participation in treatment, and treatment acceptability. Greater alliance was associated with greater therapeutic change, fewer perceived barriers, and greater treatment acceptability. The findings could not be attributed to the influence of socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction or to rater effects (common rater variance in the predictors and criteria).

Treatment of parental stress to enhance therapeutic change among children referred for aggressive and antisocial behavior

This study evaluated a parent problem-solving (PPS) intervention designed to augment the effects of evidence-based therapy for children referred to treatment for aggressive and antisocial behavior. All children (N = 127, ages 6-14 years) and their families received problem-solving skills training (PSST), and parents received parent management training (PMT). Families were randomly assigned to receive or not to receive an additional component (PPS) that addressed parental stress over the course of treatment. Children improved with treatment; the PPS intervention enhanced therapeutic change for children and parents and reduced the barriers that parents experienced during treatment. The implications of the findings for improving evidence-based treatment as well as the limitations of adding components to treatment are detailed.