Leah C. Black, Ph.D., Sophia Vinci-Booher, B.S., B.A., Elizabeth Begyn, Ph.D. ABPP,

Brenna C. McDonald, Psy.D., MBA ABPP, & Jennifer Katzenstein, Ph.D. ABPP

Indiana University School of Medicine, Indianapolis, Indiana

Neurocognitive and Behavioral Profile Differences in Children Treated for Medulloblastoma

ABSTRACT

BACKGROUND

MATERIALS and METHODS

Purpose: Research suggests negative cognitive effects of chemotherapy and radiation treatment, but has been limited by mixed samples and large age ranges. The purpose of this study was to examine the neurocognitive and behavioral functioning of a clinical sample of young children undergoing treatment for medulloblastoma.

Sample/Methods: Twenty-four children diagnosed with medulloblastoma (mean age at diagnosis = 5.09 years; SD = 2.75) underwent neuropsychological evaluation (mean age at evaluation = 8.84 years; SD = 3.79). Three groups were compared based on treatment stage: 1.) resection only (N = 3), 2.) resection and chemotherapy (N = 4), 3.) resection, chemotherapy, and radiation (N = 17).

Results: Although no significant between-group differences were found in Wechsler Full Scale IQ (F(2,23) = 0.84, p = 0.44), Verbal IQ (F(2,22) = 0.48, p = 0.63), Performance IQ (F(2,23) = 2.22, p = 0.13), or Processing Speed Index (F(2,18) = 2.09, p = 0.16), groups 2 and 3 evidenced lower IQ scores than group 1. Similar patterns were noted for behavior and adaptive functioning.

Conclusion: Findings indicate that children who received more intensive treatment for medulloblastoma tended to exhibit more cognitive and behavioral effects; however, statistically significant group differences were not found likely secondary to small sample size.

• Medulloblastomas are the most frequent malignant CNS childhood tumors (10-20% of childhood tumors) and incidence peaks in early childhood.1

• Previous research has found neurocognitive and behavioral late-effects of treatment for childhood brain tumors using chemotherapy and radiation treatments.1,2

• Cognitive late-effects include deficits in: 1,2

• Overall intelligence• Learning• Attention/Executive functions• Visual-spatial skills• Motor skills• Language• Processing speed

• Psychosocial late-effects include: 2

• Internalizing symptoms• Behavior problems• Social deficits

• Research suggests that treatment involving radiation therapy leads to increasingly devastating neurocognitive late-effects.1

• However, many studies have been limited by mixed samples including a wide variety of brain tumors and ages (childhood to adulthood).

• The purpose of this study was to use a clinically based sample of children specifically diagnosed with medulloblastoma who underwent common treatments to determine differences in neurocognitive profiles for each treatment modality.

Clinical Sample (n = 24) • Ages 9 months to 10.5 years old at diagnosis (M=5.09; SD=2.75)• Male = 17; Female = 7• Treated between ages of 1.5 to 11.75 years• Evaluated between 4.08 years and 16.42 years (M=8.84; SD=3.79)

Treatment Groups• Group 1: Resection Only (n=3)• Group 2: Resection and Chemotherapy/Stem Cell Rescue (n=4)• Group 3: Resection, Chemotherapy, and Radiation (n=17)

Exclusion Criteria: subsequent TBI (n=1); no IQ measure (n=1)

1. Rey-Casserly, C. & Fennell, E.B. (2008). Brain Tumors in Children. In J.E. Morgan & J.H. Ricker (Eds.), Textbook of Clinical Neuropsychology (171-184). New York: Taylor & Francis.

2. Gragert, M.N. & Ris, M.D. (2011). Neuropsychological late effects and rehabilitation following pediatric brain tumor. Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach, 4, 47-58.

CLINICAL IMPLICATIONS

REFERENCES

While no clinically significant differences were found between treatment groups, clinicians should remain aware of the following:

•Type of treatment for medulloblastoma can affect performance on neuropsychological measures with trends for less well developed skills in children with more intensive treatments.

•Late-effects can emerge that were not evaluated in this sample, such as executive functions, or failure to gain skills at the same rate as same age peers.

•Behavior and adaptive skills are important aspects that can also impact a child’s functioning.

DEMOGRAPHICS TABLE

Table 1. Demographic Information by Group

Resection Only Resect + Chemo + Stem Cell Resect + Chemo + RadiationGroup 1 (N = 3) Group 2 (N = 4) Group 3 (N = 17) F p

Mean age at diagnosis (SD) 4.78 (0.63) 1.67 (1.40) 5.95 (2.60) 5.45 .01

Mean age at treatment completion (SD) 4.78 (0.63) 2.36 (1.28) 7.06 (2.58) 7.16 .004

Mean age at evaluation (SD) 5.00 (0.44) 5.04 (0.71) 10.42 (3.39) 8.16 .002

Time since treatment completion (SD) 0.22 (0.24) 2.69 (0.81) 3.36 (2.93) 1.9 .17

% Male 100% 25% 77% 5.56* .06* Chi-Square value

SUMMARY

Measures UsedIntelligence Measures:• WPPSI-III/IV, WISC-IV, WAIS-IV• Full Scale IQ (FSIQ); Verbal IQ (VIQ/VCI); Performance IQ (PIQ/PRI) Processing Speed (PSI)

Behavioral Measures:• Behavior Assessment System for Children – 2nd Edition (BASC-2)• Child Behavior Checklist (CBCL)• Internalizing Problems, Externalizing Problems, Behavior Problems and Adaptive Scales

• Small sample size• Variability in measures given within the clinical

sample reduces comparison across multiple domains (i.e., language, memory).

LIMITATIONSRESULTS TABLE

Table 2. IQ, Behavior, and Adaptive Information by Group

Resection Only Resect + Chemo + Stem Cell Resect + Chemo + RadiationGroup 1 (N = 3) Group 2 (N = 4) Group 3 (N = 17) F p

Mean FSIQ (SD) 98.00 (10.44) 84.25 (8.18) 87.47 (15.89) 0.84 .44

Mean VCI/VIQ (SD) 96.67 (16.56) 86.00 (9.64) 91.35 (13.25) 0.48 .63

Mean PRI/PIQ (SD) 107.00 (19.67) 77.00 (4.69) 89.94 (20.10) 2.22 .13

Mean PSI (SD) 105.00 (7.07) 87.00 (5.66) 84.80 (13.83) 2.09 .16

Mean Externalizing (SD) 48.50 (0.71) 52.50 (11.39) 54.09 (13.99) 0.16 .85

Mean Internalizing (SD) 53.50 (3.54) 55.25 (3.69) 64.55 (13.16) 1.50 .26

Mean Behavior (SD) 51.50 (4.95) 53.75 (10.63) 58.78 (10.37) 0.62 .55

Mean Adaptive (SD) 52.00 (2.83) 45.00 (10.30) 39.56 (12.54) 1.07 .37

• No significant differences between treatment groups were found.

• There were trends for lower IQ and processing speed scores in children treated with resection/chemotherapy/stem cell rescue and resection/chemotherapy/radiation.

• There were also trends for greater symptoms of externalizing, internalizing, and overall behavior problems as reported by parents of children with more extensive treatments (groups 2 and 3).

• Parents of children with more extensive treatments tended to rate their children as less independent in adaptive skills.