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CO-OP: Childhood Cancer Survivors

CO-OP: Childhood Cancer Survivors. Natalie Cathcart Washington University School of Medicine Program in Occupational Therapy April 6, 2006. Childhood Cancer. In 1998, cancer was the fourth leading cause of death in children under the age of 20. (Reis, et al., 1999)

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CO-OP: Childhood Cancer Survivors

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  1. CO-OP: Childhood Cancer Survivors Natalie Cathcart Washington University School of Medicine Program in Occupational Therapy April 6, 2006

  2. Childhood Cancer • In 1998, cancer was the fourth leading cause of death in children under the age of 20. (Reis, et al., 1999) • The overall 5-year survival rate has increased from less than 30% in 1960 to 78% in 1995. (Robison & Bhatia, 2003; Reis, et al., 1999) • Common treatments include chemotherapy, radiation, and surgery. (Butler & Copeland, 2002; Butler & Mulhern, 2005) • The trend of research has shifted from treatment of the malignancy to examining and treating the late effects caused by treatment.

  3. Cognitive deficits Neuropsychological effects Overall decrease in health-related quality of life Second malignancies Cardiovascular effects Obesity Endocrine disorders Additional surgeries (Anderson, 2003; Robison & Bhatia, 2003) Late Effects • Defined as “unrecognized toxicities that are absent or subclinical at the end of therapy but manifest later as a result of growth, development, increased demand, or aging.” (Schwartz, 1999) • Include:

  4. Cognitive Late Effects • Found to be the most accurate predictor of how well a childhood cancer survivor will become efficiently integrated into his or her community upon entering adulthood. (Schwartz, 1999) • Include deficits in attention and executive functioning. (Robison & Bhatia, 2003; Butler & Copeland, 2002; Anderson, 2003; Butler, 1998)

  5. Cognitive Late Effects • Attention • Five components(Sohlberg & Mateer, 2001) • None are present at birth and tend to evolve as a hierarchical structure throughout development. (Butler, 1998; Sohlberg & Mateer, 2001) • Executive Functioning • Multiple components(Stuss & Benson, 1986) • Appears between the ages of two and four but develops well into the school-aged years.(Zelazo, et al., 1997) • When a child is treated for cancer, these developmental processes are interrupted leading to cognitive deficits.

  6. Occupational Performance of Children • A major occupation of all children is attending school. • Upon return to school following cancer treatment, teachers and parents both report physical, academic, and behavioral problems. (Larcombe, et al., 1990; Rynard, et al., 1999) • Attention specifically impacts all aspects of learning. (Robison & Bhatia, 2003; Butler, 1998) • Research has found that children who have undergone cancer treatment are more likely to require special education services. (Robison & Bhatia, 2003)

  7. Cognitive Rehabilitation • Attention • Cognitive Remediation Program (Butler & Copeland, 2002; Butler & Mulhern, 2005) • Attention Process Training (APT) • Metacognitive strategies • Cognitive Behavioral Therapy (CBT) • Executive Functioning • Goal Management Training (GMT) (Levine, et al., 2000)

  8. Cognitive Rehabilitation • Cognitive Orientation to daily Occupational Performance (CO-OP) (Polatajko & Mandich, 2004) • A “client-centered, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery.” • Utilizes the mnemonic device of “Goal-Plan-Do-Check” as a global cognitive strategy. • 3 Phases which revolve around this mnemonic device: • Preparation Phase (Goal) • Acquisition Phase (Plan/Do) • Verification Phase (Check)

  9. Current Study • Single Case Study • Quantitative and qualitative data • Explores the efficacy behind OT treatment using the CO-OP model of treatment with survivors of childhood cancer in their homes. • Hypothesis: Client(s) will acquire skills to achieve three functional goals and be able to use the cognitive strategies learned to compensate for the cognitive late effects of cancer treatment and successfully accomplish other functional goals associated with the occupations of typically developing adolescents.

  10. Methods • Participants • Recruited from the Late Effects Clinic of the Department of Hematology/Oncology at St. Louis Children’s Hospital. • Inclusion Criteria: cancer survivors 2 years post-treatment, age 8-17, identified attention deficits, lived within reasonable driving distance of the hospital, able to identify 3 goals, willing to participate in a 7-week study in their home • Exclusion Criteria: diagnosis of cognitive, physical, or psychiatric condition; have an Individualized Education Plan (IEP); not fluent in the English language

  11. Methods • Measures • Attention Screener • Daily Activity Log (Polatajko & Mandich, 2004) “What I Did in School Today” • Paediatric Activity Card Sort (PACS) (Mandich, et al., 2004) Adolescent Activity Card Sort (AACS) (Berg & Neufeld, in progress) • Canadian Occupational Performance Measure (COPM) (Law, et al., 1998) • Performance Quality Rating Scale (PQRS) (Henry & Polatajko, 2003) • Fieldnotes

  12. Methods • Procedures • Interest, eligibility, and consent established • Daily Activity Log or “What I Did” Survey mailed • Session 1: PACS (or AACS) and COPM administered— 3 goals established • Session 2-4: Baseline observations • Session 5: Introduction of global strategy • Session 6-12: Guided discovery of task-specific strategies • Session 13: Strategy review—re-administration of PACS (or AACS) and COPM • **Session 14 (2-month follow-up): Re-administration of PACS (or AACS) and COPM

  13. Results—Participant 1 • 10 y/o Caucasian male • PMH: Rhabdomyosarcoma diagnosed at age 5, treated with chemotherapy and radiation • Attention Screener: 6 problems (of 8 items) • Dropped from the program after the initial session due to an unwillingness to identify three goals.

  14. Results—Participant 2 • 9 y/o African-American male • PMH: Hepatoblastoma diagnosed at age 2 years, treated with chemotherapy and surgery • Attention Screener: 4 problems (of 8 items) • COPM Goals: • Remember to do and turn in all assignments on time • Decrease time required to do homework & morning routine • Improve reading comprehension • Dropped from the program after 6 sessions due to lack of participation and failure to make progress.

  15. Results—Participant 3 • 15 y/o African-American male • PMH: Rhabdomyosarcoma diagnosed at age 11 years, treated with chemotherapy and radiation • Attention Screener: 6 problems (of 8 items) • COPM Goals: • Decrease frustration while working on math work • Remember which assignments and necessary supplies to bring home from school • Maintain attention during class and CO-OP sessions • Completed the program but with less than satisfactory results.

  16. Discussion • Parental Involvement • One of the key features of CO-OP • “The primary role of the parent is to support the child in the acquisition of new skills and to facilitate the generalization and transfer of these.” (Polatajko & Mandich, 2004) • Participants 2 and 3 did not have adequate parental support available at session times while Participant 1’s parent was very interested in session goals and objectives (possibly over-involved). • For future studies, a commitment of parental involvement is necessary for positive outcomes.

  17. Discussion • Motivation • Client-chosen goals are another key feature of CO-OP. • These “ensure the child is motivated to engage in the skill, to learn to perform it (skill acquisition), to use it beyond the therapy setting (generalization), and to apply the new learning to other skills (transfer).” (Polatajko & Mandich 2004) • CO-OP was originally designed for use on motor skills (ex: riding a bicycle or tying shoes)—these goals were much more motivating for the child than the academic goals used in our study. • The use of all academically based goals is not recommended for future studies with similar populations.

  18. Discussion • Metacognition • Defined as the “awareness and understanding of one’s thinking and cognitive processes.” • In order to benefit from Guided Discovery (a key concept of CO-OP), a child must be aware of their deficits. • Participant 1 and 2 displayed a lower level of metacognition than Participant 3 although none of the participants were fully aware of how their deficits were contributing to lower grades, increased frustration, and other occupational performance deficits. • In future studies, it is important to establish the metacognition level before beginning the intervention.

  19. Conclusions • Overall, the use of CO-OP in its current form was not found to be efficacious with this population . • Limitations: • Difficulty with recruiting due to limited population size from which to recruit (age and home location) • Inability to meet all of the CO-OP pre-requisites • Lack of parental support in available participants • Participants 1 and 2 were possibly too young leading to a lack of motivation and metacognition • Insufficient amount of time to adequately address all 3 goals • Lack of information about the participants’ pre-cancer participation, attention, and executive functioning levels.

  20. References Anderson, N.E. (2003). Late complications in childhood central nervous system tumour survivors. Current Opinions in Neurology, 16(6), 677-683. Berg, C. & Neufeld, P. (in progress). Adolescent Activity Card Sort. St. Louis, MO: Washington University. Butler, R.W. (1998). Attentional processes and their remediation in childhood cancer. Medial and Pediatric Oncology Supplement, 1, 75-78. Butler, R.W. & Copeland, D.R. (2002). Attentional processes and their remediation in children treated for cancer: A literature review and the development of a therapeutic approach. Journal of the International Neuropsychological Society, 8, 115-124. Butler, R.W. & Mulhern, R.K. (2005). Neurocognitive interventions for children and adolescents surviving cancer. Journal of Pediatric Psychology, 30, 65-78. Henry, L. & Polatajko, H.J. (2003). Exploring the inter-rater reliability of the Performance Quality Rating Scale. Paper presented at the Canadian Association of Occupational Therapists Conference, Winnipeg, MB. Larcombe, I.J., Walker, J., Charlton, A., Meller, S., Jones, P.M., & Mott, M.G. (1990). Impact of childhood cancer on return to normal schooling. British Medical Journal, 301, 169-171. Law, M., Baptiste, S., Carswell, A., McColl, M.A., Polatajko, H., & Pollock, N. (1998). Canadian Occupational Therapy Measure (3rd ed.). Ottawa, ON: CAOT Publications ACE. Levine, B., Robertson, I.H., Clare, L., Carter, G., Hong, J., Wilson, B., Duncan, J., & Stuss, D.T. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312. Mandich, A., Polatajko, H.J., Miller, L., & Baum, C. (2004). The Paediatric Activity Card Sort. Ottawa, ON: CAOT Publications ACE. Polatajko, H.J. & Mandich, A. (2004). Enabling Occupation in Children: The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach. Ottawa: CAOT Publications ACE. Ries, L.A.G., Smith, M.A., Gurney, J.G., Linet, M., Tamra, T., Young, J.L., & Bunin, R.R. (Eds.). (1999). Cancer incidence and survival among children and adolescents: United States SEER Program 1975-1995, National Cancer Institute, SEER Program. NIH Pub. No. 99-4649. Bethseda, MD: Author. Robison, L.L. & Bhatia, S. (2003). Late effects among survivors of leukaemia and lymphoma during childhood and adolescence: Review. British Journal of Haematology, 122, 345-359. Rynard, D.W., Chambers, A., Klinck, A.M., & Gray, J.D. (1998). School support programs for chronically ill children: Evaluating the adjustment of children with cancer at school. Children’s Health Care, 27(1), 31-46. Schwartz, C.L. (1999). Long-term survivors of childhood cancer: The late effects of therapy. The Oncologist, 4, 45-54. Sohlberg, M.M., McLaughlin, K.A., Pavese, A., Heidrich, A., & Posner, M.I. (2000). Evaluation of Attention Process Training and brain injury education in persons with acquired brain injury. Journal of Clinical and Experimental Neuropsychology, 22(5), 656-676. Sohlberg, M.M. & Mateer, C. (2001). Management of attention disorders. In Cognitive rehabilitation: An integrative neuropsychological approach, Ch 5, p.125-161. New York: Guilford Press. Stuss, D.T. & Benson, D.S. (1986). The frontal lobes. New York: Raven Press. Zelazo, P.D., Carter, A., Reznick, J.S., & Frye, D. (1997). Early development of executive function: A problem-solving framework. Review of General Psychology, 1(2), 198-226.

  21. Acknowledgements • I would like to thank my parents for helping me to keep my sanity throughout OT school and believing in me the entire time. • I would also like to thank my fellow researchers, Dr. Christine Berg and Jessica Sweeney, for all their help and guidance. • Thank you also to Heidi Villamin and Divya Sood for their help with CO-OP sessions.

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