Family and illness predictors of outcome in pediatric brain tumors

The COVID-19 pandemic and children with PANS/PANDAS: an evaluation of symptom severity, telehealth, and vaccination hesitancy

The current study assessed the impact of the COVID-19 pandemic on children with PANS/PANDAS, a condition characterized by sudden-onset obsessive-compulsive, tic, or restrictive eating symptoms following infection. We conducted an anonymous survey between February and June 2021 of 254 self-reported caregivers of minors with PANS/PANDAS. Caregivers answered questions regarding PANS/PANDAS symptoms, telehealth care, and intention to vaccinate their child against COVID-19. PANS/PANDAS symptoms during COVID-19 infections were assessed when applicable. Children's OCD symptoms and coercive behaviors towards caregivers, along with the caregivers' mental health, relationship satisfaction, and burden, were assessed using standardized questionnaires. A majority of respondents endorsed a negative impact on their child's friendships, relationships with extended family, hobbies, and academic skills due to the pandemic. Children with suspected or diagnosed COVID-19 experienced new or worsened psychiatric symptoms, particularly mood lability, OCD, and anxiety. Telehealth care was the preferred treatment modality if the child had mild symptoms of PANS/PANDAS. A majority of caregivers reported high levels of relationship dissatisfaction and caregiver burden. As expected, these data suggest an overall negative impact of the COVID-19 pandemic on children with PANS/PANDAS and their caregivers.

Practical adaptive skills in pediatric brain tumor survivors: the contribution of medical factors and social determinants of health

Pediatric brain tumor survivors demonstrate weaknesses in adaptive functioning, most notably practical adaptive skills; however, the specific areas of weakness within practical skills are unknown. This study examined the aspects of practical adaptive functions that are most impacted in brain tumor survivors, and identified medical and socio-demographic variables that predicted outcomes. The sample included 117 pediatric brain tumor patients seen for a clinical neuropsychological evaluation and whose parents completed the Adaptive Behavior Assessment System, Second or Third Edition. T-tests compared practical adaptive skills to normative means. Correlations examined associations between medical and socio-demographic variables and each of the practical adaptive subscales (Community Use, Home Living, Health & Safety, Self-Care). Significant correlations were entered into linear regression models for each practical adaptive skill. All practical subscales were significantly below the normative mean. Community Use was positively correlated with age at diagnosis and negatively correlated with treatment burden, time since diagnosis, and neighborhood deprivation. Health and Safety was positively correlated with age at diagnosis. Home Living was positively correlated with neighborhood deprivation. Self-Care was positively correlated with age at diagnosis and parental education. Specific medical and socio-demographic factors predicted practical adaptive functioning, highlighting the importance of considering the role of medical and socio-demographic determinants of health on adaptive functioning outcomes in pediatric brain tumors.

Radiotherapy-Induced Neurocognitive Dysfunction in Brain Tumor Survivors: Burden and Rehabilitation

Radiotherapy-induced neurocognitive dysfunction after cranial irradiation has an incidence of 40-100%. It may affect both children and adults, and represents a significant burden not only on ill individuals and their caregivers but also on the health care system and society in general. Multiple patient-, tumor-, and treatment-related factors may contribute to development of this complication, but its pathophysiological mechanisms are still not understood clearly. It is hoped that introduction of more advanced techniques for conformal irradiation, optimized dosimetry, and specific prophylactic measures will decrease the risk of neurocognitive decline in brain tumor survivors in the future.

Family functioning and adaptation following pediatric brain tumor: A systematic review

INTRODUCTION

Pediatric brain tumor survivors (PBTS) experience psychosocial difficulties and poor quality of life (QOL). Family functioning may be adversely impacted by the stress of diagnosis and associated symptoms, which may, in turn, affect PBTS outcomes. The objective of this study was to complete a systematic review of family functioning and psychosocial outcomes in PBTS.

METHODS

We conducted systematic searches of PubMed and PsychInfo. Full-text articles (n = 324) were screened and 14 were included. A risk-of-bias assessment was conducted to evaluate the quality of study conclusions.

RESULTS

Studies examined associations of family functioning with adaptive, social, emotional, and behavioral outcomes, and QOL. More adaptive family functioning (cohesiveness, effective communication, lower conflict) was associated with better PBTS outcomes. Studies were limited by heterogeneous/small samples and cross-sectional designs.

CONCLUSIONS

Results provide preliminary support for the relationship between family functioning and psychosocial outcomes. Common outcome measures and prospective research designs can further advance understanding.

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.

[Formula: see text]Family environment as a predictor and moderator of cognitive and psychosocial outcomes in children treated for posterior fossa tumors

Objective. The current study examined the effects of clinical factors (i.e., treatment type, history of cerebellar mutism) as well as environmental factors (i.e., family environment) as predictors of cognitive and psychosocial outcomes in children treated for posterior fossa tumors.Method. Twenty-seven children/adolescents treated for posterior fossa tumors (treatment type: radiation [n = 12], surgery [n = 15]; history of mutism: yes [n = 7], no [n = 20]) and n = 13 healthy controls, aged 8-17 years, and their caregivers completed measures assessing cognitive and psychosocial functioning, as well as the family environment (i.e., parental education, family functioning, family psychiatric history). Hierarchical linear regression analyses were conducted to examine the role of clinical factors and the family environment as predictors of cognitive and psychosocial outcomes. Family environment was also examined as a moderator of clinical factor group differences in outcomes.Results. Regression analyses revealed lower intelligence scores among the radiation group compared to the control group, lower verbal memory scores among both treatment groups compared to the control group, and a significant positive effect of parental education on verbal memory scores. Further, history of cerebellar mutism predicted poorer performance on a speeded naming task, and this relationship was moderated by family functioning, with a greater effect of mutism present among those with poorer family functioning.Conclusions. Interventions aimed at improving the family environment may help to mitigate negative cognitive effects of pediatric brain tumors, particularly among those most at-risk for poor outcomes.

Social competence in newly diagnosed pediatric brain tumor patients

Brain tumors (BTs) are a common pediatric malignancy. Improved treatment has resulted in higher survival rates. There is, however, increasing concern about adverse effects of the disease and its treatment, including effects on social competence (i.e. effective social functioning in everyday life). The aim of this study is to examine multiple levels of social competence (i.e. social skills and social adjustment) in newly diagnosed pediatric BT patients. Thirty newly diagnosed BT patients aged 5-12 years were assessed shortly after diagnosis with a neuropsychological test battery focusing on social competence, including tests for IQ, social skills (i.e. social-affective and executive functioning) and social adjustment (rated by parents and teachers). Their performance was compared to 95 healthy controls who completed the same assessment. Patients and healthy controls were largely comparable with regard to demographic and environmental factors and did not differ on measures of IQ, social skills and social adjustment. Furthermore, age was found to have a positive significant effect on social skills independent of group. Shortly after diagnosis, pediatric BT patients did not perform different from healthy controls on IQ and measures of social skills and social adjustment. This is an encouraging finding. However, because of potentially neurotoxic adjuvant therapy and the ongoing development of social skills, longitudinal follow-up studies are needed to investigate long-term outcome regarding social competence in BT survivors.

A systematic review of factors related to children's quality of life and mental health after brain tumor

PURPOSE

Brain tumor has been found to have a major impact on children's quality of life (QOL); yet, the subjective impact of the illness is still not well understood. This review aimed to investigate factors related to children's subjective well-being (SWB), or self-reported QOL and mental health after brain tumor. A further aim was to determine the consistency between child and parent-proxy ratings of children's SWB and common factors associated with both child and parent-proxy ratings.

METHODS

A systematic search of PsycINFO, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Scopus was conducted from 1980 to May 2018 to identify eligible studies. Methodological quality of these studies was assessed by 2 independent reviewers.

RESULTS

Twenty studies investigated factors related to children's self-reported mental health or QOL. Fourteen studies examined these factors from the perspectives of both children and their parents. Overall, risk factors for poor QOL included infratentorial tumors, radiation, hydrocephalus, lower IQ, and behavioral problems. Only 5 studies examined mental health outcomes, the findings of which were mixed. Relatively few studies examined psychosocial variables related to children's SWB.

CONCLUSIONS

Although several risk factors for poor QOL were identified, further research investigating mental health outcomes and the influence of psychosocial factors on children's SWB is needed to guide support interventions for pediatric brain tumor.

Neuropsychological consequences of childhood medulloblastoma and possible interventions: A review

BACKGROUND

Children who have been treated for a medulloblastoma often suffer long-term cognitive impairments that often negatively affect their academic performance and quality of life. In this article, we will review the neuropsychological consequences of childhood medulloblastoma and discuss the risk factors known to influence the presence and severity of these cognitive impairments and possible interventions to improve their quality of life.

METHODS

This narrative review was based on electronic searches of PubMed to identify all relevant studies.

RESULTS

Although many types of cognitive impairments often emerge during a child's subsequent development, the core cognitive domains that are most often affected in children treated for a medulloblastoma are processing speed, attention and working memory. The emergence and magnitude of these deficits varies greatly among patients. They are influenced by demographic (age at diagnosis, parental education), medical and treatment-related factors (perioperative complications, including posterior fossa syndrome, radiation therapy dose, etc.), and the quality of interventions such as school adaptations provided to the child or rehabilitation programs that focus on cognitive skills, behavior and psychosocial functioning.

CONCLUSION

These patients require specialized and coordinated multidisciplinary rehabilitation follow-up that provides timely and adapted assessments and culminates in personalized intervention goals being set with the patient and the family. Follow-up should be continued until referral to adult services.

Long-term Survivors of Childhood Brain Tumors: Impact on General Health and Quality of Life

PURPOSE OF REVIEW

We review and summarize the key issues affecting general health and quality of life (QOL) of pediatric long-term survivors of brain tumors.

RECENT FINDINGS

Long-term survivors of brain tumors are at risk of considerable late morbidity and mortality. Lengthening survival in brain tumors has highlighted the deep impact of tumor and its treatment on the physical, psychological, functional, and social health and QOL of these survivors. Evolution in tumor therapy including surgery, radiotherapy, and systemic therapies, etc., has the potential to mitigate this impact to some extent. Sensitization of health staff, policy makers, and the primary designers of clinical trials towards integration of QOL end points while measuring survival in brain tumor patients is the need of the hour. New developments in tumor therapeutics must not only provide quantitative gain but also improve the quality of survival in these long-term survivors. While majority of the issues presented pertain to survivorship in pediatric brain tumor population, similar challenges are likely to exist in young adults surviving brain tumors as well.

Caregiver perspectives on the social competence of pediatric brain tumor survivors

ᅟ: Pediatric brain tumor survivors are at risk for significant difficulties related to social competence. Little research has examined factors that contribute to survivor social problems.

PURPOSE

The current study is grounded in a model of social competence for youth with brain disorder and used qualitative and quantitative methods to obtain caregiver perspectives on survivor social competence and identify pertinent risk and resistance factors.

METHODS

The study occurred in two phases, including focus groups with 36 caregivers of 24 survivors and confirmatory interviews with 12 caregivers of 12 survivors.

RESULTS

Qualitative content analyses resulted in three themes that were illustrative of the model of social competence. Themes included (1) the impact of survivor sequelae on social function; (2) the role of family in evaluating and promoting survivor social development; and (3) the match between the survivor's social context and developmental needs. Quantitative data supported the associations between survivor social skills, survivor executive function, and family functioning.

CONCLUSIONS

Overall, findings underscore the influence of risk and resistance factors across different systems on survivor social competence and suggest directions for future research and intervention efforts.

Experiences of posttraumatic growth in siblings of children with cancer

As survival rates continue to improve for children diagnosed with cancer, strides in achieving better psychosocial outcomes for both children with cancer and their families have been accentuated. The current study aimed to explore the experiences of siblings of children diagnosed with cancer and attempted to overcome some of the limitations described in previous research. Primarily, the study considered the theoretical framework of posttraumatic growth (PTG) in the project design and analysis. Semi-structured interviews were completed with six siblings. Thematic analysis was employed to identify themes within the data set as a whole. The data revealed that siblings experienced a range of difficult emotions throughout the cancer trajectory as well as experiencing remarkable changes in their lives. This included both positive and negative changes. These changes included increased empathy and resilience, improved family relationships, disrupted routine, increased responsibility and perceived changes in the ill child. Siblings described factors which they found helpful and unhelpful in adjusting to these changes. The report ends with a discussion of the themes and their clinical and theoretical implications. The report also highlights the research limitations and areas for future investigation.

Family Functioning Mediates the Association Between Neurocognitive Functioning and Health-Related Quality of Life in Young Adult Survivors of Childhood Brain Tumors

PURPOSE

Childhood brain tumor (BT) survivors experience significant neurocognitive sequelae that affect health-related quality of life (HRQOL). A model of neurodevelopmental late effects and family functioning in childhood cancer survivors suggests associations between survivor neurocognitive functioning, family functioning, and survivor HRQOL. This study examines the concurrent associations between survivor neurocognitive functioning, family functioning, and survivor emotional HRQOL, and the indirect effects of neurocognitive functioning on survivor emotional HRQOL through family functioning.

METHODS

Participants included young adult-aged childhood BT survivors (18-30 years old; N=34) who were on average 16 years post-diagnosis, and their mothers. A brief neuropsychological battery assessed working and verbal memory, processing speed, and executive functioning. Survivors and mothers completed measures of family functioning, and mothers completed a proxy-report measure of survivor HRQOL.

RESULTS

Spearman bivariate correlations examined the associations between indices of survivor neurocognitive functioning and concurrent family functioning and survivor emotional HRQOL. Poorer survivor processing speed, working memory, verbal memory, and executive function were significantly associated with worse survivor- and mother-reported family functioning (r's range: 0.36-0.58). Additionally, worse survivor processing speed and executive function were significantly associated with poorer survivor emotional HRQOL (r's range: 0.44-0.48). Bootstrapping analyses provided evidence for the indirect effects of neurocognitive functioning on survivor emotional HRQOL through family functioning.

CONCLUSION

These findings suggest that family functioning is an important variable that might mitigate the negative influence of neurocognitive late effects on survivors and is a potential target in future interventions.

Family Management Style Framework: A New Tool With Potential to Assess Families Who Have Children With Brain Tumors

Qualitative studies of families with children who have cancer or other serious illnesses have found that families often come to view their child and their lives as normal. They manage illness-related demands using family management styles that sustain usual patterns of family and child functioning. Few studies have addressed the family management styles of families who express less satisfaction with family and child functioning or who are identified by health care professionals as having difficulty with family functioning. Such families are likely to be overrepresented among those whose children are being treated for brain tumors that entail extremely burdensome treatments as well as a range of unfavorable prognoses and long-term sequelae. In fact, little is known about how these families manage on a day-to-day basis and how the interdisciplinary team can best provide supportive care to optimize their functioning. The purpose of this article is to present the Family Management Styles Framework as a tool that is useful in both clinical practice and research for assessing families who have children with cancer, including those with brain tumors.

Social competence in pediatric brain tumor survivors: application of a model from social neuroscience and developmental psychology

Pediatric brain tumor (BT) survivors are at risk for psychosocial late effects across many domains of functioning, including neurocognitive and social. The literature on the social competence of pediatric BT survivors is still developing and future research is needed that integrates developmental and cognitive neuroscience research methodologies to identify predictors of survivor social adjustment and interventions to ameliorate problems. This review discusses the current literature on survivor social functioning through a model of social competence in childhood brain disorder and suggests future directions based on this model. Interventions pursuing change in survivor social adjustment should consider targeting social ecological factors.

Health-related quality of life of adolescent and young adult survivors of childhood brain tumors

OBJECTIVE

Our aim was to expand research on predictors of health-related quality of life (HRQOL) for adolescent and young adult survivors of childhood brain tumors who are not living independently by evaluating the mediating role of family functioning in the association of disease severity/treatment late effects with survivor self-report and caregiver-proxy report of physical and emotional HRQOL.

METHODS

Mothers (N = 186) and their survivors living at home (N = 126) completed self-report and caregiver-proxy report of physical and emotional HRQOL. Mothers completed family functioning measures of general family functioning, caregiving demands, and caregiver distress. Medical file review and caregiver report were used to evaluate disease severity/treatment late effects.

RESULTS

Using structural equation models, family functioning was adjusted for sociodemographic factors. Disease severity/treatment late effects had significant direct effects on self-report and caregiver-proxy report of physical and emotional HRQOL. Family functioning had a significant direct effect on caregiver-proxy report of physical and emotional HRQOL, but these findings were not confirmed for self-report HRQOL. Model-fit indices suggested good fit of the models, but the mediation effect of family functioning was not supported.

CONCLUSIONS

Disease severity/treatment late effects explained self-report and caregiver-proxy report of physical and emotional HRQOL for these adolescent and young adult survivors of childhood brain tumors. Family functioning was implicated as an important factor for caregiver-proxy report only. To enhance physical and emotional HRQOL, findings underscore the importance of coordinated, multidisciplinary follow-up care for the survivors who are not living independently and their families to address treatment late effects and support family management.

Developing interventions for cancer-related cognitive dysfunction in childhood cancer survivors

Survivors of childhood cancer frequently experience cancer-related cognitive dysfunction, commonly months to years after treatment for pediatric brain tumors, acute lymphoblastic leukemia (ALL), or tumors involving the head and neck. Risk factors for cancer-related cognitive dysfunction include young age at diagnosis, treatment with cranial irradiation, use of parenteral or intrathecal methotrexate, female sex, and pre-existing comorbidities. Limiting use and reducing doses and volume of cranial irradiation while intensifying chemotherapy have improved survival and reduced the severity of cognitive dysfunction, especially in leukemia. Nonetheless, problems in core functional domains of attention, processing speed, working memory and visual-motor integration continue to compromise quality of life and performance. We review the epidemiology, pathophysiology and assessment of cancer-related cognitive dysfunction, the impact of treatment changes for prevention, and the broad strategies for educational and pharmacological interventions to remediate established cognitive dysfunction following childhood cancer. The increased years of life saved after childhood cancer warrants continued study toward the prevention and remediation of cancer-related cognitive dysfunction, using uniform assessments anchored in functional outcomes.

Treatment developments and the unfolding of the quality of life discussion in childhood medulloblastoma: a review

PURPOSE

To describe how the quality of life (QOL) discussion in childhood medulloblastoma (MB) relates to treatment developments, survival and sequelae from 1920 to 2014.

METHODS

Articles containing "childhood medulloblastoma" and "quality of life" were identified in PubMed. Those containing phrases pertaining to psychological, emotional, behavioral or social adjustment in the title, abstract or keywords were selected. Inclusion of relevant older publications was assured by cross-checking references.

RESULTS

1920-1930s: suction, electro-surgery, kilovolt (KV) irradiation. Survival = months. Focus on operative mortality, symptoms and survival. 1940s: radiotherapy improved. 1950s: chemotherapy and intubation. Survival = years. Opinions oscillated between optimism/awareness of physical sequelae of radiotherapy. 1960s: magnified vision, ventriculo-peritoneal (VP) shunts, megavolt (MV) irradiation. Long-term survival shifted the attention towards neurological problems, disability and carcinogenesis of radiotherapy. 1970s: CT, microscope, bipolar coagulation, shunt filters, neuroanesthesia, chemotherapy trials and staging studies. Operative mortality decreased and many patients (re)entered school; emphasis on neuropsychological sequelae, IQ and academic performance. 1980s: magnetic resonance imaging (MRI), Cavitron ultrasonic aspiration (CUSA), laser surgery, hyper-fractionated radiotherapy (HFRT). Cerebellar mutism, psychological and social issues. 1990s: pediatric neurosurgery, proton beams, stem cell rescue. Reflections on QOL as such. 21st century: molecular genetics. Premature aging, patterns of decline, risk- and resilience factors.

DISCUSSION

QOL is a critical outcome measure. Focus depends on survival and sequelae, determined after years of follow-up. Detailed measurements are limited by time, money and human resources, and self-reporting questionnaires represent a crude measure limited by subjectivity. Therapeutic improvements raise the question of QOL versus cure. QOL is a potential primary research endpoint; multicenter international studies are needed, as are web-based tools that work across cultures.

The experience of mothers caring for a child with a brain tumour

BACKGROUND

Brain tumours are the second most common form of childhood cancer, accounting for over 20% of all cases in European children. Understanding the impact of diagnosis and treatment of a brain tumour on the family is an essential pre-requisite to identifying ways to provide effective support.

AIM

(1) To explore the impact of having a child with a brain tumour on the main caregiver in the family; (2) to describe mothers' experiences of coping with their child's illness, including personal barriers and strengths; and (3) to identify causes of stress and sources of support to inform improvements in care delivery.

METHOD

Participants were drawn from a group of caregivers enrolled in a longitudinal study of outcome following diagnosis of a childhood brain tumour. Six caregivers took part, two from each of the high-, medium- and low-impact groups based on their Impact on Families Scale scores. Semi-structured interviews were used, with questions covering: (1) impact of the diagnosis on main caregiver and family; (2) personal barriers and strengths; and (3) causes of stress and sources of support. Interviews were transcribed verbatim and coded manually into five themes, which comprised 19 subthemes.

FINDINGS

Coping methods and provision of help and support were major preoccupations for main caregivers from all impact groups. Caregivers in the high-impact group reported less conflict. High- and medium-impact group caregivers had experienced less 'hindrance and heartache', than those with low impact scores, suggesting that the stress associated with diagnosis and treatment of the tumour may have increased cohesion and acceptance within these families.

CONCLUSION

Families of children diagnosed with a brain tumour experience considerable negative impact and may perceive themselves as struggling to cope. Provision of help and support, within and outside the extended family, including from health, education and other services, is perceived as helpful.

Competence in caregivers of adolescent and young adult childhood brain tumor survivors

OBJECTIVE

Caregivers of adolescents and young adults (AYA) with complex medical conditions, including brain tumor survivors, have protracted and often complex roles, yet a gap exists in understanding their perceived competence. The aim of this study is to test a hypothesized model based on the theoretical and empirical literature: better caregiver health, better survivor health, and better family functioning contribute directly to fewer caregiving demands, which in turn contribute to greater caregiver competence.

METHOD

Telephone interviews using structured self-report questionnaires were conducted in this cross-sectional study with a sample of 186 caregivers (mothers) of childhood brain tumor survivors aged 14-40 years old who live with at least one parent. Structural equation modeling (SEM) was used to test the hypothesized model.

RESULTS

The final SEM model suggests that survivor health and family functioning directly predict caregiver competence. Caregiver health indirectly predicts caregiver competence through caregiver demands and then family functioning. Family income directly predicts family functioning. The model showed adequate fit (CFI = 0.905, TFI = 0.880, and RMSEA = 0.081). Overall, the model accounted for 45% of variance in caregiver competence.

CONCLUSIONS

For this sample of caregivers of AYA with medically complex conditions, family functioning and the health of survivors are both important to how they evaluate their skills as caregivers. The results of this study underscore the crucial role of care models that focus on optimizing the health of the survivor, caregiver, and family, along with supporting a family centered approach to their care.

Family factors associated with academic achievement deficits in pediatric brain tumor survivors

PURPOSE

The purpose of this study is to examine whether parental education, socioeconomic status, or family environment moderate the extent of academic achievement deficits in pediatric brain tumor survivors (PBTS) relative to classmate case-controls. PBTS are known to be at risk for cognitive and academic impairment; however, the degree of impairment varies. Prior research has focused on treatment risk, and efforts to examine the protective role of family resources and relationships have been lacking.

METHODS

Pediatric brain tumor survivors (N = 164), ages 8-15 and 1-5 years posttreatment, were recruited at five treatment centers in the United States and Canada. A case-control classmate, matched for age, gender, and race, was recruited for each survivor. The Wide Range Achievement Test, a demographic form, and the Family Environment Scale were administered in families' homes. Treatment data were abstracted from medical charts.

RESULTS

Pediatric brain tumor survivors demonstrated lower achievement than classmate-controls in reading, spelling, and arithmetic. Parental education and socioeconomic status were associated with levels of achievement demonstrated by PBTS but did not account for discrepancies between PBTS and classmate-controls. Deficits in achievement relative to classmate-controls, across all academic domains, were greater for survivors in families lower in support and higher in conflict. These associations remained after controlling for age at diagnosis, time since treatment, and whether treatment had involved chemotherapy, focal, or whole brain radiation.

CONCLUSIONS

These results support the development of interventions to enhance family functioning as well as educational resources as part of intervention and rehabilitation services to optimize academic progress in children who have been treated for brain tumors.

Parenting stress and neurocognitive late effects in childhood cancer survivors

BACKGROUND

Surveillance of neurocognitive late effects has typically focused on the pediatric survivor alone and rarely has focused on the potential family burden. We investigated the impact of child neurocognitive effects on parenting stress and hypothesized that parents of childhood cancer survivors with greater executive difficulties experience higher stress relative to parents of children with less adverse impact.

METHODS

Parents of 44 children who survived cancer involving central nervous system-directed treatments and who had documented neurocognitive deficits completed standardized questionnaires assessing their perceived level of stress and perception of their child's executive functioning abilities in daily life. Data from performance-based cognitive tests were obtained on the children. Multiple regression models examined socio-demographic, clinical, and child's executive functioning as predictors of parent stress. Differences in parenting stress based on child's level of executive functioning were evaluated.

RESULTS

Parent stress was significantly associated with both performance-based and parent report measures of child executive functioning. Child executive functioning significantly predicted parent stress even after controlling for socio-demographic and clinical factors, and the final model accounted for 42% of the variance in parent stress levels. Significant differences in parent stress were found when comparing higher versus lower levels of child executive functioning. The nature of the executive difficulties, however, appears important, as we found increased parenting stress among children with behavioral regulation problems rather than metacognitive difficulties.

CONCLUSIONS

The associations between parenting stress and neurocognitive problems found in this study suggest the need for further research, along with professional monitoring and appropriate intervention.

School liaison program for children with brain tumors

A school liaison program that familiarized teachers with the implications of each child's brain tumor treatment with respect to learning, behavior, and socialization was implemented. The study explored the experiences of nine families and their teachers and health staff who participated in the program. The successes and challenges of the program were captured through interviews that were audio-taped and transcribed verbatim for data analysis. Individualized programs were negotiated between families and education staff to address behavioral, academic, and social needs of each child. Children were able to learn to their ability rather than be judged on the achievements of their respective grade levels. Parents reported that the program strengthened their advocacy skills and improved the children's social and learning achievements. Teachers reported an improved ability to provide more comprehensive educational programming suited to the child's needs. Overall, most children in the program achieved or exceeded their initial academic, social, and behavioral expectations. The school liaison program demonstrated significant potential to enhance the learning experience for children with brain tumors.

Neurocognitive dysfunction in survivors of childhood brain tumors

Newer treatments have resulted in increasing numbers of survivors of childhood cancer, for whom neurological and neurocognitive toxicity directly impacts overall functioning and quality of life. There are multiple disease- and host-related factors that influence the development of cancer-related neurocognitive dysfunction, which can progress over time and lead to significant functional impairments. This article provides an overview of the types of neurocognitive deficits seen in survivors of childhood brain tumors, the tools used to assess neurocognitive function, and the factors that impact its severity. This provides a framework for consideration of potential areas for primary prevention by reducing treatment-related toxicity as well as interventions, using behavioral and pharmacologic treatments.

Neurocognitive and family functioning and quality of life among young adult survivors of childhood brain tumors

Many childhood brain tumor survivors experience significant neurocognitive late effects across multiple domains that negatively affect quality of life. A theoretical model of survivorship suggests that family functioning and survivor neurocognitive functioning interact to affect survivor and family outcomes. This paper reviews the types of neurocognitive late effects experienced by survivors of pediatric brain tumors. Quantitative and qualitative data from three case reports of young adult survivors and their mothers are analyzed according to the theoretical model and presented in this paper to illustrate the importance of key factors presented in the model. The influence of age at brain tumor diagnosis, family functioning, and family adaptation to illness on survivor quality of life and family outcomes is highlighted. Future directions for research and clinical care for this vulnerable group of survivors are discussed.

Child-related determinants of health-related quality of life in children with brain tumours 1 year after diagnosis

OBJECTIVES

Infratentorial tumour site and health-related quality of life (HRQL) 1 month after diagnosis have been shown to predict HRQL 1 year after diagnosis in children with brain tumours. This study aimed to identify additional early child-related determinants of parent- and child-report HRQL.

METHODS

Longitudinal prospective study. Semi-structured interviews took place approximately 1 and 12 months after diagnosis. HRQL was measured using the self- and parent-report Pediatric Quality of Life Scales (PedsQL 4.0) Total Scale Score and Health Utilities Index Mark 3 (HUI3) multi-attribute utility function. Child variables included performance and verbal IQ, general memory, selective attention executive function, behaviour problems, adaptive behaviour, symptoms of depression and anxiety and event related anxiety. Univariate analyses were used to identify potential early predictors of HRQL. Regression analysis was then used to identify the most important determinants of HRQL at 1 year.

RESULTS

Thirty-five patients completed the 12-month interviews. Multivariate analysis showed infratentorial tumour site remained an important determinant of HRQL 1 year after diagnosis. Infratentorial tumour site and selective attention at 1 month generally best predicted poor self- and parent-report HRQL at 12 months. Adaptive behaviour and performance IQ may be important.

CONCLUSION

Selective attention and infratentorial tumour site are most important in predicting both parent- and self-report HRQL at 1 year after diagnosis. Larger prospective studies are needed to confirm these findings. Cognitive remediation or/and pharmacological intervention, particularly aimed at children with infratentorial tumours may improve attention and subsequently HRQL and both merit further investigation.

Adaptive functioning in children in the first six months after surgery for brain tumours

PURPOSE

To examine the adaptive functioning of children who underwent surgery for brain tumours with a view to analyse the related acute impairments and to describe their short-term outcome.

METHOD

We investigated adaptive functioning in 25 children (ranging from 2 to 18 years of age) for 40 days and again 3 and 6 months after they underwent surgery for various brain tumours. The Vineland Adaptive Behaviour Scales (VABS) were used to assess their adaptive functioning, considering the four main domains and all the subdomains.

RESULTS

The results remained stable over the follow-up period considered. The domain in which the scores were most severely affected was Daily Living, followed by the Socialisation and Communication domains. Within the Communication domain, the abilities investigated in the Receptive subdomain revealed the worst impairments. Within the Daily Living domain, impairments were most evident in the children's capacity to take care of themselves and handle domestic activities. In the Socialisation domain, Play and Leisure Time, and Interpersonal Relationships were the subdomains most severely impaired.

CONCLUSIONS

These findings are relevant because identifying children's adaptive functioning difficulties sooner could help their rehabilitation to be tailored and thus have a positive fallout on their long-term outcome.

Family, demographic and illness-related determinants of HRQL in children with brain tumours in the first year after diagnosis

AIMS

To evaluate the relationship between parent- and child-report Health-Related Quality of Life (HRQL) and demographic, tumour and family variables in children with a brain tumour in the first year after diagnosis and to identify determinants of HRQL at 12 months.

PROCEDURE

Longitudinal prospective study: Semi-structured interviews took place approximately 1, 6 and 12 months after diagnosis. HRQL was measured using the self- and parent-report PedsQL 4.0 Total Scale Score. Tumour and treatment variables considered included tumour site and grade, hydrocephalus at diagnosis, chemotherapy and radiotherapy. Family variables included measures of family function, family support and family stress, the primary carer's coping strategies and symptoms of depression and anxiety. Univariate analyses were used at all three time points, and to identify potential early predictors of HRQL at 1 year. Regression analysis was then used to identify the most important determinants of HRQL at 1 year.

RESULTS

Thirty-five patients completed the 12-month interviews. There were consistent significant negative correlations between concurrent family impact of illness and parent and self-report HRQL, and positive correlations between concurrent family support and parent-report HRQL. Treatment with radio- or chemotherapy correlated with child-report HRQL only at some time points. Multivariate analysis showed infratentorial tumour site, and poor HRQL at 1 month best predicted poor self- and parent-report HRQL at 12 months.

CONCLUSION

Children with infratentorial tumours and poor HRQL early after diagnosis tend to have poor HRQL at 1 year. While family factors are important modulators of concurrent HRQL, they do not appear important in predicting HRQL.

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.

Brain Tumor Survivors Speak Out

Although progress has been made in the treatment of childhood brain tumors,work remains to understand the complexities of disease, treatment, and contextual factors that underlie individual differences in outcome. A combination of both an idiographic approach (incorporating observations made by adult survivors of childhood brain tumors) and a nomothetic approach (reviewing the literature for brain tumor survivors as well as childhood cancer survivors) is presented. Six areas of concern are reviewed from both an idiographic and nomothetic perspective, including social/emotional adjustment, insurance, neurocognitive late effects, sexuality and relationships, employment, and where survivors accessed information about their disease and treatment and possible late effects. Guidelines to assist health care professionals working with childhood brain tumor survivors are offered with the goal of improving psychosocial and neurocognitive outcomes in this population.

Predictors of outcome following acquired brain injury in children

Acquired brain injury (ABI) in children and adolescents can result from multiple causes, including trauma, central nervous system infections, noninfectious disorders (epilepsy, hypoxia/ischemia, genetic/metabolic disorders), tumors, and vascular abnormalities. Prediction of outcomes is important, to target interventions, allocate resources, provide education to family or caregivers, and begin appropriate planning for the future. Researchers have identified several factors associated with better or worse outcomes after ABI, including variables related to the injury itself, postinjury factors related to intervention or trajectory of recovery, and preinjury or demographic factors. When examining the scientific literature, it is important to identify how "outcome" is defined, as the predictors may change depending on the outcome studied. In addition, key variables may be specific to the etiology of injury. Therefore, predictors of outcome cannot be generalized across the various etiologies of ABI, and this review will discuss predictors within the context of multiple etiologies of ABI. This article reviews the current literature on predicting outcomes after pediatric ABI, and areas in need of further research are discussed.

The effects of treatment for posterior fossa brain tumors on selective attention

We sought to identify whether deficits in selective attention are present in pediatric brain tumor patients. Selective attention was assessed with covert-orienting, filtering, and visual-search tasks in 54 patients with either (1) posterior fossa (PF) tumors treated with cranial radiation and surgery (n = 22); (2) PF tumors treated with surgery alone (n = 17); or (3) non-CNS tumors (n = 15), who served as a patient control group. To account for normal development, patient performance was also compared with that of healthy age-matched controls (n = 10). We found that in PF tumor patients selective attention was impaired, regardless of whether they were treated with cranial radiation and surgery or surgery alone. However, patients treated with cranial radiation were most impaired. These patients may have greater damage to posterior brain regions know to mediate selective attention as the result of tumor location, effects of surgery, and higher doses of radiation to the posterior regions of the brain. These findings help to elucidate the potential impact of pediatric brain tumors and their treatment on discrete attentional skills.

School Experiences of Families of Children With Brain Tumors

Families and children often report a diverse range of academic achievements and challenges after undergoing treatment for a brain tumor. This study explores the experiences of children, youth, and their families as they seek to reintegrate into mainstream educational systems. Despite the variable experiences, there are many common strategies that could positively influence the child's success in school. Strong communication between parents, school, and health professionals is paramount. Preparing parents to advocate for their children's academic and social needs and developing an awareness of the challenges among school staff has potential to improve outcomes for these children. Equipping the children with the social skills needed to manage social situations will strengthen their ability to overcome the challenges that they face. These study findings shed light on the academic experiences of these children and can lead to the development of strategies to support families facing similar challenges.

Predicting change in academic abilities after conformal radiation therapy for localized ependymoma

PURPOSE

Conformal radiation therapy (CRT) aims to limit the highest radiation dose to the tissue volume at risk while sparing surrounding normal tissues. This study investigated whether treatment of childhood ependymoma with CRT would preserve cognitive function. Academic competence was chosen as the primary outcome measure given it is a measure of applied cognitive abilities in a child's natural setting.

PATIENTS AND METHODS

Eighty-seven pediatric patients diagnosed with ependymoma received CRT in which doses ranging from 54.0 to 59.4 Gy were prescribed to the postoperative tumor bed with a 10-mm clinical target volume margin. Cognitive testing was conducted at the start of CRT, 6 months, and annually after the start of CRT. The median length of follow-up was 59.6 months. Academic testing included subtests from the Wechsler Individual Achievement Test (WIAT) and the Achenbach Child Behavior Checklist.

RESULTS

Linear mixed models with random coefficients revealed a modest but significant decline in reading scores during follow-up (WIAT slope estimate -0.064 +/- 0.028 points/month; P = .026). Math and spelling performance remained stable. Supratentorial tumor location and multiple surgeries were predictive of worse reading performance at CRT baseline. Male sex, longer symptomatic interval, pre-CRT chemotherapy, pre-existing endocrine deficiencies, hydrocephalus, and younger age at CRT (< 5 years) were predictive of a significant decline in reading scores over time.

CONCLUSION

CRT may result in better long-term cognitive outcomes when compared to conventional radiation therapy approaches. Reading appears more vulnerable than other academic skills and may decline over time despite stable intellectual functioning.

Follow-up care for young adult survivors of cancer: lessons from pediatrics

INTRODUCTION

Recent advances in treatment of childhood cancer have resulted in overall survival rates approaching 75%, but approximately two-thirds experience late-effects related to the disease or treatment. Consequently, recommendations for comprehensive follow-up have been made. As the number of survivors of adult cancers increase, similar concerns about how to provide follow-up and achieve optimal quality of life are being raised. In this paper we propose that management of cancer survivors diagnosed in young adulthood (18-45 years) could benefit from experience gained treating survivors of childhood cancer.

MATERIALS AND METHODS

We reviewed research relating to differences in survival rates and late-effects; current arrangements for follow-up; effectiveness; and problems in organization of follow-up separately for survivors of child and adult cancers.

RESULTS

A number of models of follow-up were identified. Rationale for follow-up included early identification and treatment of second cancer and late-effects, health promotion and screening. Increasing numbers of survivors and range of late-effects were identified as problems in organizing services. A possible solution is risk-stratified follow-up, currently being developed in pediatrics.

CONCLUSIONS

New models of follow-up are needed that take account of financial costs for health services and survivors' concerns about their current and future health. Implications for continuing refinement of treatment protocols must be an integral part of the service.

IMPLICATIONS FOR CANCER SURVIVORS

International standards are needed to ensure all survivors have access to expert follow-up care and can benefit from new information that might lead to earlier treatment of late-effects.

Parent report of attention problems predicts later adaptive functioning in children with brain tumors

Children with brain tumors are at risk for psychological and behavioral difficulties. This study examined the ability of parent report of attention problems, withdrawal, anxiety, and depression, as well as IQ, to predict later adaptive functioning in 42 children treated for brain tumors. Age at diagnosis, SES, gender, and scores on the Neurological Predictor Scale (NPS) also were examined as predictors. Parent report of attention problems, SES, and NPS were significant predictors of later adaptive functioning across domains. This finding highlights the ability of parent report of attention problems to predict later adaptive functioning in children treated for brain tumors.

I'll Show Them: The Social Construction of (In)Competence in Survivors of Childhood Brain Tumors

Multimodal therapy for the treatment of childhood cancer has resulted in increased survival rates, yet as growing cohorts of children mature, late effects are becoming apparent. Specifically, brain tumor survivors tend to have poor social skills, peer relationship problems, academic difficulties, and delayed college entry. This article addresses findings specific to the unique experience of childhood cancer survivors as they transition from adolescence to adulthood. Qualitative methods involving focus groups and in-depth interviews with 14 childhood cancer survivors and 22 family members were used. The dialectic of incompetence/competence pervaded all narratives. Contradictory concepts of integration/ isolation, realistic/unrealistic goals, and the need for special help/no help were underscored by respondents. The struggle to deal with these contradictory factors led to the simultaneous resistance and acceptance of feelings of competence.

Attention dysfunction and parent reporting in children with brain tumors

BACKGROUND

The IQ declines observed in children treated for brain tumor emerge as "late effects" and are conceptualized as secondary to changes in underlying mental processes, such as attention. Early identification of the underlying changes might help minimize the long-term adverse outcomes. We evaluated the validity of a time-efficient, standardized parent-report measure in identifying attention dysfunction in childhood brain tumor survivors.

PROCEDURE

Seventy survivors between ages 6 and 16 who met eligibility criteria and who had completed a standard neuropsychological evaluation were classified into an attention dysfunction group and a non-attention dysfunction group, based on their performance on objective measures of attention. Analysis of covariance was used to evaluate group differences on the widely used, parent report Child Behavioral Checklist (CBCL).

RESULTS

Survivors in the attention dysfunction group were reported by their parents as having significantly more attention problems relative to the group without attention dysfunction on objective testing. Furthermore, survivors categorized as having attention dysfunction based on their neuropsychological test scores were reported on the CBCL by their parents as having significantly more social problems compared to the non-attention dysfunction group.

CONCLUSIONS

Standardized parent reporting of attention problems shows promise as a screening tool to detect attention dysfunction among survivors of childhood brain tumors. Findings include a strong association of decreased social functioning with attention dysfunction in brain tumor survivors. Furthermore, exploratory data suggest that the behavioral presentation of attention dysfunction in this group may be different from other clinical groups.

Parenting stress reduces the effectiveness of early teaching interventions for autistic spectrum disorders

This community-based study examined the influence of early teaching interventions on children diagnosed with Autistic Spectrum Disorders, and the dynamics between the time intensity of the interventions and parenting stress, on child outcomes. Intellectual, educational, and adaptive behavior and social functioning were all measured. Sixty-five children were divided into four groups, based on the levels of time intensity of their intervention, and on their parents' stress levels. There were gains in intellectual, educational, and adaptive behavioral and social skills, and there was a positive relationship between the time intensity of the early teaching interventions and child outcome gains. More importantly, however, high levels of parenting stress counteracted the effectiveness of the early teaching interventions.

Early predictors of post-hospital adjustment problems in critically ill young children

Toddlers and preschool children have been identified as being at risk for post-hospital behavioral sequelae, especially when confronted with an unanticipated intensive care unit (ICU) hospitalization. The purpose of this predictive secondary analysis was to determine demographic and clinical variables that could be assessed early during hospitalization to predict internalizing and externalizing behaviors and negative behavioral change of 2- to 7-year-old children at 3 and 6 months following an unanticipated critical care hospitalization (n = 163 mother-child dyads). The children's behavioral predilections prior to hospitalization (i.e., internalizing or externalizing behaviors) and sex, as well as elevated maternal state anxiety, marital status, and level of emotional care giving by mothers, significantly predicted child internalizing and externalizing behavior and post-hospitalization behavior changes. Results suggest several risk factors that predispose children to poor outcomes following an unanticipated hospitalization that could be targeted for intervention to improve children's emotional and behavioral health.