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Published on : Feb 24, 2014
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Slide 1 - Neuropsychological Outcomes in Childhood Cancer and its Treatment Mikaela K. Sebree, Ph.D. Children’s Neuropsychology Program St. Luke’s Children’s Hospital
Slide 2 - Outline Common pediatric malignancies ALL Brain Tumors Neurocognitive late effects Model for understanding late effects Management of neurocognitive late effects
Slide 3 - Incidence of Pediatric Malignancies
Slide 4 - Acute Lymphoblastic Leukemia (ALL) Malignant disorder of lymphoid cells As recently as the 1960’s ALL was nearly always fatal Treatment for ALL Intrathecal (IT) and systemic chemotherapy Cranial radiation therapy (CRT) Treatment phases: Induction CNS prophylaxis and intensification Continuation
Slide 5 - Brain Tumors
Slide 6 - Supratentorial Tentorium Infratentorial
Slide 7 - Classification of Brain Tumors Astrocytoma – high grade and low grade Medulloblastoma Crainopharyngioma Brain Stem Glioma Ependyomomas Oligodendrogliomas
Slide 8 - ppt slide no 8 content not found
Slide 9 - Simple Typology of Brain Tumors
Slide 10 - Histology of Pediatric Brain Tumors
Slide 11 - Pediatric Brain Tumors Pediatric 50% infratentorial CNS primary site Gliomas and many others Molecular aspects Survival rates Adult 90% cerebral cortex Metastatic Gliomas/meningiomas Different molecular profile/genetic markers Poorer survival
Slide 12 - Treatment of Brain Tumors Surgery Radiation Chemotherapy
Slide 13 - Oncology Treatment ALL Standard vs high risk Chemotherapy MTX Steroids Radiation Brain Tumor Surgery Radiation Cranial Craniospinal Chemotherapy MTX
Slide 14 - Cure Rates in Pediatric Oncology * Includes both benign and malignant brain tumors
Slide 15 - Neurobehavioral Late effects
Slide 16 - Neurobehavioral Late Effects Factors Involved in Outcome Child: Genetic Factors Age Gender Tumor type/ genetic profile Premorbid factors Direct CNS injury: Location Hydrocephalus Surgery Surgical complications Treatment: Radiation Chemotherapy Medical complications Associated issues: Loss of Schooling Psychological adjustment Socialization issues Family functioning DEVELOPMENT
Slide 17 - ppt slide no 17 content not found
Slide 18 - Developmental Context Two potential consequences of tx: Loss/regression in skill development Failure to acquire skills in age-appropriate manner
Slide 19 - “Typical” Development What changes with development?? New systems come “on-line” Increasing sophistication of brain systems More interaction among systems Systems that support a skill at one age may not be the same as later Increasing specificity and integration across development
Slide 20 - Academic stress points Kindergarten 1st grade 4th grade Middle school High School College learning to learn learning to read reading to learn learning to organize learning learning to read, organize, learn – on your own Doing it all on your own
Slide 21 - Neurobehavioral Late Effects Cognitive ability Memory Attention Executive Functioning Motor Skills Academic Functioning Psychosocial Functioning
Slide 22 - Late effects: Surgery
Slide 23 - Neurosurgery Neurologic/sensory deficits Endocrine dysfunction Changes in physical appearance Posterior fossa syndrome Neuropsychological deficits Attention, memory, processing speed Lateralized/localized deficits
Slide 24 - Posterior Fossa Syndrome Consists of mutism +/- ataxia, cranial nerve deficits, and labile affect Mutism and affective lability typically resolves in 4-8 weeks As many as 20-30% of children are affected
Slide 25 - PFS cont. Children who experience PFS demonstrate persistent difficulties with social withdrawal and emotional lability Increased problems with working memory and initiation Slow processing speed Lower IQ Presence of PFS may be an index of increased risk for neurobehavioral morbidity
Slide 26 - Late Effects:Chemotherapy and Radiation
Slide 27 - Intellectual Ability Effects are slow to emerge, manifest progressively over time CRT is associated with lower IQ Estimated decline of 17 pts Reduced rate of learning – acquisition of new information at 40% expectations Age and Dose effect Even reduced dose have significant effect
Slide 28 - Attention/Concentration Deficits common in both ALL & BT Impairments in selective attention, focusing, and shifting Increased susceptibility to distraction
Slide 29 - Executive Functioning Slower speed of processing Limited working memory capacity Poor initiation Problems with planning and organization Limited cognitive flexibility/shifting Reduced hypothesis generation & problem solving
Slide 30 - Nondominant Hemisphere Functions Decreased nonverbal intelligence Spatial ability Visual motor integration skills Susceptibility to distraction Poor math skills
Slide 31 - Memory Verbal vs. visual memory Encoding, storage, and retrieval Interaction with executive deficits Dose effect – greater doses of radiation associated with greater impairments
Slide 32 - Academic Functioning Loss of schooling Declines in reading, spelling, and math Math skills are particularly vulnerable 57% of children with BT have specific LD – higher incidence of math LD
Slide 33 - Neurobehavioral Late Effects Core Deficits Attention Working Memory Engagement Processing Speed Secondary Deficits Loss of Intellectual Functioning Academic Failure
Slide 34 - Conceptual Model Disease & Treatment Age of Patient/ Neuro-development Processing Speed Attention Working Memory Intellectual Outcome Academic Achievement
Slide 35 - Risk Factors for Deficits
Slide 36 - Neuropathology of Deficits Damage to cortical and subcortical white matter Demyelination Radiation necrosis of white matter Reduction in the normal-appearing white matter DTI – reduction in white matter integrity Relationship between white matter volume intellectual outcomes
Slide 37 - Management Neuropsychological Evaluation Individualized Education Plan (IEP)/504 Plans Stimulant medication Innovative technology!!! Reading Writing Executive Functions
Slide 38 - Reading Text to speech software Available on most e-readers www.simplyaudiobooks.com www.audible.com www.bookshare.org Recording for the Blind and Dyslexic www.Ldonline.org www.fcrr.org
Slide 39 - Writing Speech to Text software Dragon Natural Speaking Organization: www.Inspiration.com Grammar/Spelling www.goqsoftware.com Ghotit.com www.spellingcity.com – spelling and vocabulary building games
Slide 40 - Executive Functioning Google calendar iphone/ipad/android apps Livescribe.com lumosity.com funbrain.com Cogmed.com
Slide 41 - Executive Function Resources Smart but Scattered: The Revolutionary "Executive Skills" Approach to Helping Kids Reach Their Potential  Peg Dawson and Richard Guare Executive Skills in Children and Adolescents, Second Edition: A Practical Guide to Assessment and Intervention Peg Dawson and Richard Guare Late, Lost, and Unprepared: A Parents’ Guide to Helping Children with Executive Functioning Joyce Cooper-Kahn, Ph.D. and Laurie Dietzel, Ph.D. Promoting Executive Function in the Classroom (What Works for Special-Needs Learners) Lynn Meltzer Fostering Independent Learning: Practical Strategies to Promote Student Success Virginia Smith Harvey Organizing the Disorganized Child: Simple Strategies to Succeed in School Martin L. Kutscher
Slide 42 - Summary Survivors are a population “at risk” Increasing impact of neuropsychological compromise over time Considerable neuropsychological morbidity Need for intervention and innovative approaches Major issue of transition to adulthood Highlights need to long term follow-up and comprehensive, multidisciplinary care
Slide 43 - Questions??? Hook ‘em Horns