Clinical diagnosis of attention-deficit/hyperactivity disorder in survivors of pediatric brain tumors
Survivors of pediatric brain tumors often have neurodevelopmental late effects, such as inattention. Symptoms may mirror those of attention-deficit/hyperactivity disorder (ADHD), which affects ~ 5–8% of the general population. This retrospective study of survivors followed at a large tertiary care center examined the prevalence of a clinical diagnosis of ADHD, and risk factors associated with ADHD diagnosis and ADHD-related medication use.
A retrospective chart review of brain tumor survivors (n = 528), diagnosed between 2000 and 2015, who were at least 6 years old and 2 years from the end of tumor-directed therapy or from diagnosis, if no interventions were received. Clinical and demographic data were extracted from the medical record.
Survivors were 55.7% male with mean age 8.15 ± 4.4 (0.0–16.0) years at brain tumor diagnosis. The most common diagnoses were low-grade glioma, medulloblastoma, and craniopharyngioma, with 52.5% of tumors supratentorial. Of the survivors, 81.3% received surgery, 40.0% radiation therapy, and 36.6% chemotherapy. Sixty-nine survivors (13.1%) had ADHD diagnoses, 105 (19.9%) had symptoms of ADHD without diagnoses, and 64 (12.1%) had ADHD medication use. ADHD diagnosis was associated with younger age at tumor diagnosis (p = 0.05) and supratentorial tumor location (p = 0.001). ADHD diagnosis was not associated with gender, tumor type, or treatment type.
Survivors of brain tumors are at increased risk of ADHD and related symptoms. The greatest increase in risk occurs for survivors with diagnoses at younger ages and supratentorial tumors. Additional research is warranted, as select survivors may benefit from behavioral or pharmacologic ADHD treatments to optimize functioning.
KeywordsAttention-deficit/hyperactivity disorder (ADHD) Secondary ADHD Brain tumor Cancer survivorship Inattention
Acute lymphoblastic leukemia
Central nervous system
Last date of contact
Study data were collected and managed using REDCap electronic data capture tools hosted at CHOP. REDCap24 is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.
Children’s Hospital of Philadelphia (Division of Developmental and Behavioral Pediatrics). Dr. Hocking is also supported by the National Institutes of Health (NIH), Grant Number K07CA178100. The authors have indicated they have no financial relationships relevant to this article to disclose.
Compliance with ethical standards
Conflict of interest
The authors have indicated they have no potential conflicts of interest to disclose.
- 1.Zeltzer LK et al (2009) Psychological status in childhood cancer survivors: a report from the childhood cancer survivor study. J Clin Oncol 27(14):2396–2404Google Scholar
- 2.Central Brain Tumor Registry of the United States (CBTRUS). Fact Sheet (2017) www.cbtrus.org/factsheet/factsheet.html. Accessed 05 Sep 2017
- 3.Wells E, Packer R (2015) Pediatric brain tumors. Continuum (Minneap Minn) 21(2):373–396Google Scholar
- 4.Vannatta K, Gartstein MA, Short A, Noll RB (1998) A controlled study of peer relationships of children surviving brain tumors: teacher, peer, and self ratings. J Pediatr Psychol 23(5):279–287Google Scholar
- 5.Schulte F, Barrera M (2010) Social competence in childhood brain tumor survivors: a comprehensive review. Support Care Cancer 18(12):1499–1513Google Scholar
- 6.Zebrack BJ et al (2004) Psychological outcomes in long-term survivors of childhood brain cancer: a report from the childhood cancer survivor study. J Clin Oncol 22(6):999–1006Google Scholar
- 7.Ness KK et al (2010) Physical performance limitations among adult survivors of childhood brain tumors. Cancer 116(12):3034–3044Google Scholar
- 8.Mulhern RK, Butler RW (2004) Neurocognitive sequelae of childhood cancers and their treatment. Pediatr. Rehabil. 7(1):1–14 discussion 15-16 Google Scholar
- 9.Palmer SN, Meeske KA, Katz ER, Burwinkle TM, Varni JW (2007) The PedsQL brain tumor module: initial reliability and validity. Pediatr Blood Cancer 49(3):287–293Google Scholar
- 10.Robinson K et al (2010) A quantitative meta-analysis of neurocognitive sequelae in survivors of pediatric brain tumors. Pediatr Blood Cancer 55:525–531Google Scholar
- 11.Reimers TS et al (2003) Cognitive deficits in long-term survivors of childhood brain tumors: identification of predictive factors. Med Pediatr Oncol 40(1):26–34Google Scholar
- 12.Brière M, Scott J, McNall-Knapp R, Adams R (2008) Cognitive outcome in pediatric brain tumor survivors: delayed attention deficit at long-term follow-up. Pediatr Blood Cancer 50(2):337–340Google Scholar
- 13.Kiehna EN, Mulhern RK, Li C, Xiong X, Merchant TE (2006) Changes in attentional performance of children and young adults with localized primary brain tumors after conformal radiation therapy. J Clin Oncol 24(33):5283–5290Google Scholar
- 14.Reddick WE et al (2003) Developmental model relating white matter volume to neurocognitive deficits in pediatric brain tumor survivors. Cancer 97(10):2512–2519Google Scholar
- 15.Kun LE, Mulhern RK, Crisco JJ (1983) Quality of life in children treated for brain tumors. Intellectual, emotional, and academic function. J Neurosurg 58(1):1–6Google Scholar
- 16.Patel SK, Lai-Yates JJ, Anderson JW, Katz ER (2007) Attention dysfunction and parent reporting in children with brain tumors. Pediatr Blood Cancer 49(7):970–974Google Scholar
- 17.Moyer K et al (2012) The impact of attention on social functioning in survivors of pediatric acute lymphoblastic leukemia and brain tumors. Pediatr Blood Cancer 59(7):1290–1295Google Scholar
- 18.T. Subcommittee on Attention-Deficit/Hyperactivity DIsorder et al (2011) ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 128(5):1007–1022Google Scholar
- 19.Willcutt EG (2012) The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics 9(3):490–499Google Scholar
- 20.Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ (2018) Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol 47(2):199–212Google Scholar
- 21.Epstein JN, Loren REA (2013) Changes in the definition of ADHD in DSM-5: subtle but important. Neuropsychiatry (London) 3(5):455–458Google Scholar
- 22.Kahalley LS et al (2011) ADHD and secondary ADHD criteria fail to identify many at-risk survivors of pediatric ALL and brain tumor. Pediatr Blood Cancer 57(1):110–118Google Scholar
- 23.Hardy KK, Willard VW, Wigdor AB, Allen TM, Bonner MJ (2015) The potential utility of parent-reported attention screening in survivors of childhood cancer to identify those in need of comprehensive neuropsychological evaluation. Neuro-Oncol Pract. 2(1):32–39Google Scholar
- 24.Hardy K, Willard V, Gioia A, Sharkey C, Walsh K (2018) Attention-mediated neurocognitive profiles in survivors of pediatric brain tumors: comparison to children with neurodevelopmental ADHD. Neuro Oncol 20(5):705–715Google Scholar
- 25.Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf 42(2):377–381Google Scholar
- 26.Nass RD (2005) Evaluation and assessment issues in the diagnosis of attention deficit hyperactivity disorder. Semin Pediatr Neurol 12(4):200–216Google Scholar
- 27.Willard VW, Conklin HM, Huang L, Zhang H, Kahalley LS (2016) Concordance of parent-, teacher- and self-report ratings on the Conners 3 in adolescent survivors of cancer. Psychol Assess 28(9):1110–1118Google Scholar
- 28.Conklin HM et al (2010) Predicting methylphenidate response in long-term survivors of childhood cancer: a randomized, double-blind, placebo-controlled, crossover trial. J Pediatr Psychol 35(2):144–155Google Scholar
- 29.Thompson MR, Leigh L, Christensen R, Ziong X, Kun LE, Heideman RL, Reddick WE, Gajjar A, Merchant T, Pui HP, Hudson MM (2001) Immediate neurocognitive effects of methylphenidate on learning-impaired survivors of childhood cancer. J Clin Oncol 19(6):1802–1808Google Scholar
- 30.Sturner R et al (2016) The PSC-17: Subscale Scores, reliability, and factor structure in a new national sample. Pediatrics 138(3):e20160038–e20160038Google Scholar
- 31.Koshy AJ, Mautone JA, Pendergast LL, Blum NJ, Power TJ (2016) Validation of the behavioral health checklist in diverse pediatric primary care settings. J Dev Behav Pediatr 37(2):132–139Google Scholar
- 32.DuPaul G, Reid R, Anastopoulos A, Lambert M, Watkins M, Power T (2016) Parent and teacher ratings of attention-deficit/hyperactivity disorder symptoms: factor structure and normative data. Psychol Assess 28(2):214–225Google Scholar