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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