 Okay, everyone, this is Sarah Burns speaking, and today we're going to have Adrienne Wittall, who's a neuropsychologist with the BrainWorks program with the Kids for Cancer Society. And I've had the pleasure of, Adrienne, probably three or four years ago. It might be 10 years ago, Adrienne, to talk about the HIV-survive cancer treatment and enlightening conversation. We then invited her to speak to the people who used to work with REC. Please be sure your microphone, mute, your microphone will be red, so it just will be red if it's muted. So I'm going to turn this over to Adrienne. And Adrienne, thank you so much for taking time out of your day. She's speaking to us from Toronto and where it's, I believe, 5.30 her time. And thank you, Adrienne, for joining us today. This is my first time doing a presentation this way, so I'm not confident in my volume, but I trust that someone will tell me if you can't hear me, right? So I... Could you speak a little bit louder or a little closer to them? That'd be great. Is this better? Yes. Okay, yeah, my voice often tends to drop when I'm speaking. Okay, so I'm excited to be here. And then I struggled with trying to figure out what I could share with you in just one hour. My friends and colleagues tell me that I'm a bit of a nerd and I can talk about these things for hours. And I always assume everyone is as excited as me in learning all of all of these kinds of things. So I hope that some of this talk is exciting and interesting. And I'd like to share my contact information with you all. If there are ever times that you'd like to know more, if you'd like to consult about a child, as Sarah said, I'm representing the BrainWorks program, which provides this kind of information, liaisons and consultations with families and children with cancer or who have ever been treated for cancer in brain teams to help with educational and academic challenges. So hopefully this is the beginning of a beautiful relationship. Today, I'd like to share with you just some of the challenges that the children going through cancer treatment and survivors will have returning to school and then talk a bit about what some of the warning signs are that you may pick up as educators or people assessing students that a student may be starting to have some difficulties that might be related to their cancer treatment or the after-effects of cancer. I think every presentation starts with some numbers and some incidents, kinds of information. So I wanted to tell you that in the northern Alberta region, so that's north of Red Deer, approximately 85 children are diagnosed with cancer every year. And that's children 16 and younger, kids over 17 are counted as adults, and yet they're still in grade 11 and 12. So this number is larger. There's also about 20 students in Red Deer north that are also diagnosed with brain tumors, which in many cases are often treated with treatment that's similar to cancer treatment. And we'll be talking about some of the issues that happen with those students. So that's half the province. If you multiply those numbers times two, you'll get a rough idea of what Alberta has in terms of incidence. The most common types of cancer in youth under the age of 19, the number one is is leukemia, which is a blood type of cancer. I think it's probably the one that we all think of. It's the most common one. The next most common one are cancers of the brain and the central nervous system. It's followed by lymphoma, which is another kind of whole body cancer. These three cancers are also the top three cancers that are most likely to cause learning, both short-term and long-term learning problems for students. The estimates are that 75% of students with these types of cancers will at least have short-term learning difficulties related to treatment, and a smaller proportion will struggle with lifelong learning difficulties related to treatment. Some of the reasons for that is the kind of treatment that we use for cancer, and that includes things like chemotherapy, which is giving a drug that impacts your entire body system. Radiation therapy in terms of it can be again anywhere in your body, but here when we're talking about learning issues, it would be radiation treatment to the brain. With the chemotherapy, it's not that it's traveling your whole body, and that's what's causing the learning difficulties. When chemotherapy, it has to include your brain for it to be whole body, so it's the impact that it has on the brain. For students with brain tumors, certain kinds of bone tumors, they will have surgery to their brain, and that can cause immediate learning difficulties or some long-term difficulties as well. Finally, I think many of us have heard of things like stem cell transplants, bone marrow transplants, and those can cause learning difficulties later on for students who fall into a certain high-risk category, and we'll talk a little bit about that. Just as an aside, all the bone marrow transplants happen in Calgary. They don't happen in Northern Alberta, so if you ever are working with a student who has a bone marrow transplant, by force, they're living in Calgary for upwards of three to six months, and that's a lot of school that's being missed on top of everything else. What are some of the common kinds of things that students will talk about when they're going through cancer treatment? One of the things that we say at the hospital and at the kids with cancer society is how important it is for students to continue going to school during treatment. So many of them will say it's the one place that I can feel like everybody else, and you see in this student that talked about some of the difficulties they were having during treatment at the end, at the end, at last sense, I just want to be like everybody else, and that's the power of school. So I think perhaps that's why I'm so passionate and talk so much about the learning challenges that students may have, because if we can adapt the school program, we give all students a gift of being like everybody else during that school day, even if they do have to go home and do treatment, or miss a few days of school each week to do treatment, and that's a precious, I believe that's a precious, precious gift. So what are some of the nuts and bolts, or what are some of the things that can really impact the student from a short-term point of view? There's something called peripheral neuropathy, which is due to, and these are three kinds of chemotherapy drugs, and they're very, very common in the kids with brain tumors will have this drug, children with leukemias will have this drug, and lymphomans will have these drugs, and Christians in Plastin and Cisplastin will, they impact the nerves in your arms, your hands, your feet, and your legs, so your hands and feet become weaker. So students will have, will develop some balance difficulties, but in terms of a more direct impact with school, many students will have difficulty with writing, especially writing for longer periods of time. If a student is starting to learn handwriting and printing skills, they'll often come, they'll learn it more slowly, the complain of pain. One really quick way to notice if this is happening is, take a peek at the underside of the paper of the student who's been writing, because one way they cope to control the hand weakness is they put more pressure from the shoulder and the upper arm into writing, and so you'll see that pencil or pen mark making marks on the underside of the paper, and if that's happening you know that there's some weakness here going on. Another treatment related side effect that causes learning problems are hearing changes. Cisplatin is a drug that can cause loss of hearing in many students. Anywhere from high frequency hearing loss, that's a very common side effect with certain kinds of brain tumors because of this drug, to more pervasive hearing difficulties. And what we're starting to learn is that there are genetic markers where we will hopefully be much better able to predict which students will develop hearing problems because of treatment and then be able to sort of proactively address that more quickly. Radiation treatment can cause hearing problems for students with brain tumors as well, so that's something that needs to be watched all the time. And the hearing changes don't happen immediately, they happen over time. We'll be talking about short-term problems which are difficulties that you might anticipate during treatment, and then long-term or late effect problems which can take up to three to four years after treatment to really show them. So if you have a student whose hearing was fine in the first year after treatment that doesn't mean that it will still be fine two or three years later. And then one very common short-term learning related difficulty is due to steroids. Steroids are used in a lot of treatment protocols to help with inflammation, to help with how to make the chemotherapy more effective. And if they're at doses that are high enough to cause changes in mood, changes in irritability, frustration, they can lighten your sleep, so your sleep is not as restful, so then you have a very fatigued child in the classroom. And for those of you who are teachers you know that the fastest way to cause attention problems is to deprive a student of some sleep. So you'll have a double whammy sense of some irritability and difficulties focusing. And then the steroids themselves, during the treatment with the steroids they have noticed that students develop short-term attention difficulties during steroid treatment, so that's another place to be watching that. So I think we've talked a little bit about some of these some of these things that you'd notice right away. I wanted to talk a bit about the fatigue because I've been working in oncology since about 2001 and I used to think the fatigue was more about my muscles and my body but working here in oncology I've just I really learned that brains gets fatigued and when brains gets fatigued it impacts many many things it impacts a student's ability to their balance becomes worse when they're fatigued their physical body might be might not be fatigued but because their brain's been working all day oh my gosh. So this is a video of all the parts of our brain that are involved in focusing and paying attention. And if you were to turn your head to the side you would be looking at that kind of a cut of your brain. So there's the neck down at the bottom and you see the head and you see that virtually every part of your brain is involved in some way in terms of focusing and paying attention. So a student who's undergoing treatment is very vulnerable to mental fatigue. The good news is that the best way to work on fatigue sorts of things are small mini breaks. With physical fatigue you need to sleep. We needed hours of sleep to deal with the physical fatigue but with the brain fatigue changing activity so you go from one subject to the next that could be enough to give that brain a rest having them go and deliver something to the office just getting out of the classroom for a few minutes that's another rest. Being able to do mindfulness or relaxation kind of exercise those those are the most powerful kinds of rest. 10 minutes of those make a big difference in terms of helping a brain rest. The worst thing for fatigue brain is to let them watch you kind of sit them down in front of the TV or to be in a place where it's very noisy like a recess or a game that's recreation that's super important but in terms of mental fatigue you really want to watch how many things am I being asked to pay attention to focus on and ignore and try to at least for a few minutes cut down on that number. So one of the things I'll talk about with parents when I talk about attention difficulties is I'll say well when you're having trouble focusing you're not available for learning it's the same as if you just aren't physically present in the classroom so and then we start to look we start to talk about all the other kinds of things that might affect attention on a daily basis and a big one is being sick so we often kind of look to see how do we sort of balance the day so that they're at school when they're feeling they're stronger so they're morning person or afternoon person and then I always ask about what kind of medication somebody's on for nausea you know that chemotherapy and nausea go hand in hand and virtually all of the anti-nausea medications and most kids will be on them cause fatigue that's just that's just a huge side effect of that so looking to see what can we do to balance those kinds of things. Mental fatigue doesn't always look like body fatigue it can look like restlessness and it can look agitation a child you could look and see it's where that child is not tired at all so that sometimes you really have to kind of judge it based on the quality of their focus and their ability to come back and pay attention and ignore distractions and if you notice that it's fluctuating and dropping that's I would feel very comfortable calling that mental fatigue so what happens to students who might only have short-term difficulties related to treating due to some of the side effects of the medication that we're talking about in some of the medical um and the brain fatigue treatment can hang up to three years for a child with leukemia um boys treatment is a bit longer than girls treatment so three years of struggling with fatigue or some of these difficulties you would see um you're falling grades are falling just um I often see students who have limited who made limited progress in reading skills um or their fine motor skills so short-term supports the year after treatment in schools can be so powerful in helping that student catch up the other thing that is so powerful is to have consistent expectations for work for the student during treatment because at that point to say well we're not and sometimes that happens too is that we feel we feel concerned about the student we don't want to push too hard and then a student has a lot of catching up when they when they've been through treatment for two years and then on third year everybody's kind of expecting them to bounce back and rebound um I used to do assessments um IQ and academic achievement testing and attention testing um the year after the year that they finished treatment to get a baseline and then retest them one year later and the change a student can make in that first year following treatment as they're building physical resilience skills as they are suddenly much more available for learning than they've been for one two or even three years is remarkable um so if you had a very limited place to add extra intervention that's the place to do it and that in that year um helping healthy students catch up to that if you had more though I'd give it all the way through all the way through if you could see me you know that I'm laughing and I'm teasing you a little bit so why am I pushing school and saying how important it is and saying um let's hold let's let's help kids have um expectations and and and where they can incur you know if they if they can't attend a full day let's do a half day let's do three days a week let's let's really focus on school it's not just for the social piece um the good news about cancer treatment is that the five-year survival rates are now over 85 percent the survival rates for leukemia in most common childhood cancer are are over 90 percent um survival rates for children with with brain tumors that when you collect when you lump them all together is about 75 percent and that's because there's still certain kinds of brain tumors that are much more relevant than the treatment we've been able to um succeed with other kinds of brain tumors so if we're talking about that on average 85 percent of children are surviving pediatric cancer um quality life issues become much more important helping prepare that student for adulthood become much more important um and then the other thing that becomes much more important is recognizing that certain kinds of treatment have long-term side effects that may not show up for five ten or fifteen years later that matters less when you are when you're um 60 years old but when you're five years old and you have leukemia we're talking about what you're helping prepare for someone or or make accommodations for certain side effects when they turn 20 and 25 years old so that's the place where research is really starting to focus on what can we do to minimize the long-term effects and what can we do to help support students so that they're successful in in adulthood so these are some of the again these are some comments that students have made as they were transitioning to being off treatment from off treatment sorry on to on to treatment and the kinds of things that we hear I hear the most are related to um being able to work quickly and being able to um catch up and then making sure that whatever source of help they could get that they could be invisible so just like just pretty much just like any other student in the classroom so late effects we were just talking about that I call them side effects so late effects are side effects that show up anywhere from three to fifteen years following treatment they can affect any part of the body we're going to be talking mostly about the psychological ones and the cognitive ones the ones that affect and thinking memory and learning we've talked a little bit about short-term hearing problems and how hearing difficulties can take can change and develop up across three to several years same thing with vision vision difficulties vision can change as a result of radiation treatment their fertility difficulties are very common especially for boys who receive treatment before puberty um the changes to the bones the heart the lung the growth growth the face are more related to radiation treatment or certain kinds of chemotherapy which may slow which may slow both down and then we were talking about um the peripheral neuropathy and how that can cause difficulties with fine motor skills and gross motor skills and in a small proportion of students those difficulties continue so with cognitive late effects so those are changes in thinking skills you I'm looking at them for students with leukemia up to about four to five years following diagnosis the most common age for leukemia are for children between the ages of three to five years old so I'm doing assessments and I'm watching very carefully tiller anywhere from eight to ten years old at any time those difficulties may arise um late effects for students with brain tumors can happen much more quickly and that's partly because of the radiation treatment if they receive radiation treatment so I'll do an assessment initially after the surgery to remove the brain tumor and then about one year after radiation treatment and then I will continue to do those those assessments till about three years post um the lymph lymphoma follows the same kind of uh assessment protocol as leukemia although the difficulties for students with lymphoma tend to be milder attention difficulties and then after cycloma something we didn't talk about those are the bone cancers those are the cancers where quite often someone has to have a limb removed because of that cancer and students with osteosarcoma also um those difficulties tend to follow more a very slower pace like the leukemia looking at something at four to five years post diagnosis and it's related and those students tend to talk more about having trouble remembering things and they're not um it's rare to see um what I call true memory difficulties in students with leukemia lymphoma and bone cancer what it is is more our difficulties related to the ability to um take information in and work with it that working memory pieces we'll be talking about which is sort of that last step that you go through as you're trying to um learn something and and assign it to to memory some of the difficulties that you'll see with students um I call I mean they're called in the research literature they're called psychological rate effects but you know the really reaction ways of coping with some of the some of the stressors and some of the difficulties um and you could with the exception of depression you could lump them into um ways of coping with stress where I tend to withdraw I tend to pull away um tend to avoid school or avoid others uh there's something called selective mutism which which is children with leukemia are at higher risk for that and that's kind of an anxiety that affects how easy it is and how willing I am to communicate with words with to people particularly people I don't know so these so these students might be described as being mute or very very very quiet and only talking to one or two very trusted people the other side of the coin would be the students who cope with the stress and and and these reactions by becoming um easily frustrated and irritable and more like the fight part of the fight or flight stress response and then I when I'm doing an assessment I always keep in mind that distress includes physical symptoms how how's my body feeling when I'm upset and do I tend to get irritable and more more energized more frustrated or do I tend to pull back and get tired and fatigued and more energy the emotional symptoms which we all kind of look for the sadness the anxiety the irritability and then the cognitive symptoms um someone who's depressed the way um how easily they remember things change um the way the way I focus when I'm feeling anxious change so there's always there's always those three areas where I might find symptoms around distress so some of the things that you might that might be clues for you that you would have a student who would be struggling perhaps with some cognitive light effects if you'd start to see a student who is working more slowly um it it's not a comprehension issue it's an input and output how quickly I can take information in and how quickly I can take input put it out I might look like I'm spacing out more I might have trouble ignoring distractions I might avoid school about two-thirds of survivors will develop some math difficulties so I may my I may rely more and more on the regardless to understand especially when math is starting to stress number lines and uh and and that mental uh manipulation of information I might start to have trouble with the pragmatics of writing um I wish I could um I wish I could that's the part my spacing might not be so good anymore my you might pick that up in math or how I'm spacing in between words another sign of where you'd want to think is this cognitive light effect starting to come up is all of a sudden discovering problems in in those grades where the speed changes or the amount of responsibilities a student is is uh expected to juggle starts to change so maybe it'd be around grade three seven or ten and finally if you've got a first grader or second grader who was treated as a three-year-old and everything was looking great and but they're having trouble learning these skills so that could show up in in terms of reading difficulty Adrienne yeah I'm just gonna ask you to speak up a little louder or the interpreter's a few feet away and we're we're not I'm great at thank you there we go um I'm going to share with you my model of how I understand the steps we all go through to learn something if you were to imagine a triangle divided into three parts and I'll be showing you this triangle later at the bottom of the triangle is attention that's the first step taking information in that's ignoring distractions and refocusing and that's how quickly I can take information in now all that information is in is at the bottom of that first third of the triangle not the next level is memory not everybody remembers everything I'm going to lose a tremendous amount of that information that just came in it's not important to remember who's out a bit of more of that information goes into the second level of that triangle into my memory I'm now memorizing that information I'm learning it I'm able to use it to solve problems and then the very last piece of that triangle it's and I and I call it the tip of the iceberg it's the part that we look at when we do IQ testing or academic achievement testing that's the problem solving piece that's my ability to understand and explain my world to myself using language using spatial skills how things fit together all that visual imagery and my ability to understand social relationships how my social skills are developing there's a pattern of difficulties that you tend to see with students who have cognitive late effects that develop that for many students looks like a learning disability a learning disability is an average IQ score so the tip of that iceberg that top of the triangle is fine but there's lots of difficulties in the first in the in the first third of that triangle in terms of attention I'm not picking information up well if I've had radiation treatment I will have difficulties possibly in that upper third of that of that triangle but for most and for most students especially the ones who have leukemia and lymphoma we're really talking about the bottom third of that triangle and that's possibly why people like me start to insist that we should do neuropsychological assessments with students because the an IQ test doesn't always pick up those changes the way the other types of tests will do that when you ask students what it feels like they'll tell you things like this the older students will be able to do be able to compare themselves to before and say something's different it feels slower when I get it I got it but I just need a little bit more time and a lot of them will describe feeling anxious about needing more time you know they just sort of do I ask for it or do I try to ignore it so what why are these things happening so we've talked about how these difficulties develop slowly over time and in the first few minutes of the presentation today I talked about how all of the treatments whether it's chemotherapy or radiation therapy or surgery are are affecting the brain in some way there's a chemotherapy and radiation treatment are successful because they affect they kill cancer cells these cells are rapidly dividing and changing but it's not um they're equal opportunity they affect all cells that are equally that that are dividing quickly that's why people lose their hair hair follicles divide quickly that's why you hear about people talking about nausea and stomach upset because the lining of your stomach cells and your gut and your throat all those cells divide and renew quickly at certain times in a child's life brain cells are also dividing and renewing quickly and so under the age of five there's a lot of there's a lot of a certain kind of cell being developed and that's the picture I just shared with you it's called myelin it's this is a this is a a neuron or a brain cell and the myelin are all these these light colored blue lumpy uh uh they look like beads sorry they look like beads um it's an insulation along the parts of the brain cell that communicate to other parts of the brain cell I think about it as um you know if you if you're going to plug something into the wall the electric cord has a white has has a white plastic around it and that's an insulation it's the same thing thanks to that white insulation around the electric cord the electricity goes from one point to the next it goes there quickly there's no there's um there's no interference and that's myelin does too it it lets brain cells communicate more quickly with one another messages transfer much more quickly they don't get lost they don't ricochet to places they shouldn't get to shouldn't go to if you think of the the way a four-year-old's attention is and compare it to what's happened even a year later when they're five you see the impact one of kids learning how to focus and pay attention and wonderful educational systems but you also see the impact of myelin thanks to the myelin that's what's also happening that's why you know it can feel like the night and day between a child being able to sit and listen to a story and not being able to listen to a story these are the things that happen so these are the cells responsible for letting us focus ignore what we need to ignore they help us with working memory which is that place that's temporary place in our brains where we can juggle information and do mental math in our head and figure out that well at least for me that pair of pants is 60 also how much that's what they're responsible for that they there's more of those cells in the right side of my brain than the left side of my brain if you were to divide my brain in half the right side has more myelin in it and the right side for many of us tends to be more involved with understanding the world bring pictures are involved and visual imagery and spatial kinds of things so that's why spatial skills are effective math is very dependent on working memory skills and spatial skills that's why students who have these kinds of myelin related changes due to treatment are at a higher risk for math difficulties so I mentioned that not everybody gets these though it's not just because you have a student in your class that had this kind of treatment we can't assume that they will have these kinds of learning we can assume that they'll have short-term learning problems but we can't assume that they'll have long-term difficulties so how do we predict who's going to need them hopefully in 10 years or so we'll also have genetic markers to be able to predict it a little more accurately but right now what the research is telling us is that girls are at higher risk than boys so one time that's actually not good to be a girl usually boys are at higher risk for early childhood kinds of things but here it's girls children under the age of nine are at higher risk for these kinds of difficulties especially under the age of five so if they were treated under the age of five we're going to watch them carefully if they got radiation treatment under the age of five they're at very very high risk so we're going to watch them very very closely and if they've got a dose it's here it says 24 cgy and that's just a that's the way they measure doses of radiation the average radiation dose for someone with a brain tumor is six weeks of about 50 so if you if you're working with a student who's had radiation treatment chances are that they're at high risk and we want to watch them carefully a student with a brain tumor who immediately following surgery had difficulties isn't at much higher risk for learning problems also a student with a brain tumor who had radiation treatment who had something called a syndrome that makes them very very sleepy for a couple of weeks when after radiation treatment is over they'll sleep 15 18 hours a day and we don't know why that raises the risk of these kinds of difficulties the type of chemotherapy the name of the chemotherapy that impacts this the most is called methotrexate and it's it's the drug that is responsible for really having cured leukemia so every child with leukemia gets this drug and then students who have the bone marrow transplant that we mentioned earlier if they as part of their bone marrow transplant ended up getting body radiation or got a donor stem cells from somebody who's not a family member they tend to have a higher risk of difficulties as well so those are those are the students that we're looking at so what are the risks for students who have stem cell transplants because their pattern is a little bit different than what I've just been talking about their pattern tends to follow of course over several years and doesn't involve changes in spatial skills the way it does with kids who have leukemia and brain tumors so what you'll see is as early as one year after the bone marrow transplant transplant in addition to any kinds of difficulties that they might have because they missed anywhere from three to six months of school is changes in visual in visual motor skills so that's that fine motor skills and short-term memory three years later this group of kids their visual motor skills tend to have improved and their short-term memory has gotten better but they they may be having more difficulties with forgetfulness especially around verbal kinds of information that narrative the kinds of things that I'm doing right now where I'm lecturing or in a classroom those sorts of things and then five years later in a very small group of these students the ones who are most effective we will see a drop in IQ scores so one of the things when you guys are working with students and if you discover that they did have a bone marrow transplant several years ago it's always and if they're not being followed by our program it's always a good thing to refer them back because we can help some of the assessments around that with children with brain tumors I'm not going to talk a lot about the nuts and bolts of this because every person's brain develops a little bit differently and it's hard to draw a lot of comparisons across the students who have with brain tumors because the their early environment makes a difference where the brain tumor is makes a difference as well as the kinds of help that they receive afterwards but if you put your hand on the back of your head and you feel that sort of bump back there that's the posterior-fossil region that's the place for that is the most common area for brain tumors for children and youth and adults it tends to be more just behind your eyes in the in the in the cortex so off the bat if you know adult if what you know about brain tumors is based on adults a lot of it doesn't apply to children with children the kinds of difficulties that they tend to have most related to their brain tumors tend to have a lot to do with attention information processing and if they received a lot of radiation treatment memory and perhaps IQ scores so going back to what kids say and how they describe this these are now comments of students who are having cognitive late effects who have who know who have the ability to kind of look and see what kind of learners they are and know what sort of things help so the student notices that they need more time that part of needing more time is that it affects how quickly they can take notes so being able to have someone else share their notes with them so that they're studying from the same from the same amount of information as everybody else makes a big difference and then having somebody help with the scribe and with the fine motor difficulty also makes a big difference we've talked about IQ scores and how IQ scores can change so i'm not going to spend a lot of time doing that and if you would like my slides i'm happy to share them with you the last thing i want to talk about before we talk a little bit i'm going to spend a bit more time talking about attention with what we've the time we have left is we've talked a lot about what happens immediately during treatment how those kinds of learning issues are related to fatigue and short-term side effects maybe due to the nausea and the fatigue and the sleepiness that happens from nausea medication or immediate short-term difficulties related to the brain tumor with time three to five years for students with leukemia you can start to see a pattern of changes in information processing speed and working memory and how and in spatial skills and where working memory and spatial skills problems can impact math for younger children it can hurt early early skill acquisition especially around reading but then once they start to really master their reading skills that difficulty seems to disappear so it looks like it's more of a learning to learn difficulty with reading as opposed to the math disability that's due that the that the other group is at risk up we talked about how the bone marrow transplant you tend to you don't see that pattern so much it tends to be changes over time that you want to be watching for change things get better and a couple things get worse then there's something very very rare which is this slide here and it happens in it happens once people are adults we were talking about how side effects or late effects due to cancer treatment can take 20 years afterwards so in a small group of but now they're young adults 20 years post treatment you see difficulties with with headaches and focal what is focal neurologic dysfunction those are pockets of difficulties so different maybe difficult increasing difficulties with fine motor skills increasing difficulties maybe with peripheral vision or increasing difficulties with long-term memory as well so in a very small group of young adults these difficulties can worsen I want to emphasize that it is a very small group but because it is present it is something that students worry about and more than that their parents worry about so are those of you when you're working with high school students who are having difficulties it is something in the back of people's mind and I just wanted to give you that information so that you also know what what people are thinking about when we talk about oh it looks like they're having more difficulties this is something that the people wonder about again we can't at this point we can't predict who that who might have that difficulty so we follow it and all I'm going to say is one more time that it's very rare so there's lots and lots of room for hope that we always have to watch so here's that that triangle I was making you imagine and I apologize for making you imagine it but being the the brain nerd that I am I know that it when you're when you can't see the speaker and you're just looking at a at a a non-moving screen it can be really hard to take what you're listening to and turn it into memories and the more I can engage you as listeners the more likely it is that you will take some of this away and the thing if you remember one thing about my presentation I want you to remember this triangle because it's an it's to me it's an easy way to remember and understand how cognitive late effects can impact someone the bottom you've got a tent well just low at the very bottom of the triangle information about the world how is that getting in where is it going we've got arrows all over the place some of it gets into our memory not everybody remembers everything so some of it flies out and at the very tip of the iceberg we have the problem problem solving piece so where am I what can I access from my brain and from the world in order to give you the best answer I possibly can I'd like to spend the eight minutes I have left to talk to you a bit more about attention because attention matters deeply here so often we think of attention and we think of attend oh the attention span it's how long can somebody focus and then that's the big piece but it really is the first step in learning and critical and knowing how you feel being able to know where to put your attention makes all the difference in the world and we know with children who have cognitive late effects that there are things that we can do to help their brains develop attention skills that have a huge impact on their math skills and their spatial skills there are studies in Toronto where students are doing fun teams sports and exercise several years after being treated for brain tumor and three times a week after three months you can measure the growth in the parts of the brain that are most involved in focus so there are there are definitely things we can do and brain works does will share that information with schools and with with families too and I could come back and talk for two hours Sarah about that so what is attention attention is all these things attention lets you notice things it lets you invite friendships it they say that the sure sign of knowing somebody loves you is how well they focus and pay attention to you and that's perhaps why I can spend hours and hours talking about how important attention is because I think if we can improve students abilities to focus and pay attention it impacts every part of their life but most importantly it impacts their ability to build relationships with others and engage with life the trouble is that attention is a very limited resource there's not enough to go around so the brain directs attention to that which it thinks is most relevant there's always always going to be more information out there than what you can process and so the dilemma is how quickly can you work with the information and the impact that the world on the outside is having and it's in your ability to continue to pay attention as well as the impact that you're having on the inside to be able to pay attention so how how do we know where to direct our attention with this great limited resource I want to leave you guys with a second model I gave you the triangle which is your brain model but I'm going to leave you with a second model of attention and that the the first part of the model is happening right here in this slide it's called bottom-up attention it's the most basic attention there is it's it's it's connected between your eyeballs and the back of your brain the parietal lobe and it's designed to only to focus on what's most important for my survival and it's driven by my senses mostly hearing and vision it pays attention to anything that's shiny that's bright that's um rushing past you as you're trying to cross the street all of those really important things when the makers of iphones and tv commercials use this kind of attention to to grab you over and over again biologically we're designed to pay attention to anything that flashes think of how often a phone flashes right commercials are flashing all the time this is why I I had mentioned to you that the worst thing a student with brain fatigue can do is to watch tv or spend time on their phone is because it this kind of attention is being triggered over and over and over again if you're and so there's no rest there's no brain rest if you're having anxiety this kind of attention takes over your brain you've you've seen that I've said I was so nervous I was running around like a chicken without a head I couldn't focus I was always here I was there I was everywhere that's what this attention is it's designed to be here there and everywhere with very little long-term focus we need it to survive this is where speed comes in when we talked about information processing speed thanks to this kind of bottom-up attention it lets us react quickly and let's us decide on what to do and quickly make that response I'm going to skip this slide because we talked about it all those two a lot but there has to be more to attention if all we had was going from here and there and everywhere there would be no learning because that you just be you'd be like this guy Homer Simpson who we all know who goes from one impulse to the next so there's a part of our brain that lets us focus that let's us take our attention this here there everywhere bottoms up kind of attention and let's us listen to the teacher when there are other things happening in the classroom let's ignore the child behind us and come back to what we're supposed to be focusing on and that happens in two ways the first way is teachers limit the bottom-up hijacking of attention when teachers say look at me look over here they tap on the desk they're directing they're making some kind of visual or sound cue you're you they're stopping this bottom-up attention from hijacking the brain they're also making it easier for a student to process more quickly teachers do this when they take advantage of that wanting to be creative in the novelty seeking part of a child let me see this let me see this let me see this and then gear it to interesting topics that's another way of taking this very normal natural bottom-up kind of attention and using it for learning when you encourage any kind of game that that it focuses on small that an attention to small details that's another way of improving focus by using this kind of innate the ability to just have my attention to hear there and everywhere but that's not enough right that's it then it's always you doing it it's always the environment driving the attention and this is such an important skill to learn as kids are getting older so there's something called top-down attention so if you remember I showed you a brain picture with fatigue at the beginning of this talk and showed you how attention is everywhere in your brain and now you see what because half of your brain is involved in the bottom-up the other half is involved in the top-down and the top-down attention this is your secret weapon in school and it improves with maturity and with practice when I talk to you about the those studies in Toronto where we're able to measure the growth of the brain centers that are involved in attention this is the part of the brain that's grown this is the part of the brain that the brain that develops um through much through probably through your early 20s so there's lots of room and time for hope this is the part of the brain that lets pull your tension back to where it needs to be so this this joke here is bottom-up attention my attention is here there and everywhere and as teachers what we're trying to do is is focus on what can we do to get Bart Simpson using the other part of his brain to learn with children who have cancer and who have the attention difficulties whether they be short-term difficulties or the long-term late effects difficulties everything that we do to help the top-down attention that piece of attention skill that keep the focus that grow the attention span that minimize the impact the negative impact that slow thinking has on learning will do great things to help students be successful and compensate for difficulties with the bottom-up that slow that that the bottom-up attention that slower ability that ability to focus quickly which has become slow whether it's short-term because of medications or fatigue or long-term because of changes to the myelin and that part of the brain