Cognitive Rehabilitation for Neurocognitive Late Effects in Adult Survivors of Childhood Acute Lymphoblastic Leukemia: A Feasibility and Case-Series Study

Neurocognitive late effects following the diagnosis and treatment of childhood acute lymphoblastic leukemia (ALL) commonly include impaired executive functions (EFs), with negative consequences for one’s health-related quality of life and mental health. However, interventions for EF impairments are scarce. Thus, the aims of this study were to (1) explore the feasibility and acceptability of the cognitive rehabilitation program Goal Management Training (GMT) and (2) examine whether GMT is associated with positive outcomes across cases of ALL survivors with EF complaints. Four participants (median age 31.5 years) underwent nine GMT modules in a total of five group sessions. Rehabilitation was focused on compensatory strategies to improve real-life EFs. Participants were evaluated at 2-week and 6-month follow-ups. Evaluation of feasibility and acceptability included adherence, a semi structured interview, self-reports, and safety. Additionally, therapists’ experience with implementation was evaluated. Outcome measures included self-reports and neurocognitive tests of attention, EF, and processing speed. All participants completed GMT and rated the intervention as useful, suitable, and satisfactory. The reliable change index showed improved daily life EFs (two participants) and neurocognitive performance (three participants) at 6-month follow-up. Additionally, all participants improved on a “real-life” task involving EF. A future randomized controlled trial is recommended.

QOL-04. INFLUENCE OF FAMILY, SCHOOL, AND HOSPITAL SYSTEMS IN SUPPORTING SURVIVORS OF PEDIATRIC BRAIN TUMORS WITH NEUROCOGNITIVE LATE EFFECTS

OBJECTIVE Pediatric brain tumor survivors (PBTS) are at risk for developing neurocognitive late effects that may interfere with academic and adaptive functioning. To mitigate the potential impact, some PBTS may implement strategies independently, while others may rely on system-level support from family, school, or hospital systems. Given the limited knowledge on survivor and family perspectives of these supports, we conducted a mixed-methods study involving PBTS and their caregivers to examine the influence of family, educational, and hospital supports, and identify areas of unmet need. PARTICIPANTS AND METHODS PBTS (N=56,Mage=18.12,range=10–25) completed questionnaires on academic accommodations. Medical chart reviews provided diagnosis and treatment information. A subset of families, who did not significantly differ from the larger sample on demographics, completed qualitative interviews (N=25). Three coders identified themes separately for parents and survivors and reached consensus (kappa’s > .78) using thematic content analysis. RESULTS Families emphasized the role of family support, including providing individualized help, setting up a structured learning environment, and suggesting metacognitive strategies. Parents also emphasized how they have adjusted their expectations. At school, 53% reported an individualized education plan. Formal accommodations (e.g., modified coursework, small group instruction, extra time) were helpful, yet some noted barriers, including embarrassment and lack of follow-through. Survivors emphasized the value of informal accommodations. Families described unmet needs related to connecting with other survivors, navigating community and educational resources, and transitioning to adulthood. CONCLUSIONS PBTS seem to rely on systems-level supports to mitigate neurocognitive effects. Future work should strengthen communication between systems and adult transition services.

Comparing the Relaxing Effects of Different Virtual Reality Environments in the Intensive Care Unit: Observational Study

Background After a prolonged intensive care unit (ICU) stay, approximately 50%-75% of all critically ill patients suffer from neurocognitive late effects and a reduction of health-related quality of life. It is assumed that the noisy and stressful ICU environment leads to sensory overload and deprivation and potentially to long-term cognitive impairment. Objective In this study, we investigated three different virtual reality environments and their potentially restorative and relaxing effects for reducing sensory overload and deprivation in the ICU. Methods A total of 45 healthy subjects were exposed to three different environments, each 10 minutes in length (dynamic, virtual, natural, and urban environments presented inside the head-mounted display, and a neutral video on an ICU TV screen). During the study, data was collected by validated questionnaires (ie, restoration and sickness) and sensors to record physiological parameters (240 hertz). Results The results showed that the natural environment had the highest positive and restorative effect on the physiological and psychological state of healthy subjects, followed by the urban environment and the ICU TV screen. Conclusions Overall, virtual reality stimulation with head-mounted display using a dynamic, virtual and natural environment has the potential, if directly used in the ICU, to reduce sensory overload and deprivation in critically ill patients and thus to prevent neurocognitive late effects.

Returning to school: Parent preferences, perceptions, and preparedness.

72 Background: Neurocognitive late-effects (LE) are among the most pervasive complications of childhood cancer and can impact academic success. Successful transition back to school can be challenging and requires parents to be knowledgeable of potential LE and procedures necessary to secure support services. It can be unclear which oncology provider has responsibility for ensuring parents have such knowledge. Further, little is known about parent preferences, perceptions, or preparedness regarding neurocognitive LE and available supports. Methods: As part of a PCORI-funded engagement award, an online parent survey was developed and disseminated about neurocognitive LE and school-related challenges after treatment. Survey items were informed by qualitative analysis of parent interviews and stakeholder input. Parents were recruited nationally via stakeholder social media, and foundation emails and websites. Results: Of the 202 parents responding, 53% reported receiving information on possible treatment related cognitive or school problems from their healthcare team, while 55% reported needing to seek information independently. Information was most often provided by the oncologist (32%), nurse/social worker (26%), or psychologist/neuropsychologist (17%). Parent preferences for topics included information on learning difficulties, physical/health problems that could impact school, and resources for neurocognitive LE. Approximately half (55%) thought their healthcare team understood the issues facing survivors returning to school, although 47% reported that the team did not inquire about school issues or only asked general questions during follow up visits. A large proportion of parents (49%) reported feeling generally underprepared for their child’s return to school. Additional information on parent preferences as well as implications for program development, advocacy, and transition procedures will be discussed. Conclusions: Oncology providers are on the frontline of educating and preparing parents to meet the challenges of children’s return to school after childhood cancer. Improved multidisciplinary services and coordination of care to ensure successful transition back to school are needed.

Feasibility and efficacy of an extended trial of home-based working memory training for pediatric brain tumor survivors: a pilot study

Background. Impaired working memory appears to play a key role in some of the neurocognitive late effects of pediatric brain tumor treatments, including declines in intellectual and executive functioning. Recent studies of pediatric cancer survivors suggest Cogmed® Working Memory Training is effective at improving working memory, although pediatric brain tumor survivors may demonstrate a less robust response than children with other cancers. The current study sought to determine if an extended course of Cogmed (35 sessions) was both feasible and efficacious for brain tumor survivors and if improvements were observable in near-transfer and far-transfer working memory measures as well as parent rating scores at 6 months post-treatment. Methods. Twenty pediatric brain tumor survivors ages 8 to 18 years with working memory deficits completed 35 sessions of Cogmed. Assessments of working memory and academic skills were completed at baseline, completion of training, and 6-month follow-up and parents completed questionnaires at baseline and 6-month follow-up. Results. Participants showed significant improvements in working memory at training completion and 6-month follow-up and math achievement at 6-month follow-up. Parents reported executive functioning improvements at follow-up as compared with baseline. Participants’ program-based working memory skills did not change significantly between sessions 25 and 35, suggesting that extended training did not provide additional benefit. Conclusions. This study replicates and extends previous research by: (1) demonstrating that brain tumor survivors at high risk for neurocognitive late effects can complete and benefit from working memory training, (2) identifying a point of diminished returns on training time investment, and (3) demonstrating benefits 6 months post-intervention.