456 Child Health Psychology
much more dif“cult than prior to their injury. They may feel
abandoned by friends and unable to be involved in activities
they enjoyed previously because of physical or cognitive lim-
itations. Parents are confronted with how to manage the mul-
tiple needs of their previously healthy child. Family members
may each have very different beliefs about the child•s current
behaviors/abilities and potential for recovery. Siblings too
may feel confused, neglected, and may blame themselves for
their sibling•s injury. It is particularly important to be aware
of family beliefs and reactions to the child•s injury, as family
environment (e.g., family stress, burden) has been shown to
have an impact on psychosocial and behavioral outcomes
(Taylor et al., 1995). This underscores the importance of
involving and supporting whole families throughout the reha-
bilitation process.
Pediatric Brain Tumors
With increasing numbers of survivors of pediatric brain tu-
mors, attention has turned to the impact of these diseases and
treatments on quality of life. Increased survival has been
linked to medical, cognitive, and psychological sequelae;
children who survive pediatric brain tumors are more fre-
quently at risk for signi“cant late ef fects from the tumor and
the treatment than other childhood cancer survivors (Ris &
Noll, 1994).
Children with brain tumors are at risk for cognitive im-
pairment due to the nature and location of the disease process
and of frequently used irradiation treatment. Ris and Noll
(1994) noted that most studies of neuropsychological func-
tioning after brain tumor diagnosis and treatment contain
samples that include various tumor types located in different
brain areas, making generalizations regarding cognitive
de“cits dif “cult. Nevertheless, there are some consistencies;
research suggests that children with supratentorial tumors are
at greater risk for intellectual impairment than infratentorial
tumors (Mulhern, Crisco, & Kun, 1983; Mulhern & Kun,
1985), and that the pattern of de“cits for children with brain
tumors resembles the pattern found in children with nonver-
bal learning disabilities (Buono et al., 1998).
Children who are treated for brain tumors exhibit lower
social competence, fewer and more negative peer relation-
ships, and more problematic social adjustment than healthy
children (Foley, Barakat, Herman-Liu, Radcliffe, & Molloy,
2000; Mulhern, Hancock, Fairclough, & Kun, 1992; Vannatta,
Garstein, Short, & Noll, 1998). Furthermore, studies have
shown an association between special education place-
ment and poor social adjustment in childhood cancer sur-
vivors (Deasy-Spinetta, Spinetta, & Oxman, 1989; Kazak &
Meadows, 1989).
Research on interventions to address the apparent social
skills de“cits that underlie problems in social adaptation of
children with brain tumors is limited. The limited data on
brain tumor survivors suggests that social skills training may
be helpful for some survivors (Die-Trill et al., 1996). In addi-
tion, there is a published report of the successful use of social
skills training with survivors of childhood cancer (Varni,
Katz, Colegrove, & Dolgin, 1993), but children with brain
tumors were not included in the sample. The authors evalu-
ated individual social skills training as a supplement to a
standard school reintegration program for children with can-
cer. Using a random sample of 64 children between the ages
of 5 and 13 years old, they found that those children who re-
ceived the social skills training reported higher perceived
peer and teacher social support at a nine-month follow-up
compared to baseline levels. Furthermore, parents of these
children reported decreased internalizing and externalizing
behavior problems and an increase in social competence. By
contrast, the standard treatment group did not report any
signi“cant change in social or behavioral functioning. The
literature on the effectiveness of social skills training with
samples similar to children with brain tumor, such as children
with learning disabilities, is promising (Schneider, 1992); so-
cial skills training programs have been widely used with this
population for more than 20 years (Kavale & Forness, 1996).
Schneider (1992) reported that social skills programs were
more successful when used with socially withdrawn children
who are much like brain tumor survivors.
One of the authors (LPB) is involved in a pilot study
testing a manual-based, social skills training intervention for
8- to 13-year-old children treated for brain tumors and as-
sessing the association of neuropsychological functioning
with social skills and with children•s ability to bene“t from
the intervention. The training took place in six weekly groups
of “ve to eight children and had a closely linked parent com-
ponent. Targeted social skills were nonverbal social skills,
starting, maintaining, and “nishing conversations, giving
compliments, empathy and con”ict resolution, and coopera-
tion. In each session, homework was reviewed “rst while
parents were present, then speci“c skills were presented,
examples demonstrated, and role-plays undertaken. Children
were given weekly homework assignments. The parent com-
ponent involved education and information regarding the
targeted social skills, problem-solving barriers to practicing
social skills, and discussions of the impact of the brain tumor
on the child and on the family. Initial feedback from families
was positive, and attendance was consistent. Preliminary
“ndings support an association of neuropsychological func-
tioning with social skills (Carey, 2000) and improved social
skills and social functioning from baseline to a nine-month