Illuminating the hidden cost: A systematic review of cognitive late effects regarding cancer-related fatigue in treated paediatric brain tumors

Objective

Globally, in 2022, 30,871 children were diagnosed with CNS-tumors. Many have been treated with radiotherapy, and a significant number suffer from chronic late effects, including fatigue. This study aims to investigate previous research on the impact of cancer-related fatigue for neurocognitive function that can be related to radiotherapy in patients who have undergone primary brain radiotherapy before the age of 18.

Methods

Conducted under PRISMA-S framework, this systematic review searched MEDLINE ALL (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid) for relevant studies. Criteria for inclusion were children under 18 who underwent radiotherapy for primary brain cancer, focusing on late cognitive side effects, published 2000-2023.

Results

From 4,067 records, 10 studies were included, examining Proton Radiation Therapy (n = 4), X-ray Radiation Therapy (n = 3), and their comparisons (n = 3). The studies used various cognitive tests, and late effects that emerged were neurocognitive functions and disorders, intellectual functioning, specific cognitive functions and daily life, social functioning, and performance. These themes can be encompassed by cancer-related fatigue.

Conclusions

The findings underscore critical need for more in-depth research to understand the health perception variations among children post-primary brain radiotherapy. Furthermore, detailed insights of treatment specifics, disease progression, target volume sizes, and doses to surrounding organs at risk are imperative.

Pediatric central nervous system (CNS) tumors cognitive and psychosocial assessment: key highlights from the Italian (AIEOP) consensus conference

Pediatric central nervous system (CNS) tumors represent one of the most intricate challenges faced by children and their families in the context of cancer illness. In Italy, the psychosocial working group (GDL) of the AIEOP, composed by professionals (psycho-oncologists/neuropsychologists) involved in the care pathways of patients with CNS tumors, has initiated a consensus process regarding the psychological/neuropsychological assessment of CNS patients to improve accessibility to standardized and shared protocols. Standardized psychological and neuropsychological instruments are proposed in the document, which provides for a selection in a tailor-made approach that is simultaneously shared by various centers.

Exploring Sex-Based Neuropsychological Outcomes in Pediatric Brain Cancer Survivors: A Pilot Study

BACKGROUND

The increasing survival rates among pediatric cancer patients underscore the critical need to understand the long-term psychosocial impacts of cancer treatments, such as cisplatin and carboplatin. While these treatments are lifesaving, they may pose risks to neurodevelopmental processes. Despite the substantial body of research highlighting cognitive impairments associated with cancer treatments, there remains a gap in understanding how these effects differ by sex. As sex differences could inform tailored interventions and support mechanisms for affected individuals, this pilot study aimed to examine the sex differences in neuropsychological outcomes in patients treated for brain cancer with cisplatin and/or carboplatin.

METHODS

Our study employed rigorous/structured neuropsychological assessments to evaluate executive functions in pediatric cancer survivors treated with cisplatin and/or carboplatin. We utilized the BRIEF and TOL tests to assess the key domains of executive function, including inhibitory control, cognitive flexibility, and problem-solving abilities. Additionally, psychosocial factors were evaluated using the Resiliency Scale to measure resilience and the PAT test to assess family psychosocial risk.

RESULTS

In our cohort of 17 patients, significant sex differences emerged, where males outperformed females in areas such as inhibitory control, impulse regulation, and strategic planning.

CONCLUSIONS

These findings highlight the complexity of cognitive outcomes in pediatric cancer survivors. Understanding sex-specific differences is essential for developing tailored interventions that optimize cognitive and psychosocial outcomes. Future research should focus on larger cohorts and longitudinal studies to validate these findings and guide targeted interventions to improve survivorship outcomes.

Full and Partial Facial Affect Recognition in Pediatric Brain Tumour Survivors and Typically Developing Children Following COVID-19 Pandemic

Affect recognition has emerged as a potential mechanism underlying the social competence challenges experienced by pediatric brain tumour survivors (PBTSs). However, many social interactions were altered during the pandemic, with the widespread use of masking potentially impacting affect recognition abilities. Here, we examine affect recognition in PBTSs and typically developing youth (TD) after the onset of the global pandemic. Twenty-three PBTSs and 24 TD between 8 and 16 years old were recruited and completed two performance-based affect recognition tasks (full and partial facial features) and a self-reported questionnaire on mask exposure in their social interactions. Their parents completed parent proxy questionnaires on their child's social adjustment and sociodemographics. The scores between the PBTSs and TD did not differ significantly in full (t(45) = 1.33, p = 0.19, d = 0.39, 95% CI [-0.69, 3.40]) or partial (t(37.36) = 1.56, p = 0.13, d = 0.46, 95% CI [-0.47, 3.60]) affect recognition, suggesting similar affect recognition between the two groups. These skills were also not significantly correlated with social adjustment or mask exposure (p > 0.05). However, the combined sample had significantly better scores in affect recognition when exposed to partial facial cues versus full. Additionally, participants obtained lower scores on a measure of full facial affect recognition and higher scores on a measure of partial affect recognition compared to pre-pandemic data. The pandemic may have influenced affect recognition across youth, underscoring the importance of further research into its lasting impact on the social competence of youth.

Social participation of school-aged survivors of pediatric brain tumors: A daily diary report

BACKGROUND

Difficulties with social functioning are common among survivors of pediatric brain tumors. Social participation is an understudied measure of social functioning that is associated with emotional health across the lifespan. This paper uses a diary method to assess the social participation of survivors of pediatric brain tumors in middle childhood.

PROCEDURE

Survivors of pediatric brain tumors (N = 47; age 10.6 ± 1.4 years; 51.1% male, 89.4% White) who were 5.3 (SD = 2.4, range: 2-9.9) years post therapy completed a daily diary assessment of social interaction (5-7 days) and an objective measure of facial affect recognition. The participant's caregiver completed the NIH Toolbox Emotion Measures and a background information questionnaire.

RESULTS

Overall, frequency and quality of reported social interactions were low for survivors, with a large subset of survivors (n = 16, 34%) endorsing fewer than 10 social interactions over the course of a typical school week, and almost half of parents (48.9%) reporting that their child participates in zero social activities outside of school during a typical week. Participants engaged in more positive social participation exhibited stronger social skills (facial affect recognition (F(2,44)  = 4.85, p < .05).

CONCLUSIONS

School-aged survivors of pediatric brain tumors seemed to be infrequently engaged in social participation and quality interaction with peers. More specifically, the interactions most commonly reported on the diary assessment are not indicative of friendship development and maintenance. Survivors of pediatric brain tumors would likely benefit from interventions designed to increase quality time spent with peers.

The neuropsychological profile of children with Diffuse Intrinsic Pontine Glioma (DIPG) before and after radiation therapy: A prospective longitudinal study

Children with Diffuse Intrinsic Pontine Gliomas (DIPG), a malignant brainstem tumor, experience poor prognosis. Because of the disease's rarity and highly aggressive course, there is a dearth of research on cognitive and psychosocial outcomes in this underserved, vulnerable population. However, evaluating effects of the disease and treatment on the cognitive and daily functioning of these patients is important to better understand their specific needs and improve their quality of life. The current longitudinal study administered prospective neuropsychological assessments to children diagnosed with CNS malignancies, including the largest sample of children with DIPG to date (n = 21, mean age = 7.86 years, range = 3-16) in neurocognitive, behavioral, social-emotional, and adaptive functioning at baseline, two weeks post-radiation, and six months later. The results describe population-based, cross-sectional characteristics and within-patient longitudinal changes. Prior to radiation, children with DIPG exhibited significant weaknesses compared to normative samples in both parent-report and performance-based measures of attention, and tests of processing speed and verbal learning/memory. Younger children demonstrated poorer inhibitory control on performance tests and worse parent-reported behavioral regulation, depression, and social withdrawal compared to older children. Six-months post-radiation, older children exhibited poorer socialization than younger children. Longitudinally, children with DIPG exhibited short-term improvements immediately post-radiation in performance-based attention tests and parent-reported behavior, including attention, hyperactivity, behavioral regulation, and executive function. However, these improvements did not persist and significant decline was documented on tests of attention by six months. Clinical implications for professionals working with children with DIPG and recommendations for cognitive remediation and quality of life interventions are provided.

Neurobehavioral Impairment in Pediatric Brain Tumor Survivors: A Meta-Analysis

Purpose: The neurocognitive outcomes of pediatric brain tumor survivors have been extensively studied but the risk and predictors for neurobehavioral impairment are less clearly defined. We systematically analyzed the rates of emotional, psychosocial, and attention problems in pediatric brain tumor survivors. Methods: PubMed, Web of Science, Embase, Scopus, and Cochrane were searched for articles published between January 2012 to April 2022. Eligible studies reported neurobehavioral outcomes for PBTS aged 2 to <23 years with a brain tumor diagnosis before 18 years of age. A random-effect meta-analysis was performed in R. Results: The search yielded 1187 unique publications, of which 50 were included in the quantitative analysis. The estimated risk of having emotional, psychosocial, and attention problems were 15% (95%CI 10−20%), 12% (95%CI 9−16%), and 12% (95%CI 9−16%), respectively. PBTS were more likely to have emotional difficulties (Hedge’s g = 0.43 [95%CI 0.34−0.52]), psychosocial problems (Hedge’s g = 0.46 [95%CI 0.33−0.58]), and attention problems (Hedge’s g = 0.48 [95%CI 0.34−0.63]) compared to normal/healthy control subjects. There was no significant difference in the rates of neurobehavioral impairment between children with and without history of cranial radiotherapy. Conclusions: PBTS are at elevated risk of neurobehavioral impairment. Neurobehavioral monitoring should be considered as the standard of care for PBTS.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of central nervous system-directed treatment on competence and adjustment among children in early cancer survivorship

BACKGROUND

Central nervous system (CNS)-directed treatments can cause long-term academic, social, and emotional difficulties for children with cancer. However, limited research has examined the emergence of problems longitudinally and has often stratified risk by diagnosis alone. Therefore, this study compared competence and adjustment in children, who did and did not receive CNS-directed treatment, over the first 3 years following a cancer diagnosis.

PROCEDURE

Mothers, fathers, and children (ages 5-18 years at diagnosis) from 217 families reported on the child's competence (academic, social) and adjustment (anxious/depressed, withdrawn/depressed) near a new cancer diagnosis or relapse and 3 years later. Children were categorized into CNS-directed treatment (n = 112; including cranial radiation, intrathecal chemotherapy, and/or neurosurgery) and non-CNS-directed treatment (n = 105) groups.

RESULTS

At enrollment, there were few differences in competence and emotional adjustment among children based on treatment or diagnostic group. At 3 years, mothers and fathers reported poorer social competence for the CNS-directed treatment group, and fathers reported poorer school competence for the CNS-directed treatment group. Over time, father ratings of social competence increased for the non-CNS-directed treatment group, but not the CNS-directed treatment group. While father ratings of academic competence declined for the CNS-directed treatment group, mother ratings declined the most for children diagnosed with a brain tumor. All children demonstrated higher anxious/depressed scores over time.

CONCLUSIONS

CNS-directed treatment may be a valuable indicator to identify childhood cancer survivors at risk for poor competence during early survivorship. Follow-up screening and supportive services are recommended, as well as additional longitudinal research.

Focusing on Young Children in Pediatric Psychology Research: Introduction to the Special Issue on Young Children

This special issue focusing on pediatric psychology research in young children highlights 15 papers that focus on infants through preschoolers. Studies selected for inclusion cover a range of pediatric health conditions such as food allergy, medical trauma, injuries/traumatic brain injury, cancer, inflammatory bowel disease, pain, and sleep. The inherent challenges of researching young children are described, and studies vary in their methods for assessment and intervention; multiple studies include an observational component or developmental evaluation. Six of the studies employ diverse samples of children and/or parents and demonstrate the feasibility as well as importance of increasing our understanding of factors related to health disparities. Taken together, the special issue demonstrates the high quality of research focusing on young children. As the special issue editors, we hope this collection will spark an interest in others to focus on research with young children across pediatric populations.