Developmental perspectives on optimizing educational and vocational outcomes in child and adult survivors of cancer

Integrative review of school integration support following pediatric cancer

PURPOSE

This study aims to understand parents' experiences of school integration support for their child's transition to K-12 schooling during or after cancer treatment.

METHODS

This integrative literature review used PubMed, CINAHL, PsycINFO, and Embase databases and included articles from January 2000 to July 2022 describing parent experiences with support from healthcare providers, school faculty/systems, and school integration programs. This review was guided by an adapted School Re-Entry Model and used constant comparison to identify common themes and guide synthesis. The Johns Hopkins Evidence and Quality Guide was used to appraise article quality and level of evidence.

RESULTS

Thirty-five articles were included in the final review: seventeen qualitative, fourteen quantitative, and four mixed or multi-method designs. Parents reported experiences receiving support from healthcare providers, school faculty/systems, school integration programs, and "other" sources. Parents reported both facilitators and barriers to communication, knowledge, and the process of receiving school integration support.

CONCLUSIONS

Parents found neuro/psychologists highly supportive but reported limited support from other healthcare providers. Most parents reported mixed experiences with school faculty and reported many barriers to school system support. Parents reported positive experiences with school integration programs; however, limited programs were available.

IMPLICATIONS FOR CANCER SURVIVORS

Future programs and research should focus on addressing identified barriers and facilitators of school integration support. Further work is also needed to understand a wider range of parent experiences during school integration.

Developing a Tool for Measuring Parent Knowledge and Barriers to Supportive School Integration After Diagnosis of Childhood Cancer

Background: Children treated for cancer are at risk for long-term neurocognitive late effects that can impact school attainment, employment, and quality of life. Obtaining formal education support can be critical to later success but may depend upon parent knowledge and ability to access needed support. The purpose of this study was to develop and evaluate the psychometric properties of a scale to measure the perceived support that parents received upon their child's return to school during or after cancer treatment. Methods: Exploratory factor analyses evaluated the construct validity of survey items. Cronbach's alpha was used to test the internal consistency and independent t-tests evaluated the concurrent criterion validity of resulting subscales. Results: The exploratory factor analyses resulted in two subscales, Barriers to Supportive School Integration (13 items) and Parent School Integration Knowledge (three items). All items loaded at least 0.49 onto each factor, with Cronbach's alpha values of 0.927 and 0.738, respectively. The Knowledge subscale additionally demonstrated concurrent criterion validity; higher Knowledge subscale scores were found among parents who reported receiving information about treatment-related cognitive/school problems from healthcare providers (p < .001). Discussion: The Parent School Integration Knowledge and Barriers to Supportive School Integration subscales demonstrated preliminary evidence for good construct validity and internal consistency. These subscales may be used in future research to assess parent knowledge, barriers to receiving support, and overall experience of supportive school integration after the diagnosis of pediatric cancer.

Meta-analysis of neurocognitive rehabilitation for cognitive dysfunction among pediatric cancer survivors

Cancer and its treatment significantly affect the cognitive functioning of pediatric cancer survivors. This meta-analysis aimed to examine the effects of neurocognitive rehabilitation interventions on the cognitive functioning and intellectual performance of pediatric cancer survivors. Four databases were searched until December 15, 2021. RevMan 5.4 was used to analyze the effects of neurocognitive rehabilitation interventions on the cognitive functioning of pediatric cancer survivors. Ten eligible randomized controlled trials were initially identified, and nine of these were included in the meta-analysis. For the working memory outcome, the pooled effect results favored study interventions and had statistical significance at postintervention assessment (Z = 2.24, P = 0.03). For the attention outcome, there were significant statistical differences at postintervention and 3/6-month follow-up assessment (Z = 2.72, P = 0.007 and Z = 10.45, P < 0.001, respectively). For the executive functioning outcome, there were significant statistical differences at postintervention and 3/6-month follow-up assessment (Z = 2.90, P = 0.004 and Z = 14.75, P < 0.001, respectively). For the academic/intellectual performance secondary outcome, the pooled overall effects of study interventions on the academic/intellectual outcome were positive at postintervention and follow-up assessment (Ps < 0.001). No studies reported any adverse events related to neurocognitive and educational interventions. This meta-analysis found that neurocognitive rehabilitation interventions improve the working memory, attention, and executive functioning of pediatric cancer survivors at postintervention and short-term follow-up. Neurocognitive rehabilitation also has positive effects on the academic/intellectual performance of this study population during a vulnerable period in their development.

Cognitive function of children and adolescent survivors of acute lymphoblastic leukemia: A meta-analysis

Pediatric cancer and its treatment may have an impact on the neurocognitive functions of childhood cancer survivors (CCS). The aim of the present meta-analysis was to compare the intelligence quotient (IQ) scores between CCS of acute lymphoblastic leukemia (ALL) and controls. A comprehensive electronic search identified original research articles that reported scores of the Wechsler Intelligence Scale (WISC; WISC-III, WISC-IV and WISC-R) for children and adolescents, aged 6-16 years at evaluation, survivors of ALL and healthy controls. The included CCS had completed anticancer treatment and were in remission at the time of assessment. A total of 16 studies were included in the meta-analysis, out of 128 extracted studies, and involved a total of 1,676 children and adolescents: 991 CCS (ALL) and 685 healthy controls. Among the studies, a random effects model revealed a moderate estimate of effect size [standardized mean difference (SMD), -0.78; 95% CI, -1.05 to -0.50], indicating that the WISC scores for total IQ were significantly lower in the CCS than in the controls. The mean total IQ range was 85.2-107.2 in the CCS and 88.4-114.1 in the controls. The difference in the mean total IQ between controls and CCS ranged from -13.8 to 20.6. As regards the WISC scores for verbal IQ, 11 studies were included. A random effects model revealed a moderate estimate of effect size (SMD, -0.71; 95% CI, -1.05 to -0.38), indicating that the WISC scores for verbal IQ were significantly lower in the CCS than in the controls. Among the 9 studies that had available data for performance IQ scores, a fixed effect model revealed a moderate estimate of effect size (SMD, -0.80; 95% CI, -1.09 to -0.52), indicating that the WISC scores for performance IQ were significantly lower in the CCS than in the controls. As the survival rates of children and adolescents with ALL are steadily increasing, regular, lifelong follow-up for neurocognitive late effects is imperative in order to improve their education and employment prospects and overall, their quality of life.

Adolescent survivors' information needs for transitions to postsecondary education and employment

BACKGROUND

Adolescent and young adult (AYA) survivors of cancer and central nervous system (CNS) tumors endure major life disruptions with their diagnosis, treatment, and the burden of emerging learning difficulties. Survivors and their parents often struggle to obtain more academic support as survivors transition through school. This study explored the knowledge and experience survivors and their parents need as they progress through school to college.

METHODS

This cross-sectional study examined childhood cancer and CNS tumor survivors, aged 11 to 21 years, with a known learning difficulty (Individual Education Plan, 504 Plan) and their parents. We assessed participants' knowledge of and experience with transition planning for postsecondary education and independent living.

RESULTS

Ninety-two AYA survivors and parents (45 survivors, 47 parents) completed the survey. High school-aged survivors described their learning difficulties better than middle school-aged survivors. Survivors estimated their abilities higher than did their parents. Despite a majority of survivors expecting to attend college, 68.5% of survivors and 57.9% of parents were not certain how to get special accommodations for standardized college entrance exams. Only 20.8% of survivors were aware of what a transition plan includes. Parents understood the transition planning process and when it should begin better than the students (P = 0.001), but many parents (40.0%) were still unsure.

CONCLUSIONS

AYA survivors and parents lack knowledge necessary to successfully transition to their goals after high school. Greater education is needed.

Developmental Work Personality Among Young Adult CNS Cancer Survivors: An Exploratory Study

The primary aim of this brief exploratory study is to examine differences in developmental work personality in a sample of young adult CNS cancer survivors and a group of young adult college students without disabilities. Participants were 43 young adults with central nervous systems cancer (females = 58.1%, Mean age = 21.64, SD = 3.64) and a comparison sample of 45 typically developing others who were college students (females = 77.3%, mean age = 20.91, SD = 1.04). They completed the Developmental Work Personality Scale (DWPS). Group differences in developmental work personality were examined using multivariate analysis of variance procedures. Results indicated that overall developmental work personality, and subscale scores of work tasks, and social skills were significantly lower among CNS cancer survivors compared to typically developing other young adults. Findings suggest influences of developmental atypicality in work personality with CNS cancer survivorship.

Mathematics intervention for prevention of neurocognitive deficits in childhood leukemia

BACKGROUND

Despite evidence that CNS treatment is associated with cognitive and academic impairment, interventions to prevent or mitigate these problems are limited. The purpose was to determine if early intervention can prevent declines in mathematics abilities.

PROCEDURES

Fifty-seven children with ALL were enrolled and randomized to a Mathematics Intervention or Standard Care. Subjects completed neurocognitive assessments prior to the intervention, post-intervention, and 1 year later. Parents received written results and recommendations for use with their school. The Mathematics Intervention was based on Multiple Representation Theory and delivered individually over 1 year.

RESULTS

Thirty-two of 57 subjects completed the study and were included in data analyses. These 32 subjects completed all neurocognitive assessments and, for those in the Intervention Group, 40-50 hours of the Mathematics Intervention. There were no group differences on relevant demographic variables; risk stratification; number of intrathecal methotrexate injections; or high dose systemic methotrexate. Significant improvements in calculation and applied mathematics from Baseline to Post-Intervention (P = 0.003 and 0.002, respectively) and in visual working memory from Baseline to 1 year Follow-up (P = 0.02) were observed in the Intervention but not the Standard Care Group. Results from repeated measures ANOVA demonstrated significant between group differences for applied mathematics [F(2,29) = 12.47, P < 0.001] and visual working memory [F(2,29) = 5.53, P = 0.009].

CONCLUSIONS

The Mathematics Intervention improved mathematics abilities and visual working memory compared to standard care. Future studies are needed to translate the Mathematics Intervention into a "virtual" delivery method more readily available to parents and children.

Parental follow-through of neuropsychological recommendations for childhood-cancer survivors

In the past 40 years, outcomes for children with cancer have changed considerably. The survival rate has increased to approximately 80%. With success and survival come detriments that often occur over time called late effects of cancer treatment. When the central nervous system is treated with radiation or chemotherapy, we often see impairment to the senses, cognition, and learning. For children who receive central nervous system treatment, follow-up with a neuropsychological evaluation is an excellent tool to evaluate learning and behavior in relationship to a child's brain. The authors' research examined neuropsychological evaluations for common themes related to diagnosis, age, sex, and/or treatment received, and the authors investigated whether the families implemented recommendations suggested in the neuropsychological evaluation. Less than 50% of recommendations from evaluations were implemented. The authors found that families need ongoing support and knowledge to implement the neuropsychological testing recommendations. Families need assistance navigating the school system and advocating for their child's needs. Continued surveillance of the child's academic needs by both the psychology and oncology teams is essential for long-term success.

Educational and vocational achievement among long-term survivors of adolescent cancer in Germany

BACKGROUND

Adolescence involves graduating from school and preparing one's professional career. The accomplishment of these tasks may be hampered by the experience of cancer. This study investigates the educational and professional achievements of German long-term survivors of adolescent cancer.

PROCEDURE

Adult survivors of cancer during adolescence (n = 820, age at onset between 15 and 18 years; M = 15.8, SD = 0.9 years; age at follow-up: M = 30.4, SD = 6.0 years) were recruited through the German Childhood Cancer Registry. They completed self-reports with standard items on their educational and vocational level and their current occupational situation. Outcomes were compared to an age-matched sample from the general population (German Socio-Economic Panel, n = 820, age: M = 30.4, SD = 6.7). Risk factors for educational and vocational underachievement were identified by subgroup analyses.

RESULTS

Compared to peers from the general population, survivors of cancer during adolescence achieved higher educational and vocational levels. A higher proportion of survivors was employed; however, survivors were significantly older when starting their first occupation. Subgroup analyses revealed that neuropsychological late effects were associated with reduced rates of graduation from university and of employment among the survivors. No such effect of neuro-cognitive late effects occurred for high school graduation.

CONCLUSIONS

Most German survivors of cancer during adolescence participate in school and vocational life without major difficulties. Problems particularly arise for survivors with neuropsychological sequelae. Further research should investigate whether these results can be attributed to the German support system for pediatric cancer patients or to sample effects.

Factors associated with resilience of school age children with cancer

AIM

To identify factors associated with resilience of school age children with cancer.

METHODS

The participants were 74 children, 10-15 years old who were diagnosed with cancer at least 6 months prior to data collection. The instruments used were; a self-reported questionnaire on resilience, Family Adaptability and Cohesion Evaluation Scale III, measurements of relationship with friends and teachers. Descriptive, Pearson correlation and multiple regression analyses were used to analyse the data.

RESULTS

The average score for resilience was 98.49 (range: 32-128). There was no statistically significant relationship with resilience for age, gender, religion, existence of siblings, mother's age, academic performance, duration of illness or type of cancer. In bivariate analysis, family adaptability and cohesion (r= 0.535, P < 0.001), relationship with friends (r= 0.520, P < 0.001) and teachers (r= 0.318, P < 0.01) were significantly related to resilience. However, the results of multiple regression analysis showed that only family function (beta= 0.257, P < 0.05) and relationship with friends (beta= 0.581, P < 0.01) were significantly associated with resilience.

CONCLUSIONS

School age children with cancer who reported higher family function and positive relationships with friends showed higher resiliency than their counterparts. Thus, it is important to help the families of children with cancer to enhance family function and help children to adjust to school re-entry by maintaining ties with school friends and teachers during treatment. Development of counselling programmes for parents to promote family adaptation and cohesion and educational programmes for classmates and teachers are recommended.

Educational attainment among adult survivors of childhood cancer in Great Britain: a population-based cohort study

BACKGROUND

Previous studies of educational attainment among childhood cancer survivors were small, had contradictory findings, and were not population based. This study investigated educational attainment in a large population-based cohort of survivors of all types of childhood cancer in Great Britain.

METHODS

Four levels of educational attainment among 10,183 cancer survivors--degree, teaching qualification, advanced (A') levels, and ordinary (O') levels--were compared with expected levels in the general population. A questionnaire was used to obtain educational attainment data for survivors, and comparable information for the general population was available from the General Household Survey. Factors associated with level of educational attainment achieved by cancer survivors were identified using multivariable logistic regression together with likelihood ratio tests. Logistic regression adjusting for age and sex was used for comparisons with the general population. All statistical tests were two-sided.

RESULTS

Childhood cancer survivors had lower educational attainment than the general population (degree: odds ratio [OR] = 0.77, 99% confidence interval [CI] = 0.68 to 0.87; teaching qualification: OR = 0.85, 99% CI = 0.77 to 0.94; A'level: OR = 0.85, 99% CI = 0.78 to 0.93; O'level: OR = 0.81, 99% CI = 0.74 to 0.90; P < .001, all levels). Statistically significant deficits were restricted to central nervous system (CNS) neoplasm and leukemia survivors. For leukemia, only those treated with radiotherapy were considered. Odds ratios for achievement by irradiated CNS tumor survivors were 50%-74% of those for cranially irradiated leukemia or nonirradiated CNS tumor survivors. Survivors at greater risk of poorer educational outcomes included those treated with cranial irradiation, diagnosed with a CNS tumor, older at questionnaire completion, younger at diagnosis, diagnosed with epilepsy, and who were female.

CONCLUSIONS

Specific groups of childhood cancer survivors achieve lower-than-expected educational attainment. Detailed educational support and implementation of regular cognitive assessment may be indicated for some groups to maximize long-term function.

Late effects of therapy for pediatric brain tumor survivors

Approximately 2 of every 3 of all pediatric patients with brain tumors will be long-term survivors. However, there is a steep cost for pediatric brain tumor survivors, and the group as a whole faces significantly more late effects than many other survivors of pediatric cancers. Most of these effects can be attributed to direct neurologic damage to the developing brain caused by the tumor and its removal, the long-term toxicity of chemotherapy, or the effects of irradiation on the central nervous system. The late effects experienced by childhood brain tumor survivors involve multiple domains. This article will review the significant late effects that occur within the medical, neurocognitive, psychosocial, and economic domains of the survivorship experience. We conclude by discussing how the late effects in different domains often coexist and can create a complex set of obstacles that pose significant challenges for a survivor of a pediatric brain tumor on a daily basis.