Helping the Child with Learning Problems After Transplant
Cognitive problems, also referred to as neurodevelopmental problems, are problems with a child’s ability to learn, remember, and perform mental tasks. The problems are caused by damage to the brain and blood vessels in the brain, or interruption in the development of the brain. Some children who undergo a bone marrow transplant (BMT) have an increased risk of developing cognitive problems after treatment.
Dr. Daniel Armstrong
BMT InfoNet: Which children are at greatest risk for developing cognitive problems after transplant?
Dr. Armstrong: Children can develop cognitive problems for a number of reasons, many of them unrelated to BMT. Prior chemotherapy or radiation can cause learning problems, as can changes in brain structure caused by a tumor.
Total body irradiation (TBI) given to children as part of their transplant can also cause cognitive problems, depending on the dosage. The risk is greatest for younger children and those who previously received craniospinal radiation and intrathecal methotrexate.
Events during BMT, such as central nervous system encephalitis, may also cause severe acute and
long-term problems. Long hospitalization due to chronic graft-versus-host disease or other complications can delay a child’s development as well.
BMT InfoNet: Do children lose the cognitive skills they have already developed?
Dr. Armstrong: No. Children usually retain the skills they had already developed prior to treatment. It is the ability to learn new cognitive skills at an age-appropriate time that may be affected.
BMT InfoNet: Do the risks differ depending on whether the child had an autologous transplant using his own bone marrow, or allogeneic transplant using donor bone marrow?
Dr. Armstrong: Research does not show any severe cognitive problems associated with autologous transplants unless the child had a pre-existing developmental problem or an acute central nervous system infection during treatment.
However, this data, as well as data about allogeneic transplant long-term effects, must be interpreted with caution since neurodevelop-mental problems may not be detected until long after treatment.
BMT InfoNet: What kind of developmental delays can occur?
Dr. Armstrong: Children can have attention or memory problems. It may take them longer to accomplish academic tasks than other children. Organization, fine motor skills, and reading or math may be difficult. Often, children with developmental delays will have difficulty with social interactions as well.
BMT InfoNet: Can the problems be corrected?
Dr. Armstrong: Medications such as Ritalin®, Concerta®, and other forms of methylphenidate can be helpful. Patients can also use cognitive rehabilitation to lessen the problem. In the same way that a patient goes to physical therapy to rebuild his muscles after an injury, cognitive rehabilitation helps patients with cognitive deficits rebuild the their brain function.
BMT InfoNet: What sort of help can I expect from my child’s school if he is experiencing learning difficulties after transplant?
Dr. Armstrong: If your child attends a public school or a school that receives federal funding, you can ask the school for neuropsychological testing of your child. The tests can identify the areas of weakness, and determine the type of special assistance the school needs to provide your child. This is formalized in a document called an individ-ualized education plan (IEP) or 504 Plan.
Typical accommodations made for children with cognitive problems include tutoring by a special education teacher to help with math or reading difficulties, extending time allowed to complete homework or reducing the amount of homework, additional time for taking standardized tests, and changes in teaching strategies.
BMT InfoNet: What sort of changes in teaching strategies help?
Dr. Armstrong: Children with learning difficulties often learn better by hearing information, rather than seeing or reading it. They also find it easier to relate their comprehension of a subject orally than by writing it.
Switching to a “listen-speak” form of learning rather than a “read-write” form of learning may better match the child’s learning style. This strategy allows children with reading difficulties to listen to books on tape, rather than reading lengthy texts. Children with math difficulties can use a calculator rather than writing to complete problems. Voice recognition software installed on a computer can allow a child to speak his writing assignments, rather than write or type them, and have the computer convert his speech to text.
Children with organizational difficulties can sometimes be helped by tools such as PDAs or audible reminders on phones or other devices. Color coding classroom assignments, such as putting all math in the blue folder, all reading assignments in the yellow folder, etc. can help train children to find their work more easily.
BMT InfoNet: How long do cognitive problems last?
Dr. Armstrong: Cognitive difficulties may not be apparent until many years after treatment. Children should be tested into young adulthood to detect problems so that appropriate accommodations can be made while educating the child. Testing can also help young adults plan for careers that draw on their strengths, rather than challenge their weaknesses.
BMT InfoNet: Are there any resources you would recommend for parents whose child has cognitive problems after transplant?
Dr. Armstrong: Yes. Three good resources are Childhood Cancer Survivorship available from the www.nap.edu, Educating the Child with Cancer, available from www.candlelighters.org and Learning and Living With Cancer, available from the www.leukemia-lymphoma.org.
   
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