Enhancing Decision-Making in Pediatric Radiotherapy: Internal Validation and Expansion of the M.A.P.-RT Schedule for Sedation Need Prediction and Identification of Psychological Support Needs in a Prospective Cohort of 268 Pediatric Patients

Background: Pediatric radiotherapy is often associated with high levels of psychological distress and vulnerability, affecting both patients and their families. In younger children, sedation is frequently required to ensure safety and adequate immobilization during treatment. The original RADAR Project demonstrated that the Multidimensional Assessment for Pediatric Patients in Radiotherapy (M.A.P.-RT) tool accurately predicts the need for sedation in pediatric patients undergoing radiotherapy. The present study aims to extend the validation of the M.A.P.-RT, including a larger cohort of patients, to confirm the tool’s predictive robustness and to identify clinical and psychosocial factors associated with sedation requirements, and to profile psychosocial and behavioural vulnerability according to age and gender. Methods: Pediatric patients referred for RT were prospectively enrolled and assessed with the M.A.P.-RT schedule during the first multidisciplinary consultation. Two outcomes were analysed: the need for procedural sedation and the level of psychological support required (intensive vs. standard). The questionnaire items, domain scores, and total score were examined to identify the factors most strongly associated with these outcomes. Predictive models were then developed using the domain scores, while the total score was evaluated separately. Model performance was assessed by repeated, fully nested 10 × 10-fold cross-validation (internal validation only), and odds ratios with 95% confidence intervals were calculated to estimate the strength of the associations. Linear regression models with age group (children ≤ 11 years vs. adolescents and young adults ≥ 12 years), gender, and their interaction were then fitted to test demographic predictors of psychological difficulties and behavioural reactions at treatment entry. Results: A total of 268 patients (mean age 9.6 years, SD 5.7; 59.3% male) were included in the analysis. Procedural sedation was required in 22.8% of patients, while 51.1% received intensive psychological support. The M.A.P.-RT showed excellent ability to identify children requiring sedation, with previous collaboration during radiotherapy procedures, age-related discomfort, and higher questionnaire scores emerging as the main predictors. The overall questionnaire score alone also provided high predictive accuracy. In contrast, the tool was less effective in distinguishing patients who required intensive psychological support: it misclassified roughly one patient in three, with a significant bias toward over-classifying patients into the higher-need category. Age group, but not gender, predicted psychosocial vulnerability: compared with adolescents and young adults, children aged ≤11 years showed significantly greater psychological difficulties, parental anxiety, post-diagnosis distress, and externalising coping and patient-management difficulties and more pronounced reactions across all five dimensions of the Children’s Emotional Manifestation Scale (CEMS), included in the M.A.P.-RT, at treatment entry. Conclusions: In this large single-centre cohort, and under internal validation only, the M.A.P.-RT confirmed its value as a reliable tool for predicting the need for procedural sedation in pediatric radiotherapy, while its ability to predict the intensity of psychological support was more limited, indicating that it is better used to prompt psychological assessment than to allocate support; this was probably due to different properties of the two targets. Age was the main profiling variable, identifying younger children as systematically more vulnerable; sex was not associated with any outcome. These findings highlight that integrating structured psychosocial information into patient profiling may facilitate the early identification of individual vulnerabilities and support the delivery of more personalized psychosocial care. They also underscore the potential of multidisciplinary assessment tools to enable the early identification of individual needs and vulnerabilities, supporting the development of personalized supportive interventions to improve the radiotherapy experience of children and their families. Because validation was internal and conducted in a single centre, external validation remains necessary before the schedule is adopted elsewhere.