Post Hoc Analyses
Post hoc analyses were conducted for the BT group to help contextualize the unexpected, crossed interaction between baseline Irony & Empathy and social skills and peer relationships over time. We examined whether the crossed interactions varied as a function of time-since-diagnosis, the intensity of treatment using the Pediatric Neuro-Oncology Rating of Treatment Intensity (PNORTI) [20] and treatment risk factors using the Neurological Predictor Scale (NPS) [21]. Results showed that the 3-way interaction between time, Irony & Empathy and time-since-diagnosis was significant (b = -0.04, se = 0.01, t = - 2.76, p = .011), with simple slopes demonstrating an increase in the crossed interaction between time and Irony & Empathy with an increase in time-since-diagnosis. Results failed to demonstrate a significant 3-way interaction between time, social skills, and time-since-diagnosis (b = -0.00, se = 0.00, t = - 0.91, p = .375). Results also failed to demonstrate moderating effects of treatment intensity or risk factors (b = 0.33, se = 0.17, t = 2.00, p = .058) and (b = 0.09, se = 0.06, t = 1.46, p = 0.159), respectively.
DISCUSSION
The goal of this longitudinal study was to evaluate components of social competence, including social information processing, social skills, and peer relationship quality, over time in survivors of pediatric brain tumors and non-CNS solid tumors who recently completed treatment. Due to improvements in survival rates among BT, there is now an emphasis on understanding their social functioning to better inform what supports may be needed throughout their lifetime. This is one of the first longitudinal studies to focus on SIP and peer relationships in BT and highlights the complexities in how SIP and social skills may relate to peer relationships in BT over time in comparison to ST. Among ST, we found positive associations between baseline measures of social skills and theory of mind and peer relationships over time. Conversely, BT showed an inverse association between baseline social skills and theory of mind and peer relationships over time. Those with better social skills and SIP at baseline had a decline in peer relationships, while those with worse social skills and SIP at baseline had an improvement in peer relationships over time. These findings add to a growing area of research evaluating the importance of social skills in BT [5,15].
Our hypothesis that BT would have worse social skills and SIP compared to ST over time was not supported by the findings. There were no differences in social skills and SIP over time between these two groups and, notably, these variables did not change over time for either group. This could be because study assessments occurred within the first 18 months after treatment completion and may be too early to capture the neurodevelopmental late effects that arise in BT. A previous study found that BT who were farther out from end of treatment (3-9 years) showed significantly poorer face processing skills compared to youth with Juvenile Rheumatoid Arthritis [14]. Future longitudinal studies should follow BT for longer periods of time following treatment completion to identify when impairments in social skills and SIP develop.
Across the study, both BT and ST self-reported peer relationship scores were in the average range. However, the trajectory of self-reported peer relationship scores over time was affected by both group membership and baseline theory of mind and social skills. When comparing BT and ST on peer relationships over time, ST showed relatively stable peer relationships over time regardless of baseline theory of mind or social skills. However, for BT, social skills and theory of mind appeared to be more relevant to peer relationships over time in unanticipated ways. Face processing was not predictive of peer relationships in BT, which differs from previous cross-sectional studies which found associations poor face processing and social functioning [12, 22]. BT with significantly lower baseline social skills and theory of mind had improvements in peer relationships over time whereas BT with significantly higher baseline social skills and theory of mind had declines in peer relationships over time. Previous literature has noted a similar inverse association in processing speed abilities in survivors of pediatric brain tumors who received radiation therapy with those scoring the highest having the most marked decline in processing speed over time [23]. Moreover, exploratory post-hoc analyses of the present study suggested that this inverse association is most prominent in BT who were furthest from diagnosis which was seen in the previously mentioned study as well. Other factors, such as treatment modalities (e.g., radiation therapy) and neurological risk, did not affect this interaction in our analyses. Given that participants were enrolled in this study within 6 months of completing tumor-directed therapy, further time since diagnosis may be a proxy for more complex, lengthy treatments and, therefore, potentially having more sequelae.
Additionally, prior research suggests that BT may overestimate their social status among peers [24]. In the current study, participants rated their own levels of social acceptance by peers using the PROMIS measure. A potential explanation for these findings is that those with better baseline theory of mind may have better self-awareness of their status among peers and more accurately noted their decline in peer acceptance over time secondary to potential sequelae. Conversely, those with poorer baseline theory of mind may overestimate their peer acceptance over time due to difficulty interpreting social cues. Studies employing peer-reported data would be needed to elucidate these findings.
This study has several strengths. Data on the social competence of survivors of pediatric brain and solid tumors upon treatment completion is relatively limited. Additionally, the longitudinal nature of this study allows for evaluation of SIP and social acceptance over time to inform the provision of support services. Lastly, this study utilized a multi-informant method to evaluate variables of interest in survivors. Despite these strengths, these data should be viewed in the context of certain limitations. First, participant attrition led to smaller sample sizes at time point 2. Retention primarily was affected by participant relapses and deaths. Second, this study is not racially and ethnically diverse and findings may not generalize to the population writ large.
This study contributes to the growing body of research on the social competence of BT [14, 25] and offers numerous directions for future research and clinical efforts. Due to the variability in perceived social acceptance across time points, BT social functioning should be monitored regularly after the completion of treatment to determine if and when intervention services would be beneficial. Future research studies could expand on this work by following survivors for multiple years post-treatment completion and obtaining peer reports of survivor social acceptance.
CoI STATEMENT
The authors have no conflicts of interest to report
ACKNOWLEDGEMENTS
This research was supported by the National Cancer Institute of the National Institutes of Health (K07CA178100). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank all the participants who provided their time for this study.
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