ABSTRACT
BACKGROUND/OBJECTIVES: Survivors of pediatric brain tumors (BT) are at increased risk for difficulties with social competence, including poor social information processing (SIP) and peer relationships. Due to improved survival rates among BT, there is a need to better understand these challenges and if they are specific to BT versus other survivors of childhood cancer.
METHODS: 51 BT and 34 survivors of pediatric solid tumors (ST) completed evaluations of SIP and peer relationship quality within 6 months of completing treatment and at one year follow-up. Caregivers also completed a measure of social skills. Linear mixed models evaluated (1) differences between BT and ST on SIP and social skills and (2) how indices of SIP were associated with peer relationships over time for ST and BT.
RESULTS: BT did not differ from ST on indices of SIP or social skills over time. There was a three-way interaction between measures of SIP, group, and time to predict peer relationships. ST showed a positive association between baseline social skills and theory of mind and peer relationships over time, whereas BT showed an inverse association between baseline social skills and theory of mind and peer relationships over time.
CONCLUSION: Baseline SIP and social skills affected the trajectory of BT peer relationships. BT social functioning should be monitored regularly after the completion of treatment to determine if and when intervention services would be beneficial.
INTRODUCTION:
Survivors of pediatric brain tumors (BT) are increasing in number due to advances in treatment over the past 20 years [1]. The original focus on survival for this population has shifted over time to encompass the cognitive, physical, and social ramifications of disease and treatments on individuals from diagnosis through the course of their lives. With a more holistic understanding of the impact of cancer treatment on the developing central nervous system (CNS), more recent research has shown that BT are less likely than typically developing peers to go to college, live independently, have close friends, and marry [2]. In the short-term, BT also struggle socially and are less likely to establish friendships compared to survivors of non-CNS tumors (ST) and are more socially isolated than their peers [3, 4]. The majority of studies of social functioning in BT has been cross sectional in nature, and longitudinal research is needed to better understand the trajectory and predictors of social functioning in BT over time.
A model of social competence in children with insults to the brain [5] integrates risk and resilience factors related to CNS insults, the family environment, and individual characteristics and offers direction for research. Insults to the developing brain may impair cognitive and executive functioning which can in turn lead to poor social skills and, subsequently, poor social adjustment, including peer relationships [6]. Social skills are defined as skills required to interact appropriately across a variety of social contexts [7]. Developmentally inappropriate social skills may cause individuals to react inappropriately to social situations, in turn leading to peer isolation and rejection. This model of social competence has been applied to the BT population [8] as they experience social late effects as a result of CNS insult.
Social Information Processing (SIP) is emphasized as a key determinant of social interaction and social adjustment. Two important elements of SIP include properly identifying facial expressions and correctly interpreting others’ motivations, also known as theory of mind [5]. These are common struggles in youth with Autism Spectrum Disorder (ASD) [9] which contribute to difficulties with social interactions [10]. If an individual is unable to correctly identify the emotion of another, it becomes far more difficult to react in a socially appropriate manner which can lead to social isolation and peer rejection. The inability to understand when an individual’s comments are sarcastic or ironic can cause someone to misinterpret the speakers’ intent and hinder appropriate social responses. While there is a large body of research examining these domains of social deficits in youth with ASD, research in BT is in its inception [8]. Preliminary studies have found that BT perform significantly worse than youth with juvenile rheumatoid arthritis in identifying adult facial expressions [11] and that BT with high levels of social impairment were worse at identifying facial expressions compared to typically developing youth and youth with ASD [12]. Longitudinal research is needed to better understand the social competence of BT over time in order to inform targeted interventions.
The goal of this longitudinal study was to evaluate important facets of social competence among ST and BT over time and to identify predictors of peer relationships. We hypothesized that (a) BT will have worse SIP and social skills over time compared to ST and that (b) worse SIP and social skills would predict worse peer relationship quality.
METHODS:
Participants :
Participants were youth ages 7-14 who had completed tumor-directed treatment for either a non-central nervous system (CNS) solid tumor (n=34) or brain tumor (n=51) within the six months prior to enrollment. Survivors of pediatric non-CNS solid tumors (ST) were chosen as the comparison group because they undergo similar treatments and comparable changes to their daily life during treatment, yet treatment does not directly affect the brain and they do not tend to show difficulties with SIP in survivorship. Exclusion criteria included: (1) a multi-systemic genetic condition affecting cognitive functioning (e.g., Neurofibromatosis Type 1, Trisomy 21); or (2) a cognitive or developmental delay prior to tumor diagnosis. Survivors of non-CNS solid tumors who completed treatments affecting the CNS (e.g., total body irradiation) were excluded as well. Caregiver inclusion criteria consisted of living with the participant at least 50% of the time, being fluent in English, and having actively participated in the participants’ cancer treatment.
127 families were approached for this study (n = 72 BT, n = 55 ST) and 83 (65.3%, n = 49 BT, n = 34 ST) agreed to participate. Reasons for declining participation included lack of interest (n=22), being too busy to participate (n=7), and passive refusal (n=15). Two BT were unable to complete study procedures upon enrollment due to language barriers resulting in a total sample of 81. There were no differences in demographic or medical characteristics between consenting and non-consenting individuals.
Procedures :
The current data are from a longitudinal study of social competence in survivors of pediatric brain and non-CNS solid tumors conducted at a large, urban pediatric medical center. All procedures were reviewed and approved by the Institutional Review Board and written informed consent and child assent were obtained upon enrollment. Potentially eligible patients were identified through cooperation with medical teams and tumor registry records. All potential participants were contacted by study staff via letter, phone, and/or during follow-up visits. This paper encompasses data from the baseline study visits and the first follow-up, which occurred approximately 12 months after the baseline visit. Participants and their primary caregiver were asked to complete questionnaires (see below) during study visits. Relevant information was collected via chart review. Participants received a brief feedback letter and a $20 gift card as compensation after each study visit.