<div>ABSTRACT</div><div>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.</div><div>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.</div><div>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.</div><div>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.</div><div>INTRODUCTION:</div><div>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.</div><div>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.</div><div>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.</div><div>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.</div><div>METHODS:</div><div><i>Participants</i> :</div><div>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.</div><div>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.</div><div><i>Procedures</i> :</div><div>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.</div>