Child Neuropsychology

A Journal on Normal and Abnormal Development in Childhood and

Adolescence

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Parent-reported executive functioning in young

children treated for cancer

Jennifer L. Harman, Andrew E. Molnar Jr., Lauren E. Cox, Niki Jurbergs,

Kathryn M. Russell, Jillian Wise & Victoria W. Willard

To cite this article: Jennifer L. Harman, Andrew E. Molnar Jr., Lauren E. Cox, Niki Jurbergs,
Kathryn M. Russell, Jillian Wise & Victoria W. Willard (2019) Parent-reported executive
functioning in young children treated for cancer, Child Neuropsychology, 25:4, 548-560, DOI:
10.1080/09297049.2018.1503647

To link to this article: https://doi.org/10.1080/09297049.2018.1503647

Published online: 26 Jul 2018.

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CHILD NEUROPSYCHOLOGY
2019, VOL. 25, NO. 4, 548–560
https://doi.org/10.1080/09297049.2018.1503647

Parent-reported executive functioning in young children

treated for cancer
Jennifer L. Harman, Andrew E. Molnar Jr., Lauren E. Cox, Niki Jurbergs,
Kathryn M. Russell, Jillian Wise and Victoria W. Willard
Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA

ABSTRACT ARTICLE HISTORY

It is well known that children treated for cancer are at risk for Received 3 April 2018
cognitive and functional impairments. Such research is largely Accepted 13 July 2018
based on studies of late effects in school-aged or older children. KEYWORDS
However, far less is known about executive function weaknesses in Executive functioning;
preschool-aged children treated for cancer. Thus, the aim of this young children; preschool;
study was to examine executive functioning in a clinically referred childhood cancer; pre-
sample of young oncology patients, and its association with academic skills
broader domains of functioning. Data from 61 young children
with cancer, who were referred for clinical cognitive evaluations,
were abstracted and included in this study. Patients were
5.00 years of age (SD = 0.72) at assessment, 54.1% male, and
two-thirds (63.9%) had been treated for brain tumors. Most execu-
tive functions were significantly discrepant from the mean, with
47.5% of preschoolers having parent-reported working memory
concerns within the clinically significant range. There were no
differences in executive functioning based on diagnosis or treat-
ment status. Parent-reported executive functioning was strongly
correlated with global intelligence and adaptive functioning, with
some indices also associated with nonverbal problem solving and
pre-academic skills. Ultimately, results indicate the presence of
emerging weaknesses in executive functioning in young children
with cancer, and add to a growing body of literature highlighting
the potential cognitive and behavioral risks associated with a
cancer diagnosis in early childhood.

Childhood cancer has high incidence among young children, with the majority of
diseases such as acute lymphoblastic leukemia (ALL), brain tumors, and retinoblastoma
primarily diagnosed in those under 4 years of age (Ward, DeSantis, Robbins, Kohler, &
Jemal, 2014). Although treatment advances over the past several decades have led to
improved overall survival for many types of childhood cancer, it often comes at a cost
to cognitive and psychosocial functioning (Chintagumpala & Gajjar, 2015; Mulhern,
Merchant, Gajjar, Reddick, & Kun, 2004; Pui & Evans, 2013). Indeed, young children
treated for cancer appear especially vulnerable to cognitive late effects (Mulhern et al.,
2004; Schreiber et al., 2014; Turner, Rey-Casserly, Liptak, & Chordas, 2009).

CONTACT Victoria W. Willard victoria.willard@stjude.org Department of Psychology, St. Jude Children’s

Research Hospital, 262 Danny Thomas Place, MS 740, Memphis, TN 38103, USA
© 2018 Informa UK Limited, trading as Taylor & Francis Group
 CHILD NEUROPSYCHOLOGY 549

Cognitive late effects are multifaceted and commonly involve deficits in attention,
processing speed, and executive functions. Weaknesses in these areas typically become
more pronounced as children age and are often detectable 2 to 5 years following
treatment completion (Palmer et al., 2013; Palmer, Reddick, & Gajjar, 2007; Patel,
Mullins, O’Neil, & Wilson, 2011). These effects are believed to emerge secondary to
treatments such as cranial radiation therapy and intrathecal methotrexate due to the
association with compromised white matter integrity and frontal lobe development
(Reddick et al., 2003; Schatz, Kramer, Ablin, & Matthay, 2000). In addition to treat-
ment, clinical and demographic factors such as disease type and location in brain tumor
patients, age at diagnosis, and gender are associated with increased risk for cognitive
late effects (Mulhern et al., 2004; Schreiber et al., 2014).
Impairment in executive functioning is fundamental to cognitive late effects among
children treated for cancer (Wolfe, Madan-Swain, & Kana, 2012). Executive functions
are regarded as a cluster of skills involved in higher-order, goal-directed behaviors
associated with both cognitive and behavioral components (Buss & Spencer, 2014;
Diamond, 2013, 2014; Garon, Bryson, & Smith, 2008; Zelazo et al., 2003). They are
largely supported by the prefrontal cortex and follow a protracted developmental
trajectory from early childhood to young adulthood (Diamond, 2013; Diamond,
Prevor, Callender, & Druin, 1997; Moriguchi & Hiraki, 2013). Given the high incidence
of cancer in young children, executive functions are seen as particularly vulnerable.
Working memory, inhibitory control, and cognitive flexibility are considered founda-
tional aspects of executive functioning and related to higher level skills (Diamond, 2013,
2014; Miyake et al., 2000). Of these skills, working memory appears to be one of the
more vulnerable in children treated for cancer (Conklin et al., 2012; Robinson et al.,
2010).
Impairment in executive functions during early childhood is predictive of psycho-
social difficulties later in life (see Diamond, 2016, for a review). More specifically,
executive functioning in preschool has been linked to elementary school academic
functioning (Escolano-Pérez, Herrero-Nivela, Blanco-Villaseñor, & Anguera, 2017;
Purpura, Schmitt, & Ganley, 2017), as well as social relationships with peers and
teachers in elementary school (De Wilde, Koot, & Van Lier, 2016) and adolescence
(Holmes, Kim-Spoon, & Deater-Deckard, 2016). Early executive functioning is also
associated with long-term outcomes such as physical health, community integration,
and independence, even after accounting for individual intelligence, social class, and
psychosocial challenges in adolescence (Moffitt et al., 2011). In keeping with the
importance of early executive functions, several recent papers have examined executive
functioning in preschoolers with various medical conditions, including epilepsy
(Maiman et al., 2017), neurofibromatosis (Casnar & Klein-Tasman, 2017), and trau-
matic brain injury (Ganesalingam et al., 2011). However, there is limited information
about executive function in young children treated for cancer and their potential
association with other domains of functioning.
Given that children with cancer are at risk of impairment in executive functions like
attention and working memory, in combination with the peak age of cancer diagnosis
in early childhood, further examination of the cognitive skills and early executive
functioning of young children treated for cancer is important. As such, the aim of
this study was to retrospectively examine executive functioning among a clinically
550 J. L. HARMAN ET AL.

referred sample of preschool-aged oncology patients. We hypothesized that these

patients would have weaknesses in parent-reported executive functioning, with working
memory likely being an area of more pronounced concern. We also hypothesized that
there would be associations between parent-reported executive functioning and both
subjective and objective measures of broader functioning, including intellectual func-
tioning, school-readiness skills, and adaptive functioning. Finally, medical factors were
also examined, with executive functioning weaknesses expected to be more pronounced
in patients with brain tumors and those off-therapy at the time of assessment.

Method
Participants
The current sample included 61 children with cancer that were evaluated over a 5-year
period in a hospital-based psychology clinic. Participants ranged in age from 3 to
almost 6 years (M = 5.00, SD = 0.72) at the time of evaluation. Children were included
in the current study if their assessment incorporated either the preschool or school-
aged version of the parent-report Behavior Rating Inventory of Executive Function
(BRIEF) (Gioia, Espy, & Isquith, 2003; Gioia, Isquith, Guy, & Kenworthy, 2000).
Participants were predominantly white (62.3%), and over half (54.1%) were boys.
Children were diagnosed with either brain tumor (63.9%), non-CNS solid tumor
(21.3%), or leukemia (14.8%). The majority of children (75.4%) were off-therapy at
the time of evaluation. See Table 1 for all medical and demographic information.

Procedures
This study utilized clinical data and was approved by the hospital’s Institutional Review
Board prior to data abstraction. Data were abstracted from clinical reports housed in an
electronic medical record. Psychological reports reviewed were completed for children
who were referred for a clinical evaluation through the psychology clinic at a children’s
cancer center between July 1 2010 and June 30 2015. The clinic routinely completes
clinical evaluations to assess cognitive, academic, emotional, behavioral, and adaptive
functioning, and guide educational programming and intervention. Although informa-
tion related to the specific referral patterns for patients included in this study is
unavailable, attending physicians, clinical psychologists, other medical team profes-
sionals (e.g., nurse practitioners, rehabilitation specialists, social workers), and parents
commonly make referrals for assessment services. It is likely that some patients were
referred for routine surveillance; whereas others may have been referred due to concern
regarding functioning in some area.
Abstracted data included measures of intellectual abilities and school readiness skills
as well as parent-reported executive and adaptive functioning. Relevant demographic
and medical information was also included. Multiple licensed clinical psychologists and
psychology trainees were involved in providing the assessment services and writing
reports; thus, no standard battery was employed for these evaluations. To increase the
number of participants eligible for this study, scores from multiple measures within the
 CHILD NEUROPSYCHOLOGY 551

Table 1. Demographic and treatment information (n = 61).

M ± SD, range/N (%)
Demographic information
Age at assessment (years) 5.00 ± 0.72, 3.04–5.98
Gender
Male 33 (54.1)
Female 28 (45.9)
Race
White 38 (62.3)
Black 17 (27.9)
Other 6 (9.8)
Diagnosis and treatment information
Age at diagnosis (years) 2.62 ± 1.32, 0–5.75
Diagnostic Category
Brain tumor 39 (63.9)
Solid tumor 13 (21.3)
Leukemia 9 (14.8)
Most common diagnoses
Retinoblastoma 9 (14.8)
Acute lymphoblastic leukemia 8 (13.1)
Ependymoma 7 (11.5)
Medulloblastoma 6 (9.8)
Treatmenta
Surgery 40 (65.6)
Chemotherapy 41 (67.2)
Radiation therapy 32 (52.5)
Cranial radiation therapy 29 (90.6)
Bone marrow transplant 3 (4.9)
Time since diagnosis (years) 2.30 ± 1.65, 0–5.25
Treatment status at assessment
On therapy 15 (24.6)
Off therapy 46 (75.4)
a
Many patients received multiple treatments, thus percentages do not equal 100.

same domain (i.e., intellectual, executive, or adaptive functioning) were combined as

appropriate.

Measures
Executive functioning
The parent-report BRIEF (Gioia et al., 2000) and Preschool Version (BRIEF-P;
Gioia et al., 2003) were used to measure the behavioral aspects of executive
functioning. Specifically, 7 (11.5%) parents completed the BRIEF and 54 (88.5%)
the BRIEF-P. The BRIEF and BRIEF-P assess similar broad domains, with the
BRIEF having more items and domains as it is intended for older children.
However, considerable overlap between the two measures allowed for scores
from the Inhibit, Shift, Emotional Control, Working Memory, and Plan/
Organize subscales as well as the Global Executive Composite to be combined
for analysis. Data are presented as T scores (M = 50, SD = 10), with scores ≥65
indicating clinically significant concerns.

Intellectual functioning
Some indicator of intellectual functioning was administered to 53 (86.9%) children. A
variety of measures were used by clinicians, with 22 participants (41.5%) administered
552 J. L. HARMAN ET AL.

the Differential Ability Scales – 2nd Edition (DAS-II; Elliott, 2007); 14 (26.4%) the
Wechsler Preschool and Primary Scale of Intelligence – 3rd Edition (WPPSI-III;
Wechsler, 2002); 14 (26.4%) the WPPSI-IV (Wechsler, 2012); 2 (3.8%) the Stanford-
Binet Intelligence Scales – 5th Edition; and 1 (1.9%) the Woodcock-Johnson Tests of
Cognitive Abilities – 3rd Edition (WJ-III; Woodcock, McGrew, & Mather, 2007). All
quotients are Standard Scores (M = 100, SD = 15). Additionally, a measure of con-
structional ability (e.g., Block Design, Pattern Construction) was used as an indicator of
nonverbal problem solving (Kenworthy et al., 2014), and was available for those
children (n = 50) administered either the DAS-II, WPPSI-III, or WPPSI-IV (scaled
score, M = 10, SD = 3).

School readiness skills

The Bracken Basic Concept Scale, Receptive, 3rd edition (Bracken, 2006) was adminis-
tered to 44 (72.1%) children. This measure provides a School Readiness Composite
(scaled score, M = 10, SD = 3) that assesses pre-academic skills such as letter/number
identification, color/shape identification, and understanding of size comparisons.

Adaptive functioning
A measure of adaptive functioning was completed by parents for 44 (72.1%) children.
The Adaptive Behavior Assessment System – 2nd Edition (ABAS-II; Harrison &
Oakland, 2003) and Vineland Adaptive Behavior Scales, 2nd Edition Survey Interview
Form (Vineland-II; Sparrow, Cicchetti, & Balla, 2005) were administered, with 79.5%
(n = 35) parents completing the ABAS-II. Several composite scores are common across
the two measures, including indicators of Socialization and Practical/Daily Living Skills,
as well as a broader Adaptive Behavior Composite. All indicators are standard scores
(M = 100, SD = 15).

Analytic plan
Descriptive statistics including mean, standard deviation, range of scores, and number
of patients in the clinically significant range (T ≥ 65) were calculated for the BRIEF.
One-sample-tests were calculated to compare ratings on the BRIEF to normative means.
Similar procedures were used for all other measures, with means, standard deviations,
ranges, and one-sample t-tests against normative means calculated. Pearson correlations
were then computed between indicators of executive functioning and broader function-
ing (intellectual and adaptive functioning, school readiness). Finally, independent
samples t-tests were used to assess differences in executive functioning based on
medical risk factors: diagnostic category (brain tumor vs. other cancer), and treatment
status at assessment (on vs. off-therapy).

Results
On the BRIEF, participants had statistically higher scores than the normative sample on
all indices examined, with the exception of Emotional Control (Table 2). However,
mean scores were largely within normal limits, with no mean score above the cut-off for
clinically significant impairment. However, at the individual level, a significant
 CHILD NEUROPSYCHOLOGY 553

Table 2. Parent-reported executive functioning on the BRIEF/BRIEF-P.

Mean ± SD Range t Cohen’s d N (%) ≥65
Executive Functioning
Global executive composite 57.52 ± 14.14 35–93 4.16*** .61 19 (31.1)
Inhibit 55.38 ± 12.14 36–83 3.46** .48 16 (26.2)
Shift 52.79 ± 9.53 38–84 2.28* .29 5 (8.2)
Emotional control 53.30 ± 13.81 36–93 1.86 .27 12 (19.7)
Working memory 61.61 ± 14.86 36–04 6.10*** .92 29 (47.5)
Plan/Organize 56.25 ± 13.96 32–97 3.50** .51 13 (21.3)
T-score, M = 50, SD = 10. *p < .05, **p < .01, ***p < .001

proportion of participants had scores above the cut-off for each subscale. Specifically,
31.1% of participants had clinically significant impairments on the Global Executive
Composite, and 47.5% on the Working Memory subscale. On other indices, the percent
of the sample above clinical cut-offs ranged from 8.2% (Shift) to 26.2% (Inhibit).
Mean scores were significantly discrepant from the normative mean on the other
domains of functioning as well, including IQ (t = −5.73, p < .001), nonverbal problem
solving (t = −5.80, p < .001), school readiness skills (t = −4.20, p < .001), and adaptive
functioning (t = −5.05, p < .001) (Table 3). Performance across these measures was
generally in the Low Average range, with mean scores about one standard deviation
below expectations.
Correlations between BRIEF indices and other domains of functioning are presented
in Table 4. Broadly, BRIEF indices were highly associated with IQ, with correlations
ranging from −.28 (Inhibit, p = .04) to −.53 (Shift, p < .001). In contrast, BRIEF indices
were minimally associated with measures of nonverbal problem solving and school
readiness skills. More specifically, only Shift was associated with Block Design (r = −.34,
p = .016); and, only Shift (r = −.34, p = .026) and Emotional Control (r = −.30, p = .04)
were associated with school readiness skills. For adaptive functioning, the broad
Adaptive Behavior Composite and the Socialization domain were highly associated
with BRIEF indices, with correlations ranging from −.40 (Shift, Adaptive Behavior
Composite, p = .008) to −.72 (Working Memory, Socialization, p < .001). In contrast,
associations with the Practical/Daily Living Skills domain were slightly lower, and two
(Shift, Emotional Control) were non-significant. Of note, across all measures,

Table 3. Participant functioning on measures of cognitive functioning, school readiness, and parent-
reported adaptive functioning.
N Mean ± SD Range t†
Cognitive functioning
IQa 53 86.53 ± 17.12 43–129 −5.73***
Block designb 50 6.72 ± 4.00 0–18 −5.80***
School readiness
Brackenb 44 7.73 ± 3.59 1–15 −4.20***
Adaptive functioninga
Composite 42 86.86 ± 16.87 53–120 −5.05***
Socialization 43 91.88 ± 19.20 49–130 −2.77**
Practical/Daily living skills 42 86.76 ± 15.93 55–126 −5.35***
**p < .01, *** p < .001
†
One-sample t-test against the normative mean
Standard Score, M = 100, SD = 15
Scaled Score, M = 10, SD = 3
554 J. L. HARMAN ET AL.

Table 4. Associations between parent-reported executive functioning and objective and subjective
indicators of broader psychological functioning.
Objective measures Subjective/Parent-report measures
Block School Adaptive Practical/Daily living
IQ design readiness functioning Socialization skills
Executive Functioning
Global Executive −.40** −.22 −.24 −.62*** −.65*** −.47**
Composite
Inhibit −.28* −.16 −.20 −.44** −.47** −.32*
Shift −.53*** −.34* −.34* −.40** −.51** −.23
Emotional Control −.37** −.24 −.30* −.46** −.52** −.30
Working Memory −.37** −.18 −.20 −.70*** −.72*** −.56***
Plan/Organize −.29** −.01 −.08 −.56*** −.55*** −.48**
*p < .05, **p < .01, ***p < .001

impairment in executive functioning on the BRIEF was associated with poorer global
adaptive and intellectual functioning.
Independent samples t-tests indicated no significant differences in BRIEF indices
between patients with brain tumors (n = 39) and those with other diagnoses (n = 22).
Review of mean scores revealed similar means for the two groups. Results also revealed
no significant differences based on treatment status at assessment: on-therapy (n = 15)
versus off-therapy (n = 46). Again, mean scores were similar for the two groups, though
scores were slightly higher for patients who were off-therapy at the time of assessment.
See Figure 1 for mean scores for both analyses.

Discussion
Weaknesses in executive functions are one of the most common late effects experienced
by survivors of CNS-impacting childhood cancers (Robinson et al., 2014; Ventura et al.,
2018; Winter et al., 2014). However, to date, limited attention has focused on the
potential for the early appearance of these weaknesses in young children with cancer.
Given the protracted development of executive functions in typically developing chil-
dren (Diamond, 2013; Moriguchi & Hiraki, 2013), as well as their importance for both

Figure 1. Comparison of BRIEF indices based on diagnosis (brain tumor vs. other cancer) and
treatment status at assessment (on vs. off-therapy).
 CHILD NEUROPSYCHOLOGY 555

current and future outcomes (Moffitt et al., 2011), it was deemed critical to assess
executive functioning and its associations with broader domains of functioning in a
sample of young children with cancer.
Results of this retrospective clinical study indicated that almost all indices from a
parent-reported measure of executive functioning were statistically discrepant from
normative means. Additionally, a significant proportion of participants – ranging
from 8 to 47% – fell within the clinical range on each subscale. Further, executive
functioning indices were highly associated with other areas of functioning, including
intellectual functioning and parent-reported adaptive functioning, and to a lesser
extent, nonverbal problem solving and school readiness skills. Notably, in this small,
clinically referred sample, parent-reported executive functioning did not differ by
theoretically important risk factors such as diagnostic category and treatment status.
Ultimately, results suggest that executive functioning may represent an important area
of emerging weakness in young children with cancer, and one that may be associated
with broader global functioning.
Our finding that the highest mean score on the BRIEF was Working Memory and
that almost half of our sample had clinically significant concerns in working memory is
worth highlighting. Working memory and attention impairments are among the most
common neurocognitive late effects experienced by older survivors of childhood cancer
(Ashford et al., 2010; Conklin et al., 2012; Robinson et al., 2010); however, these
domains have not been explicitly assessed in younger children. This study would
suggest that these concerns are present and observable by parents at a very young
age, and are associated with broader functioning. As such, it would seem reasonable for
the interventions that have been developed to target these concerns in older children
(Conklin et al., 2015, 2010; Hardy, Willard, Allen, & Bonner, 2013) also be explored for
use with younger patients.
Analyses indicated that overall cognitive functioning was strongly correlated with all
indices of parent-reported executive functioning. In contrast, an indicator of nonverbal
problem solving was only associated with one index (Shift), and school readiness skills
were only associated with two (Shift and Emotional Control). Although the lack of
association between parent-reported and objective indicators of executive functioning is
well documented (Toplak, West, & Stanovich, 2013), the minimal correlations with pre-
academic skills were more surprising. In a recent study of older children with brain
tumors (Ventura et al., 2018), executive functioning was associated with academic skills,
and several papers have highlighted the importance of executive function development
to academic achievement in typically developing children (Fuhs, Nesbitt, Farran, &
Dong, 2014; Nesbitt, Farran, & Fuhs, 2015). It may be that the heterogeneity of this
clinical sample; particularly with regards to age and history of school attendance, may
have played a role, as may our use of a broad indicator of school readiness as compared
with the more specific measures of early reading or math skills. Future studies would
benefit from a more homogenous sample of children as well as use of other measures to
further explore the potential link between early executive functioning and academic
achievement.
Results of this study, coupled with other recent reports (Bornstein et al., 2012;
Willard et al., 2014), suggest an increased need to examine the functioning of all
young children with cancer, irrespective of diagnosis. Indeed, we found similar mean
556 J. L. HARMAN ET AL.

scores on the BRIEF regardless of diagnostic category. These findings highlight the
potential risk to executive functioning for young children with cancer, even in the
absence of a CNS impact. However, what remains to be seen, is the trajectory of
executive functions in children with non-CNS impacts, and whether these children
are able to make gains in skills as they enter school and move further out from
treatment. Unfortunately, longitudinal studies of cognitive and psychosocial function-
ing in children with non-CNS cancers are extremely rare. Results from this preliminary
study suggest a strong need for additional work in this area.
In concert with a need for further assessment is a need for intervention and
prevention efforts. To date, most cognitive interventions for children with cancer
have focused on school-aged and adolescent survivors of brain tumors and ALL,
those deemed at highest risk for deficit (Olson & Sands, 2016). Results from this
study suggest that a focus on younger children of all diagnoses and those who are on
treatment is indicated. There are numerous executive functioning interventions avail-
able for preschool- and school-aged children (Diamond & Lee, 2011), many of which
are designed for implementation in schools, but could potentially be modified for a
hospital setting. Alternatively, there is some suggestion that indirect approaches to
executive function improvement may also be beneficial, including exercise (Riggs
et al., 2017), and naps in young children (Cremone, McDermott, & Spencer, 2017), as
well as other activities that may provide opportunities to foster development and
practice of executive functions (Diamond, 2014). Relatedly, for the youngest patients
(less than 3 years), access to Early Intervention services during treatment may also be a
means of improving outcomes (Harman, Wise, & Willard, 2018).
The current paper is not without limitations. First, our sample was abstracted from
clinical records, which likely introduced an element of bias into our findings. More
specifically, we were restricted to exclusive reliance upon documentation included in
patients’ clinical records. Additionally, data were not obtained solely for research
purposes and only available for young children who were referred to the clinical
assessment service. As such, one should be cautious when generalizing these results
to all young children treated for cancer. Rather, this study demonstrates relationships
among a clinically referred sample and highlights the strong need for additional,
prospective research to further investigate. Relatedly, given that selection of measures
was individualized to meet the clinical needs of each patient, collapsing similar domains
across various measures was necessary, which both limited our sample size and the
variables available to us. Future studies would benefit from a prospective design that
involves young patients from a variety of diagnoses and includes both subjective and
objective reports of executive functioning, as well as other domains including adaptive
functioning and academic achievement, among others. When possible, the use of
multiple informants to assess executive functioning may also be beneficial, though
this is more difficult for a sample of young children who are on treatment as they are
unlikely to be enrolled in school. However, prospective longitudinal studies would
benefit from the inclusion of teacher reports at later off-treatment time points.
Finally, to gain a true understanding of the emergence of executive function weaknesses
in children with cancer, prospective longitudinal studies must be designed that include
both on treatment assessments as well as follow-up into survivorship.
 CHILD NEUROPSYCHOLOGY 557

Ultimately, results of the current clinical study highlight the potential for emerging
weaknesses in executive functioning, and particularly working memory, in young
children with cancer, irrespective of diagnosis. Moreover, such weaknesses are highly
associated with broader domains of functioning, including intelligence, problem sol-
ving, pre-academic skills, and adaptive functioning. These findings add to a growing
body of literature highlighting the potential cognitive, behavioral, and psychosocial
risks associated with the diagnosis and treatment of cancer during early childhood,
and provide support for additional work with regards to both assessment and
intervention.

Acknowledgments
We would like to thank Karen Martin-Elbahesh, MS and Jamilla Griffith, MSW for their
assistance with medical record abstraction.

Funding
ALSAC

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