Predicting neurocognitive function in pediatric brain tumor early survivorship: The neurological predictor scale and the incremental validity of tumor size.

BACKGROUND: The Neurological Predictor Scale (NPS) quantifies cumulative exposure to conventional treatment-related neurological risks but does not capture potential risks posed by tumors themselves. This study evaluated the predictive validity of the NPS, and the incremental value of tumor location and size, for neurocognitive outcomes in early survivorship following contemporary therapies for pediatric brain tumors. PROCEDURE: Survivors (N = 69) diagnosed from 2010 to 2016 were administered age-appropriate versions of the Wechsler Intelligence Scales. Hierarchical multiple regressions examined the predictive and incremental validity of NPS score, tumor location, and tumor size. RESULTS: Participants (51% female) aged 6-20 years (M = 13.22, SD = 4.09) completed neurocognitive evaluations 5.16 years (SD = 1.29) postdiagnosis. The NPS significantly predicted Full-Scale Intelligence Quotient (FSIQ; ΔR2  = .079), Verbal Comprehension Index (VCI; ΔR2  = 0.051), Perceptual Reasoning Index (PRI; ΔR2  = 0.065), and Processing Speed Index (PSI; ΔR2  = 0.049) performance after controlling for sex, age at diagnosis, and maternal education. Tumor size alone accounted for a significant amount of unique variance in FSIQ (ΔR2  = 0.065), PRI (ΔR2  = 0.076), and PSI (ΔR2  = 0.080), beyond that captured by the NPS and relevant covariates. Within the full model, the NPS remained a significant independent predictor of FSIQ (ß = -0.249, P = 0.016), VCI (ß = -0.223, P = 0.048), and PRI (ß = -0.229, P = 0.037). CONCLUSIONS: Tumor size emerged as an independent predictor of neurocognitive functioning and added incrementally to the predictive utility of the NPS. Pretreatment disease burden may provide one of the earliest markers of neurocognitive risk following contemporary treatments. With perpetual treatment advances, measures quantifying treatment-related risk may need to be updated and revalidated to maintain their clinical utility.

Treatment age and neurocognitive outcomes following proton beam radiotherapy for pediatric low- and intermediate-grade gliomas.

The relationship between age and neurocognitive functioning following proton beam radiotherapy (PRT) in low- and intermediate-grade gliomas (LIGG) has yet to be examined. Eighteen LIGG patients treated with PRT were prospectively enrolled and received annual neurocognitive evaluations of perceptual/verbal reasoning, working memory, and processing speed postradiotherapy. The median age at diagnosis was 8.2 years (range 1.0-14.7) and the median age at PRT was 9.9 years (range 4.2-17.0). Patients' neurocognitive performance did not change on any measure following PRT (p ≥ .142). We did not observe significant changes in cognitive function over time among a small group of LIGG patients treated with PRT.

Facilitating Transitions to Adulthood in Pediatric Brain Tumor Patients: the Role of Neuropsychology.

PURPOSE OF REVIEW: Transition-age patients with history of a pediatric brain tumor are at significant risk for difficulties transitioning to adulthood. We review current transition models and the potential role of neuropsychology in the transition process for adolescent and young adult brain tumor survivors. RECENT FINDINGS: Several recently developed healthcare transition models include consideration of patients' cognitive and functional capacities, yet currently available transition readiness tools are limited in scope and do not possess adequate normative data across pediatric medical populations. We explore the potential utility and added benefit of systematically incorporating neuropsychology in the transition process for pediatric brain tumor survivors. The literature supports increased evaluation and intervention targeted at psychosocial barriers to transition. Based on these findings, we propose a family-centered and multidisciplinary care model that promotes both medical and broader psychosocial transition processes. Neuropsychology is ideally suited to assess the wide-ranging areas encompassed in transition readiness and to facilitate the transition process.

Brief Behavioral Intervention for Disruptive Behavior in a Child with a Hypothalamic Hamartoma: A Case Report.

Most children with hypothalamic hamartoma (HH) manifest symptoms of epilepsy and associated cognitive deficits and behavioral difficulties as well as central precocious puberty (CPP). However, there is little to no research examining behavioral difficulties in children with HH without epilepsy, nor is there research examining treatments to address the behavioral difficulties of patients with HH without epilepsy. In the current case report, the authors implemented a validated parent management training program [the Brief Behavioral Intervention (BBI)], to treat symptoms of ADHD and disruptive behavior in a 6-year-old female patient with HH and CPP. The family participated in six BBI sessions over a period of 8 weeks. Parent behavioral ratings suggested significant reductions of symptoms of ADHD and disruptive behaviors to the normal range. The current case report demonstrates the effectiveness of the BBI program in the treatment of behavioral difficulties in a patient with HH and CPP. Further, the present study explores behavioral manifestations rarely explored in patients with HH without epilepsy.

Implementing guidelines: Proposed definitions of neuropsychology services in pediatric oncology.

Several organizations have published guidelines for the neuropsychological care of survivors of childhood cancer. However, there is limited consensus in how these guidelines are applied. The model of neuropsychology service delivery is further complicated by the variable terminology used to describe recommended services. In an important first step to translate published guidelines into clinical practice, this paper proposes definitions for specific neuropsychological processes and services, with the goal of facilitating consistency across sites to foster future clinical program development and to clarify clinical practice guidelines.

Fellow and training director perspectives on personal leaves during fellowship training in neuropsychology and considerations for best practice.

Objective: Management of personal leaves represents an important component of diversity, equity, and inclusion (DEI) initiatives. This study aims to understand the ways in which both training directors and fellows in neuropsychology training programs understand, perceive, communicate about, and plan for personal leaves during fellowship training. We also aim to provide empirically based recommendations for training directors communicating with fellows about personal leaves. Method: Training directors (N = 40) and postdoctoral fellows (N = 51) were recruited to complete surveys examining their knowledge and perspectives on personal leaves through a professional listserv. Results: While most training directors reported that their programs offer paid personal leave options, a substantial minority did not. There were discrepancies between training directors' and fellows' knowledge about leave policies and perceptions of the professional implications of taking a personal leave, such that fellows reported less knowledge and a greater perception that taking a leave during training may have a negative professional impact. Conclusions: Findings suggest that training directors in neuropsychology should clearly communicate institutional leave policies early in, or even before the start of, the fellowship period and work to cultivate a culture of openness around both broad issues of work-life balance and specific issues related to personal leaves with trainees.

Neuropsychological functioning following surgery for pediatric low-grade glioma: a prospective longitudinal study.

OBJECTIVE: High survival rates have led to an increased emphasis on the functional outcomes of children diagnosed with low-grade glioma. Most outcomes research has focused on risks associated with radiotherapy, but less is known about neuropsychological risks for patients treated with surgery alone. Here, the authors sought to examine the neuropsychological trajectories of children diagnosed with a low-grade glioma and monitored up to 6 years postsurgery. Secondarily, they explored demographic and clinical predictors of neuropsychological performance. METHODS: The neuropsychological functioning of 32 patients (median age at diagnosis 10.0 years) was prospectively assessed annually for up to 6 years after surgery (median days from surgery at baseline = 72). Tumor location was predominately supratentorial (65.6%). A combination of performance-based and parent-reported measures was used to assess intelligence, memory, executive functioning, and fine motor control in all patients. RESULTS: Binomial tests at the postoperative baseline revealed that the proportion of children falling below the average range (< 16th percentile) was significantly higher than the rate expected among healthy peers on measures of verbal memory, processing speed, executive functioning, and fine motor control (p < 0.05). Even so, linear mixed models indicated that neuropsychological functioning at the postoperative baseline did not significantly change over time for up to 6 years after surgery across all domains. A larger tumor size was associated with a slower reaction time (p < 0.01). A supratentorial tumor location and history of seizures were associated with more parent-reported executive difficulties (p < 0.01). CONCLUSIONS: While radiotherapy is a known risk factor for neuropsychological deficits in pediatric brain tumor patients, findings in this study indicate that children treated for low-grade glioma with surgery alone (without radiotherapy or chemotherapy) remain susceptible to difficulties with memory, executive functioning, and motor functioning that persist over time. Over half of the children in the study sample required school support services to address neuropsychological weaknesses. Although low-grade glioma is often conceptualized as a benign tumor, children treated for this lesion require ongoing monitoring and intervention to address neuropsychological weaknesses resulting from the tumor itself as well as the surgery.

Utility of the General Ability Index (GAI) and Cognitive Proficiency Index (CPI) with survivors of pediatric brain tumors: Comparison to Full Scale IQ and premorbid IQ estimates.

INTRODUCTION: Pediatric brain tumor survivors are at risk for working memory and processing speed impairment. The General Ability Index (GAI) provides an estimate of intellectual functioning that is less influenced by working memory and processing speed than a Full Scale IQ (FSIQ). The Cognitive Proficiency Index (CPI) provides a measure of efficient information processing derived from working memory and processing speed tasks. We examined the utility of the GAI and CPI to quantify neurocognitive outcomes in a sample of pediatric brain tumor survivors. METHOD: GAI, CPI, and FSIQ scores from the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) were examined for 57 pediatric brain tumor survivors (ages 6-16 years) treated with cranial radiation therapy (RT). RESULTS: GAI scores were higher than FSIQ and CPI scores, both p < .001. Lower CPI scores were associated with history of craniospinal irradiation and time since RT. Lower FSIQ and GAI scores were associated with higher RT dose and time since RT. The rate of clinically significant GAI-FSIQ discrepancies in our sample was greater than that observed in the WISC-IV standardization sample, p < .001. Estimated premorbid IQ scores were higher than GAI, p < .01, and FSIQ scores, p < .001. CONCLUSIONS: Pediatric brain tumor survivors exhibit weaker cognitive proficiency than that expected for age, while general reasoning ability remains relatively spared. The GAI may be useful to quantify the intellectual potential of a survivor when appropriate accommodations are in place for relative cognitive proficiency weaknesses. The CPI may be a particularly sensitive outcome measure of treatment-related cognitive change in this population.

Neuropsychological late effects and rehabilitation following pediatric brain tumor.

The modern era of research into the neurobehavioral late effects of pediatric brain tumor has been one of refinement in outcome measurement and advances in identification of risk factors for neurobehavioral impairment. There is no neuropsychological phenotype that encompasses all tumor types, treatments, and risk factors, though attention, working memory, processing speed, new learning, visuospatial and visuomotor functioning, executive functioning, and areas of academic achievement have been found to be at particular risk. Additional socioemotional and broader quality of life problems have been found in both survivors and their families. Past research has identified neuropsychological risk factors that include tumor location, radiation therapy and dose, certain chemotherapy agents, neurological complications, and demographic factors such as young age and female gender. Recent refinement in measurement of risk is improving our prediction of neurobehavioral outcomes. Neuropsychological and psychosocial interventions are now being developed, and the evidence base supporting these interventions is growing. Simultaneous advances in each of these areas will facilitate translation of research into risk-adapted rehabilitative care such that resources can be most effectively re-allocated and the best possible outcomes achieved.