Impact of home-based cognitive or academic intervention on working memory and mathematics outcomes in pediatric brain tumor survivors: the Keys to Succeed pilot randomized controlled clinical trial.

Pediatric brain tumour survivors experience deficits in mathematics and working memory. An open question is whether it is most optimal to target direct cognitive skills (i.e. working memory) or focus on specific academic outcomes (i.e. mathematics) for in remediation. We conducted a pilot randomized controlled trial to determine the feasibility of comparing a working memory versus mathematics intervention. Pediatric brain tumor survivors (7-17 years) were randomly assigned to Cogmed or JumpMath interventions, or an Active Control/Reading group. All participants received Educational Liaison support and completed ~12-weeks of home-based intervention with weekly, telephone-based consultation in one of the three conditions. Standardized assessments of auditory and visual working memory, mathematics calculation and reasoning were completed pre- and post- intervention. Twenty-nine participants completed the interventions; 94% of parents reported a high degree of satisfaction with the interventions and ease of implementation. Participants in JumpMath demonstrated improved mathematics calculation from pre- to post- intervention (p=0.02). Further, participants in both Cogmed and JumpMath showed evidence of pre- to post- intervention improvements in auditory working memory relative to controls (p=0.01). The Cogmed group also showed improvements in visual working memory (p=0.03). Findings suggest that targeted intervention is feasible in survivors of pediatric brain tumors, though with a relatively low recruitment rate. With preliminary findings of improved calculation and working memory following JumpMath and working memory following Cogmed, this pilot trial lays the groundwork for future programs that investigate different inteCognitiveRehabilitationrventions that may be applied to target the unique needs of each survivor.

[Formula: see text]Examining parent and clinician views of a hospital-based pediatric neuropsychological service: a Canadian perspective.

Understanding how pediatric neuropsychological evaluations support families and the child's medical team is an important component of ensuring evidence-based care. For the first time within a Canadian context, we investigated the impact of neuropsychological assessments on parent knowledge, advocacy, and stress and the role of socioeconomic factors in parents' perceptions of the assessment. Responses from referring clinicians were also examined. As part of a hospital quality improvement project, 91 parents of children between the ages of 3 and 17 years (M = 8y7m; SD = 4y1m) and 45 clinician consumers (clinical staff who use neuropsychological services) completed one of two online questionnaires in English: Parent Overall Assessment of Supports and Testing, or Clinician Overall Assessment of Supports and Testing. Most parents indicated the neuropsychological evaluation promoted understanding of their child's cognitive profile and improved their ability to support their child at home and at school or in the community. Families characterized as being at higher social risk indicated that the evaluation led to more changes in how they approached their child at home than families with lower social risk status. Referring clinicians indicated neuropsychological reports were effective in communicating findings to them and patients/families. The most valuable sections of the report according to referring clinicians included the diagnosis/impression and recommendations sections. Parents and referral providers reported many benefits from the neuropsychological evaluation but also identified areas for service delivery improvement. Parent perceptions varied based on family and socio environmental factors, offering important targets for future research and clinical consideration.

Cognitive Correlates of Math Performance in School-Aged Children with Sickle Cell Disease and Silent Cerebral Infarcts.

OBJECTIVE: Attention, processing speed, executive functioning, and math difficulties are common in youth with sickle cell disease (SCD) with silent cerebral infarcts (SCI). This study investigated the cognitive underpinnings of math difficulties in children with SCD and SCI. METHOD: Youth (n = 68) with SCD and SCI completed measures of attention [Digit Span forward (DSF); Conners Continuous Performance Test-Third Edition/Kiddie Conners Continuous Performance Test-Second Edition (CPT-3/KCPT-2)]; working memory [Wechsler Intelligence Scales (WPPSI-IV, WISC-IV, WISC-V, WAIS-IV), Working Memory Index (WMI), Digit Span backwards (DSB)]; processing speed [WPPSI-IV, WISC-IV, WISC-V, WAIS-IV Processing Speed Index (PSI)]; math reasoning [Wechsler Individual Achievement Test-Third Edition (WIAT-III) Mathematics composite (MC)]; and math fluency [WIAT-III Math Fluency composite (MF)] as part of a clinical neuropsychological evaluation. Parent ratings of attention and executive functioning were obtained [Behavior Assessment System for Children-Third Edition (BASC-3), Behavior Rating Inventory of Executive Function (BRIEF)]. RESULTS: MC was positively correlated with WMI (r = 0.59, p = 0.00), PSI (r = 0.40, p < 0.001), DSF (r = 0.29, p = 0.03), DSB (r = 0.47, p < 0.001), and MF (r = 0.71, p < 0.001). Correlations between MC, sustained attention, and parent ratings were nonsignificant. The linear regression model using correlated variables was significant [F(4,51) = 8.29, R2 = 0.39, p < 0.001]. WMI was the only significant variable within the model (p = 0.02). CONCLUSIONS: Working memory deficits account for significant variance in untimed mathematical performance in this population-consistent with other populations with white matter dysfunction. Interventions targeting both mathematics and working memory may be beneficial.

Intellectual changes after radiation for children with brain tumors: which brain structures are most important?

BACKGROUND: The objective of this study was to evaluate the contribution of radiation dose to different intracranial structures on changes in intellectual function for children with brain tumors. METHODS: We evaluated children with brain tumors treated in 2005-2017 who had longitudinal neuropsychological assessments and available photon dosimetric data (if radiation therapy [RT] given). Full Scale Intelligence Quotient (FSIQ) and index scores were evaluated (perceptual reasoning index [PRI], processing speed index [PSI], verbal comprehension index [VCI], and working memory index [WMI]). Multivariable linear mixed effects models were used to model endpoints, with age at RT and dose to different brain regions as fixed effects and patient-specific random intercepts. P-values (P*) were adjusted for multiple comparisons. RESULTS: Sixty-nine patients were included, 56 of whom received RT. Median neuropsychological follow-up was 3.2 years. Right temporal lobe mean dose was strongly associated with decline in FSIQ (P* = 0.005); with each gray increase in mean dose, there was a decrease of 0.052 FSIQ points per year. Dose to 50% (D50) of the supratentorial brain was associated with decline in PSI (P* = 0.006) and WMI (P* = 0.001). Right and left hippocampus D50 were individually strongly associated with declines in VCI (P* = 0.009 for each). Presence of a ventriculoperitoneal shunt decreased FSIQ by 10 points. CONCLUSIONS: We reported associations between dosimetry to specific brain regions and intellectual outcomes, with suggested avoidance structures during RT planning. These models can help clinicians anticipate changes in neurocognition post-RT and guide selection of an optimal RT plan.

Outcomes of haemoglobin Bart's hydrops fetalis following intrauterine transfusion in Ontario, Canada.

OBJECTIVES: With improved access to intrauterine transfusion (IUT), more fetuses with haemoglobin Bart's hydrops fetalis (HBHF; homozygous α0-thalassaemia) will survive. DESIGN: To evaluate the long-term outcome of affected fetuses with and without IUT in Ontario, Canada, we retrospectively collected data on IUTs and pregnancy outcomes in all cases of HBHF, from 1989 to 2014. Clinical outcome and neurocognitive profiles of long-term survivors were also collected and compared with data from 24 patients with transfusion-dependent ß-thalassaemia (TDT-ß). RESULTS: Of the 99 affected pregnancies (93 prenatally diagnosed), 68 resulted in miscarriage or elective termination of pregnancy. Twelve mothers (12%) continued their pregnancies without IUT, and none of those newborns survived the first week of life. All 13 fetuses that received IUT(s) were live-born, but 3 died due to severe hydrops at birth and 1 died due to infection. The remaining nine survivors, in comparison with TDT-ß patients, had earlier iron overload requiring iron chelation therapy. Endocrinopathies and short stature were more frequent in these patients. Neurocognitive outcome was not significantly affected in five patients who were assessed, and none were diagnosed with intellectual impairment. In three patients, MRI studies demonstrated brain white matter changes in keeping with 'silent' ischaemic infarcts. CONCLUSIONS: In patients with HBHF, IUT is associated with improved survival. While acceptable neurocognitive outcome can be expected, these patients have more clinical complications compared with their TDT-ß counterparts. The clinical and neurocognitive outcomes of HBHF should be discussed in detail when counselling and offering IUT for patients.

Reirradiation for recurrent craniopharyngioma.

PURPOSE: Reirradiation is rarely administered to patients with recurrent craniopharyngioma owing to concerns regarding visual and endocrine side effects. The purpose of this case series was to evaluate our institutional experience of patients with craniopharyngioma treated with 2 courses of fractionated radiation therapy. METHODS AND MATERIALS: A retrospective study was performed of all patients with craniopharyngioma treated with 2 courses of fractionated radiation therapy at a single institution. Electronic medical records and radiation therapy records were reviewed. RESULTS: We identified 4 eligible patients with recurrent craniopharyngioma. With a median follow-up of 33 months after reirradiation, 3 patients attained disease control; 1 patient developed progressive disease, 27 months after reirradiation. In 3 evaluable patients, vision remained stable or improved after reirradiation; one patient had no light perception before reirradiation. None of the patients experienced additional endocrine toxicities after reirradiation, apart from one patient who had low serum thyroid stimulating hormone before reirradiation and later developed hypothyroidism after treatment. CONCLUSIONS: Reirradiation may represent a safe and effective therapeutic option for selected patients with recurrent, refractory craniopharyngioma and without other salvage treatment options. Larger studies with longer-term follow up are warranted to better understand outcomes in these patients.

Neuropsychological impact of trametinib in pediatric low-grade glioma: A case series.

Clinical trials of MEK inhibitors are underway in pediatric low-grade glioma (PLGG) with BRAF oncogene mutations and recurrent/refractory disease. Cognitive and behavioral impacts of MEK inhibitors, such as trametinib, are unknown as these outcomes have not yet been studied. This case series compared cognition and behavior in eight PLGG cases prior to and while on treatment with trametinib compared to four PLGG controls. Intelligence in the trametinib cases was mainly unchanged while on treatment, with mild decline in one of seven cases with complete data. Parent-reported depression symptoms increased in five of eight trametinib cases relative to one of four controls.

Executive functions and social skills in pediatric brain tumor survivors.

Pediatric brain tumor survivors (PBTSs) may experience impairment in executive functions and social competence, but their interrelation is not well understood. This study aimed to address the specificity of this relationship. PBTSs (n = 91) were on average 11.21 years old, 5 years from diagnosis, and 48.4% female. One parent and PBTS completed the Social Skills Rating System (subscales: Cooperation, Assertiveness, Empathy, Self-Control, and Total), and parents also completed the Behavior Rating Inventory of Executive Function (General Executive Composite [GEC], Metacognition [MI], and Behavioral Regulation [BRI] indices) and the (Withdrawal scale). Based on proxy reports, more PBTSs had deficits in Cooperation, Assertiveness and Responsibility skills relative to normative data. MI was more consistently associated with parent reported social skills deficits than BRI. PBTSs reported fewer deficits in social skills relative to normative data across all scales; none of the correlations between PBTSs reported social skills and executive functions were significant. Time since diagnosis and proxy reported lower total social skills predicted greater withdrawal. These findings highlight the importance of assessing differential perspectives of PBTSs social competence, and that metacognitive strategies may bear particular importance for the social skills of PBTSs.

Medulloblastoma has a global impact on health related quality of life: Findings from an international cohort.

BACKGROUND: Understanding the global impact of medulloblastoma on health related quality of life (HRQL) is critical to characterizing the broad impact of this disease and realizing the benefits of modern treatments. We evaluated HRQL in an international cohort of pediatric medulloblastoma patients. METHODS: Seventy-six patients were selected from 10 sites across North America, Europe, and Asia, who participated in the Medulloblastoma Advanced Genomics International Consortium (MAGIC). The Health Utilities Index (HUI) was administered to patients and/or parents at each site. Responses were used to determine overall HRQL and attributes (ie specific subdomains). The impact of various demographic and medical variables on HRQL was considered-including molecular subgroup. RESULTS: The majority of patients reported having moderate or severe overall burden of morbidity for both the HUI2 and HUI3 (HUI2 = 60%; HUI3 = 72.1%) when proxy-assessed. Self-care in the HUI2 was rated as higher (ie better outcome) for patients from Western versus Eastern sites, P = .02. Patients with nonmetastatic status had higher values (ie better outcomes) for the HUI3 hearing, HUI3 pain, and HUI2 pain, all P < .05. Patients treated with a gross total resection also had better outcomes for the HUI3 hearing (P = .04). However, those who underwent a gross total resection reported having worse outcomes on the HUI3 vision (P = .02). No differences in HRQL were evident as a function of subgroup. CONCLUSIONS: By examining an international sample of survivors, we characterized the worldwide impact of medulloblastoma. This is a critical first step in developing global standards for evaluating long-term outcomes.

Superior Intellectual Outcomes After Proton Radiotherapy Compared With Photon Radiotherapy for Pediatric Medulloblastoma.

PURPOSE: Proton radiotherapy (PRT) may lessen the neuropsychological risk traditionally associated with cranial radiotherapy for the treatment of pediatric brain tumors by reducing the dose to normal tissue compared with that of photon radiotherapy (XRT). We examined the change in intellectual scores over time in patients with pediatric medulloblastoma treated with craniospinal PRT versus XRT. METHODS: Intelligence test scores were obtained for a sample of pediatric patients treated between 2007 and 2018 on the same medulloblastoma protocols that differed only in radiotherapy modality (PRT v XRT). Growth curve analyses compared change in scores over time since diagnosis between groups. RESULTS: Longitudinal intelligence data from 79 patients (37 PRT, 42 XRT) were examined. Groups were similar on most demographic/clinical variables, including sex (67.1% male), age at diagnosis (mean, 8.6 years), craniospinal irradiation dose (median, 23.4 Gy), length of follow-up (mean, 4.3 years), and parental education (mean, 14.3 years). Boost dose (P < .001) and boost margin (P = .001) differed between groups. Adjusting for covariates, the PRT group exhibited superior long-term outcomes in global intelligence quotient (IQ), perceptual reasoning, and working memory compared with the XRT group (all P < .05). The XRT group exhibited a significant decline in global IQ, working memory, and processing speed (all P < .05). The PRT group exhibited stable scores over time in all domains with the exception of processing speed (P = .003). CONCLUSION: To our knowledge, this is the first study to compare intellectual trajectories between pediatric patients treated for medulloblastoma with PRT versus those treated with XRT on comparable, contemporary protocols. PRT was associated with more favorable intellectual outcomes in most domains compared with XRT, although processing speed emerged as a vulnerable domain for both groups. This study provides the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.

Social attainment in survivors of pediatric central nervous system tumors: a systematic review and meta-analysis from the Children's Oncology Group.

PURPOSE: Improved therapies for pediatric central nervous system (CNS) tumors have increased survival rates; however, many survivors experience significant long-term functional limitations. Survivors of pediatric CNS tumors can experience deficits in social attainment. The aim of this review was to systematically amalgamate findings pertaining to social attainment (i.e., educational attainment, marriage, employment outcomes) in survivors of pediatric CNS tumors. METHODS: PubMed (web-based), PsycINFO (EBSCO), EMBASE (Ovid), and Web of Science (Thomson Reuters) were used to identify articles published between January 2011 and September 2018. Eligible studies reported outcomes for survivors of pediatric CNS tumors diagnosed before age 21 years and > 5 years from diagnosis and/or > 2 years off therapy. All data were independently abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0. RESULTS: The search yielded 7021 unique publications. Forty-six were included in the current review. Meta-analyses revealed survivors of CNS tumors were significantly more likely to have completed compulsory education only (OR = 1.87, 95% CI = 1.66, 2.12, p < 0.00001), less likely to be married (OR = 4.70, 95% CI = 3.89, 5.68, p < 0.00001), and more likely to be unemployed (OR = 2.84, 95% CI = 2.62, 3.08, p < 0.00001) compared to non-cancer controls. Cranial radiation therapy, neurocognitive deficits, and younger age at diagnosis were associated with poorer outcomes. Hearing loss and bilateral blindness were also related to poorer outcomes. Sex did not impact social attainment outcomes. CONCLUSIONS: Survivors of pediatric CNS tumors are at elevated risk for poor attainment of key adult social outcomes. IMPLICATIONS FOR CANCER SURVIVORS: There is a critical need to develop interventions to support survivors in becoming independent and productive adults.

Are we friends? Best friend nominations in pediatric brain tumor survivors and associated factors.

BACKGROUND: Pediatric brain tumor survivors (PBTSs) are at risk of impairments in social competence. Limited information is available regarding nominations and reciprocated nominations of PBTSs as best friends and factors which may predict these. PROCEDURE: Caregivers of children (n = 32) aged 8-16 (38% low-grade glioma, 34% medulloblastoma, 28% other) completed ratings of child adjustment at baseline (T1) and PBTSs and classmates completed the Three Best Friends measure approximately 12 months later (T2). Sociometric data yielded ratings of best friend nominations and reciprocated best friend nominations. RESULTS: Nominations of PBTSs as best friends were not significantly different than controls, but PBTSs had fewer reciprocated best friend nominations than controls. Approximately half of PBTSs in this study did not have any reciprocated best friend nominations and 25% were not nominated by any peer as a best friend. Greater symptoms of depression and lower social skills in PBTSs were associated with fewer nominations as a best friend by peers and a greater likelihood of no reciprocal best friend nominations. Greater difficulties in emotional control were associated with fewer nominations as a best friend by peers. CONCLUSIONS: The discrepancy between reciprocated best friend nominations and best friend nominations highlights a need to attend to reciprocal friendships in PBTSs and further understand social information processes in this population. Longitudinal analyses illustrate the impact of emotional adjustment on PBTS friendships.

Survival and functional outcomes of molecularly defined childhood posterior fossa ependymoma: Cure at a cost.

BACKGROUND: Posterior fossa ependymoma (PFE) comprises 2 groups, PF group A (PFA) and PF group B (PFB), with stark differences in outcome. However, to the authors' knowledge, the long-term outcomes of PFA ependymoma have not been described fully. The objective of the current study was to identify predictors of survival and neurocognitive outcome in a large consecutive cohort of subgrouped patients with PFE over 30 years. METHODS: Demographic, survival, and neurocognitive data were collected from consecutive patients diagnosed with PFE from 1985 through 2014 at the Hospital for Sick Children in Toronto, Ontario, Canada. Subgroup was assigned using genome-wide methylation array and/or immunoreactivity to histone H3 K27 trimethylation (H3K27me3). RESULTS: A total of 72 PFE cases were identified, 89% of which were PFA. There were no disease recurrences noted among patients with PFB. The 10-year progression-free survival rate for all patients with PFA was poor at 37.1% (95% confidence interval, 25.9%-53.1%). Analysis of consecutive 10-year epochs revealed significant improvements in progression-free survival and/or overall survival over time. This pertains to the increase in the rate of gross (macroscopic) total resection from 35% to 77% and the use of upfront radiotherapy increasing from 65% to 96% over the observed period and confirmed in a multivariable model. Using a mixed linear model, analysis of longitudinal neuropsychological outcomes restricted to patients with PFA who were treated with focal irradiation demonstrated significant continuous declines in the full-scale intelligence quotient over time with upfront conformal radiotherapy, even when correcting for hydrocephalus, number of surgeries, and age at diagnosis (-1.33 ± 0.42 points/year; P = .0042). CONCLUSIONS: Data from a molecularly informed large cohort of patients with PFE clearly indicate improved survival over time, related to more aggressive surgery and upfront radiotherapy. However, to the best of the authors' knowledge, the current study is the first, in a subgrouped cohort, to demonstrate that this approach results in reduced neurocognitive outcomes over time.

Predicting social withdrawal, anxiety and depression symptoms in pediatric brain tumor survivors.

OBJECTIVE: Pediatric brain tumor survivors (PBTSs) are at risk for impairments in social adjustment and psychological distress. This study investigated longitudinal associations between symptoms of social withdrawal and anxiety/depression in PBTS, as well as medical, demographic, and personal characteristics that may also influence reports of social withdrawal and anxiety/depression. METHOD: About 91 PBTS (51% male, mean age 11.21 years, off-treatment) participated. At baseline and 8 months follow-up, primary caregivers of PBTS completed measures of social withdrawal, anxiety, and depression symptoms. Medical information (e.g. tumor type and location, cranial irradiation therapy) and child personal characteristics (e.g. child's age and gender, executive function, social skills) were obtained at baseline. RESULTS: Baseline reports of depression symptoms and social skills predicted social withdrawal 8 months later. Social withdrawal at baseline predicted greater combined anxiety and depression symptoms 8 months later. Depression alone predicted greater anxiety symptoms at follow-up. Anxiety symptoms and poor global executive functioning predicted greater depression symptoms at follow-up. CONCLUSIONS: The social adjustment and psychological distress of PBTSs are interrelated and can influence each other across time. These findings support the importance of multifaceted interventions targeting both psychological distress and social adjustment, in order to support the optimal psychosocial adjustment of PBTSs.

A randomized control intervention trial to improve social skills and quality of life in pediatric brain tumor survivors.

BACKGROUND: To determine if a group social skills intervention program improves social competence and quality of life (QOL) in pediatric brain tumor survivors (PBTS). METHODS: We conducted a randomized control trial in which PBTS (8-16 years old, off therapy for over 3 months) were allocated to receive social skills training (eg, cooperation, assertion, using social cognitive problem solving strategies, role playing, games, and arts and crafts) in 8 weekly 2-hour sessions, or an attention placebo control (games and arts and crafts only). Outcomes were self-reported, proxy-reported (caregiver), and teacher-reported using the Social Skills Rating System (SSRS), to measure social competence, and the Pediatric Quality of Life (PedsQL4.0, generic) to measure QOL at baseline, after intervention, and at 6 months follow-up. At baseline, SSRS were stratified into low and high scores and included as a covariate in the analysis. RESULTS: Compared to controls (n = 48), PBTS in the intervention group (n = 43) reported significantly better total and empathy SSRS scores, with improvements persisting at follow-up. The PBTS in the intervention group who had low scores at baseline reported the greatest improvements. Proxy and teacher reports showed no intervention effect. CONCLUSIONS: Participating in group social skills intervention can improve self-reported social competence that persisted to follow up. The PBTS should be given the opportunity to participate in social skills groups to improve social competence.

Determinants of social competence in pediatric brain tumor survivors who participated in an intervention study.

PURPOSE: This prospective study describes disease/treatment, personal characteristics, and social/family contextual variables as risk and resilience factors that predict social competence in pediatric brain tumor survivors (PBTS). METHODS: Ninety-one PBTS (51% male, mean age 11.21 years, off-treatment, attending a regular classroom >50% of the time) participated. PBTS and their primary caregivers (proxy) completed the Social Skills Rating System (SSRS) to assess social competence at baseline, 2, and 8 months follow-up. At baseline, medical information (e.g., tumor type and location, cranial irradiation therapy (CIT)), personal characteristics (e.g., child's age and gender, intelligence, executive function, attention, and memory), and social/family factors (family income and ethnicity) were obtained. RESULTS: Using mixed model multivariable analyses with a longitudinal component, tumor type (medulloblastoma) (p < 0.01) and poor executive function, specifically, emotional control, were the best predictors of low total and assertion self-reported SSRS scores (p < 0.02). Receiving CIT was associated with low proxy-reported assertion (p = 0.035), and cooperation score (p = 0.02). Poor emotional control was associated with low proxy-reported total (p = 0.032), assertion (p = 0.023), and self-control scores (p = 0.007). Being non-White was associated with low proxy-reported total (p = 0.016), self-control (p = 0.040), responsibility (p = 0.035), and cooperation scores (p = 0.002). There were no significant changes over time. CONCLUSIONS: This study supports a multifactorial model of insult and non-insult factors (medical, personal, and social context) as determinants of social competence in PBTS. Data from both informants identify determinants of social competence. These factors need to be considered in future interventions to help children better improve their social competence.

Determinants of quality of life outcomes for survivors of pediatric brain tumors.

INTRODUCTION: To describe the quality of life (QOL) of pediatric brain tumor survivors (PBTSs) prospectively and to identify potential medical, personal and family contextual factors associated with QOL. METHODS: Ninety-one PBTSs (8-16 years) who were off treatment and attending a regular classroom participated. Self- and caregiver-proxy-reported on QOL at baseline, 2 and 8 months. At baseline, cognitive, executive function, attention and memory, medical and demographics information were attained. RESULTS: Significant improvements over time in PBTS's emotional QOL were self- and proxy-reported (P < 0.01) and global QOL proxy-reported (P = 0.04). Receiving cranial irradiation therapy (CIT) and poor behavioral regulation predicted poor global QOL scores reported by both informants (P < 0.017). Poor behavioral regulation also predicted poor self-reported school functioning, and poor proxy-reported emotional and social QOL (P < 0.037). Boys reported better emotional QOL (P = 0.029), and PBTSs over 11 years old were reported to have better emotion and school-related QOL. Finally, being non-White and having low income predicted poor self-reported global and emotional QOL (P = 0.041). CONCLUSIONS: Receiving CIT, having poor behavioral regulation, being a female, under 11 years old and coming from low-income, non-White families place PBTSs at risk for poor QOL.

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.

Clinical neuropsychology practice and training in Canada.

OBJECTIVE: This invited paper provides information about professional neuropsychology issues in Canada and is part of a special issue addressing international perspectives on education, training, and practice in clinical neuropsychology. METHOD: Information was gathered from literature searches and personal communication with other neuropsychologists in Canada. RESULTS: Canada has a rich neuropsychological history. Neuropsychologists typically have doctoral-level education including relevant coursework and supervised practical experience. Licensure requirements vary across the 10 provinces and there are regional differences in salary. While training at the graduate and internship level mirrors that of our American colleagues, completion of a two-year postdoctoral fellowship in neuropsychology is not required to obtain employment in many settings and there are few postdoctoral training programs in this country. The majority of neuropsychologists are employed in institutional settings (e.g. hospitals, universities, rehabilitation facilities), with a growing number entering private practice or other settings. There are challenges in providing neuropsychological services to the diverse Canadian population and a need for assessment measures and normative data in multiple languages. CONCLUSIONS: Canadian neuropsychologists face important challenges in defining ourselves as distinct from other professions and other psychologists, in maintaining funding for high-quality training and research, in establishing neuropsychology-specific training and practice standards at the provincial or national level, and ensuring the clinical care that we provide is efficient and effective in meeting the needs of our patient populations and consumers, both within and outside of the publically funded health care system.