PROMIS® Parent Proxy Report Scales: an item response theory analysis of the parent proxy report item banks

The Validity of Patient-reported Outcome Measurement Information System (PROMIS) Parent Proxy Instruments to Assess Function in Children With Talipes Equinovarus

BACKGROUND

Idiopathic talipes equinovarus (ITEV) is a prevalent structural deformity of the foot and ankle in children. The disease-specific instrument (DSI) has commonly been used as an outcomes metric in these patients. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. PROMIS has been validated for multiple conditions; however, no studies have evaluated the use of the PROMIS in children with ITEV.

METHODS

A prospective analysis was performed whereby the 2 questionnaires were mailed out to the parents of 91 patients, aged 5 to 17 years, with ITEV. Construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue, Pain Interference, and Pain Intensity to the DSI Function domain and PROMIS domains of Anxiety, Depressive Symptoms, Peer Relationships, and Pain Intensity to DSI Satisfaction domain.

RESULTS

Thirty-one complete responses (34% response rate) were returned. The patients' current mean age was 8.8 years, 7 were female individuals, and 12 had unilateral ITEV. Bivariate correlation analysis, using Spearman correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (rs=0.52) and a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (rs=-0.56), as well as the PROMIS Pain Intensity domain (rs=-0.75). A fair negative correlation (rs=-0.38) with PROMIS Fatigue domain was found. Correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship.

CONCLUSIONS

These results provide support for the validity of the PROMIS Mobility, Pain Interference, and Pain Intensity domains in this population, however there are no items in PROMIS that can assess overall satisfaction, as with the DSI.

LEVEL OF EVIDENCE

Level II-prospective comparative study.

Positive emotions despite substantial burden: The alchemy of haemophilia caregiving

INTRODUCTION

Qualitative interviews when developing the haemophilia caregiver impact measure^© (HCI) documented the importance of capturing the positive aspects of caregiving, not just the negative.

AIM

The present study thus investigates the construct underlying the positive emotions HCI subscale and tests models proposing a more comprehensive way of thinking about this construct.

METHODS

Secondary analysis was implemented on longitudinal web-based survey data (n = 323) from haemophilia A or haemophilia B caregivers. Person-reported outcomes (PROs) included the HCI, the PROMIS-10 and Ryff psychological well-being subscales. Predictors included caregiver demographics; patient haemophilia characteristics; exercise; adherence; and quality-of-life (QOL) appraisal processes as measured by the brief appraisal inventory (BAI) which yields composite scores assessing awareness of challenges, fulfillment and growth, stay positive, social comparison and interpersonal problem-solving. Second-order factor analysis, structural equation modelling and residual modelling were implemented.

RESULTS

A structural equation model fit the data well that contained bifactor representation of well-being with a general factor comprised of environmental mastery, positive relations with others, physical functioning and emotional functioning. Positive emotions was modelled as a component of well-being, with a unique component ('Alchemy') characterized by its associations with stay positive, and awareness of challenges appraisals, and difficulty paying bills. Alchemy had positive linear relationships with the first two, and a positive quadratic relationship with difficulty paying bills.

CONCLUSIONS

Adopting positive-focused ways of thinking about one's life limitations may transform the negatives of haemophilia caregiving into something positive. Such cognitive habits reflect an awareness and acceptance of the limitations imposed by haemophilia caregiving.

Parental Proxy PROMIS Pain Interference Scores are Only Modestly Concordant With Their Child's Scores: An Effect of Child Catastrophizing

OBJECTIVES

Pediatric patients with chronic musculoskeletal conditions such as idiopathic scoliosis awaiting surgical correction can experience pain that interferes with their daily functioning. Reports of this interference are commonly gathered from patients through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale and through parent-proxy scores. However, the child and parent/caregiver reports vary. To provide appropriate treatment for young patients with pain, the nature of the discrepancies and under which circumstances the reports differ needs to be understood. This report offers new information on the level of concordance among parent and child report of pain interference within this patient population, and which parent and child characteristics may influence concordance rates.

METHODS

Youth (age=10 to 17 y) with a history of musculoskeletal disorders, including idiopathic scoliosis, under consideration for surgical correction of that scoliosis and parent/caregiver dyads (n=103) completed the PROMIS Pain Interference Scale during an orthopedic presurgical visit. The current data was taken from a larger study examining postsurgical pain among patients undergoing orthopedic surgical procedures to correct scoliosis. The purpose of the current study was to measure the degree of agreement between parent and child reports of pain interference and discovery of relationships among predictors of pain interference score correspondence among dyads.

RESULTS

Correspondence between parent/caregiver and child reports of pain interference was modest (intraclass correlation coefficient=0.530). In total, 46% of dyads had similar pain interference scores, whereas 24% of parents reported higher pain interference in comparison to their child, the remaining 30% reported lower pain interference in relation to their child's report. Among children where discrepancies appeared, using logistic regression models, only child catastrophizing scores were associated with differences in parent and child estimation of child's pain interference scores. No parental characteristics predicted discrepancies between dyad pain interference reports.

DISCUSSION

Parent-proxy and child reports generally correspond, but when discrepant, 24% of parents reported higher pain interference in relationship to the child report of pain interference and 31% noted less intense pain interference than their child's pain interference. Given these results, care should be taken when interpreting parent reports of child pain interference, especially when a child reports higher degrees of pain interference.

Acupressure to Reduce Treatment-Related Symptoms for Children With Cancer and Recipients of Hematopoietic Stem Cell Transplant: Protocol for a Randomized Controlled Trial

Background

We describe the study design and protocol of a pragmatic randomized controlled trial (RCT) Acupressure for Children in Treatment for a Childhood Cancer (ACT-CC).

Objective

To describe the feasibility and effectiveness of an acupressure intervention to decrease treatment-related symptoms in children in treatment for cancer or recipients of a chemotherapy-based hematopoietic stem cell transplant (HSCT).

Design

Two-armed RCTs with enrollment of 5 to 30 study days.

Setting

Two pediatric teaching hospitals.

Patients

Eighty-five children receiving cancer treatment or a chemotherapy-based HSCT each with 1 parent or caregiver.

Intervention

Patients are randomized 1:1 to receive either usual care plus daily professional acupressure and caregiver delivered acupressure versus usual care alone for symptom management. Participants receive up to 20 professional treatments.

Main Outcome

A composite nausea/vomiting measure for the child.

Secondary Outcomes

Child's nausea, vomiting, pain, fatigue, depression, anxiety, and positive affect.

Parent Outcomes

Depression, anxiety, posttraumatic stress symptoms, caregiver self-efficacy, and positive affect. Feasibility of delivering the semistandardized intervention will be described. Linear mixed models will be used to compare outcomes between arms in children and parents, allowing for variability in diagnosis, treatment, and age.

Discussion

Trial results could help childhood cancer and HSCT treatment centers decide about the regular inclusion of trained acupressure providers to support symptom management.

Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures

BACKGROUND

Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress.

METHODS

Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized.

RESULTS

Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred.

CONCLUSIONS

LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

Use of the PROMIS-29® to identify subgroups of mothers with chronic pain

OBJECTIVE

Children of mothers with chronic pain are at increased risk for poor health, but few studies have examined what characteristics of maternal chronic pain may be associated with children's risk. This study identified subgroups of mothers based on patterns of pain, physical function, and emotional function on the 29-item Patient-Reported Outcomes Measurement Information System® (PROMIS-29®) and evaluated associations between maternal subgroups and children's pain and emotional functioning.

METHODS

Mothers with chronic pain (n = 334) completed the PROMIS-29® and reported on pain intensity, pain interference, physical functioning, anxiety, depression, fatigue, sleep disturbance, and participation in social activities. Mothers and their school-age children also completed measures of child pain and emotional functioning.

RESULTS

Latent profile analysis of PROMIS® domains indicated a 4-class solution (Group 1: 13.5%, Group 2: 9.9%, Group 3: 43.5%, and Group 4: 32.9%). Group 4 reported the most severe pain, psychological distress, and sleep disturbances and the lowest functioning. Group 1 reported the lowest pain, psychological distress, and sleep disturbances and the highest functioning, while Groups 2 and 3 represented moderate symptoms. Groups significantly differed on maternal reports of children's pain frequency, but not intensity, and children's self-reported somatic symptoms. Further, child depressive symptoms (mother-proxy and self-reported), anxiety (mother-proxy reported), and pain catastrophizing (self-reported) differed by maternal group.

CONCLUSIONS

Patterns of maternal symptoms and functioning were associated with pain frequency and emotional symptoms in children. Further examination of individual differences in mothers with chronic pain that may confer risk for chronic pain and psychological disorders in children is warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Development of a parents' short form survey of their children's oral health

BACKGROUND

Parents play an important role in their children's oral health behaviors, provide oral health access, initiate prevention, and coping strategies for health care.

AIM

This paper develops a short form (SF) to assist parents to evaluate their children's oral health status using Patient-Reported Outcome Measurement Information System (PROMIS) framework that conceptualized health as physical, mental, and social components.

DESIGN

Surveys of parents were conducted at dental clinics in Los Angeles County, together with an on-site clinical examination by dentists to determine clinical outcomes, Children's Oral Health Status Index (COHSI), and referral recommendations (RRs). Graded response models in item response theory were used to create the SF. A toolkit including SF, demographic information, and algorithms was developed to predict the COHSI and RRs.

RESULTS

The final SF questionnaire consists of eight items. The square root mean squared error for the prediction of COHSI is 7.6. The sensitivity and specificity of using SF to predict immediate treatment needs (binary RRs) are 85% and 31%.

CONCLUSIONS

The parent SF is an additional component of the oral health evaluation toolkit that can be used for oral health screening, surveillance program, policy planning, and research of school-aged children and adolescents from guardian perspectives.

Use of the new pediatric PROMIS measures of pain and physical experiences for children with sickle cell disease

BACKGROUND

There are new pediatric domains to measure patients' pain and physical experiences in the Patient-Reported Outcomes Measurement Information System (PROMIS). The objective of this study was to establish the psychometric properties of these domains for children with sickle cell disease (SCD).

PROCEDURE

We conducted a cross-sectional analysis of PROMIS assessments of children with SCD recruited from a pediatric tertiary care clinic. Validity of the new PROMIS domains was determined by comparing scores between known groups and describing their correlations with previously validated PROMIS measures. Cronbach's alpha and item response theory (IRT) reliability were used to assess internal consistency reliability. Agreement between parent-proxy and child self-report was determined for all domains.

RESULTS

Our study included 164 subjects, of whom 117 were eligible to self-report. The mean T-scores for physical stress experience, strength impact, pain behavior, and pain quality sensory scores were significantly different between children who used pain medications in the prior week and those who did not. There were also differences in T-scores across children reporting mild, moderate, and severe pain on the pain intensity scale. All measures had Cronbach's alpha and IRT reliability > 0.80. The percentage of agreement between child and parent-proxy PROMIS domains ranged from 36% to 60% depending on the domain.

CONCLUSIONS

The new PROMIS domains of physical stress experience, strength impact, pain behavior, and pain quality sensory domains are valid and reliable for children with SCD. The low-moderate agreement between parent-proxy and child self-report scores support the complementary information provided by the two perspectives.

Quality and Correlates of Peer Relationships in Youths with Chronic Pain

Youths with chronic pain may experience difficulties with peer relationships. We investigated the quality and correlates of peer relationships in a sample of 181 youths with chronic pain. A majority of youths were satisfied with their relationships with peers; however, levels were highly variable. Higher functional impairment and depression levels predicted lower peer relationship quality, controlling for demographic and other pain-related factors. In addition, peer relationship quality and pain severity predicted child depression and anxiety symptoms, whereas peer relationship quality only predicted anger symptoms. Relationship quality moderated the association between pain severity and functional impairment, suggesting that strong relationships with peers may buffer the effects of pain on functioning. Peer relationships seem particularly important for the adjustment and psychological well-being of youths with chronic pain. Particular attention should be given to functionally impaired and depressed children, who may be at higher risk of peer difficulties.

Translation, psychometric validation, and baseline results of the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric measures to assess health-related quality of life of patients with pediatric lymphoma in Malawi

INTRODUCTION

Internationally validated tools to measure patient-reported health-related quality of life (HRQoL) are available, but efforts to translate and culturally validate such tools in sub-Saharan Africa (SSA) are scarce, particularly among children.

METHODS

The Patient-Reported Outcomes Measurement Information System 25-item pediatric short form (PROMIS-25) assesses six HRQoL domains-mobility, anxiety, depression, fatigue, peer relationships, and pain interference-by asking four questions per domain. There is a single-item pain intensity item. The PROMIS-25 was translated into Chichewa and validated for use in Malawi using mixed qualitative and quantitative methods. The validity and reliability of the PROMIS-25 was assessed.

RESULTS

Fifty-four pediatric patients with lymphoma completed the PROMIS-25. Structural validity was supported by interitem correlations and principal component analysis. Reliability of each scale was satisfactory (range alpha = 0.71-0.93). Known group validity testing showed that anemic children had worse fatigue (P = 0.016) and children with poor performance status had worse mobility (P < 0.001) and pain interference (P = 0.005). Compared to children with cancer in the United States, children from Malawi reported lower levels of mobility, higher anxiety, higher depressive symptoms, higher fatigue, better satisfaction with peer relationships, and higher pain interference.

CONCLUSION

Translation and cultural validation of the PROMIS-25 into Chichewa for Malawi was successful. Baseline HRQoL for patients with pediatric lymphoma in Malawi is poor for all domains except peer relationships. This emphasizes an urgent need to address HRQoL among children undergoing cancer treatment in SSA using self-reported instruments validated within the local context.

Agreement Between Parent Proxy Reports and Self-Reports of Adolescent Emotional Distress

Parents' recognition of adolescents' emotional distress is a significant determinant of early detection and treatment of mental disorders. However, there is dearth of research exploring parent-adolescent agreement regarding adolescents' emotional distress. This cross-sectional, school-based study compared parents' proxy reports and self-reports of adolescent's emotional distress among 289 parent-adolescent dyads in Korea. Findings revealed low agreement between adolescents' and parents' reports of depression, anxiety, and anger, with an average polychoric r of .25 to .27. The agreement was particularly low for high school students, boys, and father-adolescent dyads. Additionally, parents tended to underestimate adolescents' emotional distress symptoms; a significant percentage of adolescents experiencing symptoms were rated in the normal range by parents, particularly high school students experiencing anger. Interventions are needed to help adolescents learn to manage and express their negative emotions. Moreover, parent education programs that improve parents' recognition of emotional distress and appropriate help-seeking behaviors are needed.

Examination of psychometric properties of PROMIS®: Pediatric upper limb measures in youth with cerebral palsy

Introduction

This study examines the validity and distribution characteristics of the PROMIS® pediatric upper limb measures in a sample of young people with cerebral palsy.

Method

Data are a cross-sectional subset of a larger prospective study of the responsiveness to change of PROMIS® pediatric measures following surgery to improve functioning in young people with cerebral palsy. Ninety-three participants between the ages of eight and 21 years completed the PROMIS® pediatric mobility and upper limb computer adaptive tests and short forms in conjunction with a set of static “legacy” measures of physical functioning, including a parent-report of upper limb function.

Results

The PROMIS® Pediatric upper limb short form demonstrated acceptable internal consistency (Cronbach’s alpha = 0.85). PROMIS® pediatric upper limb computer adaptive tests and short form mean values (42.1(11) and 43(10.4), respectively) were nearly 1 SD below normal, which is appropriate when a generic measure is used in a sample of young persons with cerebral palsy. The PROMIS® pediatric upper limb computer adaptive tests had a higher frequency of ceiling effects (29.50%) compared to the short form (18.30%).

Conclusion

Results of this study suggest that the PROMIS® pediatric upper limb computer adaptive tests and the short form are valid indicators of upper limb function in young people with cerebral palsy. The item bank can be replenished to address ceiling effects.

Do Injured Adolescent Athletes and Their Parents Agree on the Athletes' Level of Psychologic and Physical Functioning?

BACKGROUND

Although a parent's perception of his or her child's physical and emotional functioning may influence the course of the child's medical care, including access to care and decisions regarding treatment options, no studies have investigated whether the perceptions of a parent are concordant with that of an adolescent diagnosed with a sports-related orthopaedic injury. Identifying and understanding the potential discordance in coping and emotional distress within the athlete adolescent-parent dyads are important, because this discordance may have negative effects on adolescents' well-being.

QUESTIONS/PURPOSES

The purposes of this study were (1) to compare adolescent and parent proxy ratings of psychologic symptoms (depression and anxiety), coping skills (catastrophic thinking about pain and pain self-efficacy), and upper extremity physical function and mobility in a population of adolescent-parent dyads in which the adolescent had a sport-related injury; and (2) to compare scores of adolescents and parent proxies with normative scores when such are available.

METHODS

We enrolled 54 dyads (eg, pairs) of adolescent patients (mean age 16 years; SD = 1.6) presenting to a sports medicine practice with sports-related injuries as well as their accompanying parent(s). We used Patient-reported Outcomes Measurement Information System questionnaires to measure adolescents' depression, anxiety, upper extremity physical function, and mobility. We used the Pain Catastrophizing Scale short form to assess adolescents' catastrophic thinking about pain and the Pain Self-efficacy Scale short form to measure adolescents' pain self-efficacy. The accompanying parent, 69% mothers (37 of 54) and 31% fathers (17 of 54), completed parent proxy versions of each questionnaire.

RESULTS

Parents reported that their children had worse scores (47 ± 9) on depression than what the children themselves reported (43 ± 9; mean difference 4.0; 95% confidence interval [CI], -7.0 to 0.91; p = 0.011; medium effect size -0.47). Also, parents reported that their children engaged in catastrophic thinking about pain to a lesser degree (8 ± 5) than what the children themselves reported (13 ± 4; mean difference 4.5; 95% CI, 2.7-6.4; p < 0.001; large effect size 1.2). Because scores on depression and catastrophic thinking were comparable to the general population, and minimal clinically important difference scores are not available for these measures, it is unclear whether the relatively small observed differences between parents' and adolescents' ratings are clinically meaningful. Parents and children were concordant on their reports of the child's upper extremity physical function (patient perception 47 ± 10, parent proxy 47 ± 8, mean difference -0.43, p = 0.70), mobility (patient perception 43 ± 9, parent proxy 44 ± 9, mean difference -0.59, p = 0.64), anxiety (patient perception 43 ± 10, parent proxy 46 ± 8, mean difference -2.1, p = 0.21), and pain self-efficacy (patient perception 16 ± 5, parent proxy 15 ± 5, mean difference 0.70, p = 0.35).

CONCLUSIONS

Parents rated their children as more depressed and engaging in less catastrophic thinking about pain than the adolescents rated themselves. Although these differences are statistically significant, they are of a small magnitude making it unclear as to how clinically important they are in practice. We recommend that providers keep in mind that parents may overestimate depressive symptoms and underestimate the catastrophic thinking about pain in their children, probe for these potential differences, and consider how they might impact medical care.

LEVEL OF EVIDENCE

Level I, prognostic study.

Family accommodation of anxiety symptoms in youth undergoing intensive multimodal treatment for anxiety disorders and obsessive-compulsive disorder: Nature, clinical correlates, and treatment response

BACKGROUND

Family accommodation is associated with a range of clinical features including symptom severity, functional impairment, and treatment response. However, most previous studies in children and adolescents investigated family accommodation in samples of youth with obsessive-compulsive disorder (OCD) or anxiety disorders receiving non-intensive outpatient services.

AIMS

In this study, we aimed to investigate family accommodation of anxiety symptoms in a sample of youth with clinical anxiety levels undergoing an intensive multimodal intervention for anxiety disorders or OCD.

PROCEDURES

We first assessed the internal consistency of the Family Accommodation Scale - Anxiety (FASA). We next examined family accommodation presentation and correlates.

RESULTS

The FASA showed high internal consistency for all subscales and total score, and good item and subscale correlations with the total score. All parents reported at least mild accommodation, and the mean levels of family accommodation were particularly high. Child age, anxiety severity, and comorbid depressive symptoms predicted baseline accommodation. However, the association between anxiety severity and family accommodation no longer remained significant after adding the other factors to the model. In addition, family accommodation partially mediated the relationship between anxiety severity and functional impairment. Finally, post-treatment changes in family accommodation predicted changes in symptom severity and functional impairment.

CONCLUSIONS

These findings suggest the FASA is an appropriate tool to assess family accommodation in intensive treatment samples. Further, they underline the importance of addressing family accommodation in this population given the particularly high levels of accommodating behaviors and the evidence for adverse outcomes associated with this feature.

Leveraging pediatric PROMIS item banks to assess physical functioning in children at risk for severe functional loss

Background

Pediatric neuromuscular illnesses often result in decreased health-related quality of life (HRQL), notably in physical functioning. Generic HRQL measures have been developed for use in general populations, but may not adequately assess patients with severe functional loss. To address this measurement gap, we created two custom parent-proxy physical functioning short forms for use among children at risk for low levels of functioning, using pediatric Patient Reported Outcomes Measurement Information System (PROMIS) item banks for Upper Extremity and Mobility.

Methods

Two custom short forms from PROMIS Upper Extremity (13 items) and Mobility (13 items) parent-proxy item banks were created and administered to parents of children (ages 5 - 22 years) enrolled in an integrated care program for management of chronic respiratory insufficiency, largely due to neuromuscular illnesses. Standardized PROMIS T-scores have a mean of 50 (SD = 10); higher scores indicate better functioning. Physicians rated clinical severity. Single proxy-rated items on mental and physical health from the Child Health Rating Inventories (CHRIs) global health scale were completed by parents. Psychometric properties, including known groups comparisons, were explored.

Results

Fifty-seven parents completed the parent-proxy custom PROMIS short forms. The mean Upper Extremity T-score was 21 (SD = 13); the mean Mobility T-score was 22 (SD = 11). Some participants scored at the measurement floor; two items on assistive devices did not perform well in this sample and were excluded from the Mobility T-score. Known groups comparisons showed that those with lower clinical severity had better median Upper Extremity (22 vs. 14, p < 0.001) and Mobility (28 vs. 16, p = 0.004) function than those with worse clinical severity. Both Upper Extremity and Mobility T-scores were higher in the subgroups defined by better physical and mental health, as measured by the CHRIs.

Conclusions

Upper Extremity and Mobility T-scores were nearly three standard deviations below the PROMIS pediatric calibration population mean. Preliminary psychometrics demonstrated the potential to more accurately measure lower physical functioning using items from PROMIS item banks. However, some participants scored at the measurement floor despite targeting items at the lower end of the scale. Further short form refinement, enrichment of the item banks, and larger-scale field testing are needed.

Comparison of pediatric self reports and parent proxy reports utilizing PROMIS: Results from a chiropractic practice-based research network

OBJECTIVE

To measure the cross-informant variant of pediatric quality of life (QoL) based on self-reports and parent proxy measures.

METHODS

A secondary analysis of baseline data obtained from two independent studies measuring the QoL based on the pediatric PROMIS-25 self-report and the PROMIS parent-proxy items banks. A scoring manual associated raw scores to a T score metric (mean = 50; SD = 10). Reliability of QoL ratings utilized the ICC while comparison of mean T Scores utilized the unpaired t-test.

RESULTS

A total of 289 parent-child dyads comprised our study responders. Average age for parents and children was 41.27 years and 12.52 years, respectively. The mean T score (child self-report: parent proxy) for each QoL domains were: mobility (50.82:52.58), anxiety (46.73:44.21), depression (45.18:43.60), fatigue (45.59:43.92), peer-relationships (52.15:52.88) and pain interference (47.47:44.80).

CONCLUSION

Parents tend to over-estimate their child's QoL based on measures of anxiety, depression, fatigue, peer-relationships and pain interference.

Patient-reported outcomes of pain and physical functioning in neurofibromatosis clinical trials

OBJECTIVE

Tumors and other disease complications of neurofibromatosis (NF) can cause pain and negatively affect physical functioning. To document the clinical benefit of treatment in NF trials targeting these manifestations, patient-reported outcomes (PROs) assessing pain and physical functioning should be included as study endpoints. Currently, there is no consensus on the selection and use of such measures in the NF population. This article presents the recommendations of the PRO group of the Response Evaluation in Neurofibromatosis and Schwannomatosis (REiNS) International Collaboration for assessing the domains of pain and physical functioning for NF clinical trials.

METHODS

The REiNS PRO group reviewed and rated existing PRO measures assessing pain intensity, pain interference, and physical functioning using their systematic method. Final recommendations are based primarily on 4 main criteria: patient characteristics, item content, psychometric properties, and feasibility for clinical trials.

RESULTS

The REiNS PRO group chose the Numeric Rating Scale-11 (≥8 years) to assess pain intensity, the Pain Interference Index (6-24 years) and the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference Scale (≥18 years) to evaluate pain interference, and the PROMIS Physical Functioning Scale to measure upper extremity function and mobility (≥5 years) for NF clinical trials.

CONCLUSIONS

The REiNS Collaboration currently recommends these PRO measures to assess the domains of pain and physical functioning for NF clinical trials; however, further research is needed to evaluate their use in individuals with NF. A final consensus recommendation for the pain interference measure will be disseminated in a future publication based on findings from additional published research.

Pediatric-Collaborative Health Outcomes Information Registry (Peds-CHOIR): a learning health system to guide pediatric pain research and treatment

The pediatric adaptation of the Collaborative Health Outcomes Information Registry (Peds-CHOIR) is a free, open-source, flexible learning health care system (LHS) that meets the call by the Institute of Medicine for the development of national registries to guide research and precision pain medicine. This report is a technical account of the first application of Peds-CHOIR with 3 aims: (1) to describe the design and implementation process of the LHS; (2) to highlight how the clinical system concurrently cultivates a research platform rich in breadth (eg, clinic characteristics) and depth (eg, unique patient- and caregiver-reporting patterns); and (3) to demonstrate the utility of capturing patient-caregiver dyad data in real time, with dynamic outcomes tracking that informs clinical decisions and delivery of treatments. Technical, financial, and systems-based considerations of Peds-CHOIR are discussed. Cross-sectional retrospective data from patients with chronic pain (N = 352; range, 8-17 years; mean, 13.9 years) and their caregivers are reported, including National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) domains (mobility, pain interference, fatigue, peer relations, anxiety, and depression) and the Pain Catastrophizing Scale. Consistent with the literature, analyses of initial visits revealed impairments across physical, psychological, and social domains. Patients and caregivers evidenced agreement in observable variables (mobility); however, caregivers consistently endorsed greater impairment regarding internal experiences (pain interference, fatigue, peer relations, anxiety, and depression) than patients' self-report. A platform like Peds-CHOIR highlights predictors of chronic pain outcomes on a group level and facilitates individually tailored treatment(s). Challenges of implementation and future directions are discussed.

Mental Health and Self-Worth in Socially Transitioned Transgender Youth

OBJECTIVE

Social transitions are increasingly common for transgender children. A social transition involves a child presenting to other people as a member of the "opposite" gender in all contexts (e.g., wearing clothes and using pronouns of that gender). Little is known about the well-being of socially transitioned transgender children. This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups: age- and gender-matched controls and siblings of transgender children.

METHOD

As part of a longitudinal study (TransYouth Project), children (9-14 years old) and their parents completed measurements of depression and anxiety (n = 63 transgender children, n = 63 controls, n = 38 siblings). Children (6-14 years old; n = 116 transgender children, n = 122 controls, n = 72 siblings) also reported on their self-worth. Mental health and self-worth were compared across groups.

RESULTS

Transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers (p = .311), and they reported marginally higher anxiety (p = .076). Compared with national averages, transgender children showed typical rates of depression (p = .290) and marginally higher rates of anxiety (p = .096). Parents similarly reported that their transgender children experienced more anxiety than children in the control groups (p = .002) and rated their transgender children as having equivalent levels of depression (p = .728).

CONCLUSION

These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. These findings lessen concerns from previous work that parents of socially transitioned children could be systematically underreporting mental health problems.

The Mental Health of Transgender Youth: Advances in Understanding

This review provides an update on the growing body of research related to the mental health of transgender youth that has emerged since the 2011 publication of the Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender people. The databases PubMed and Ovid Medline were searched for studies that were published from January 2011 to March 2016 in English. The following search terms were used: transgender, gender nonconforming, gender minority, gender queer, and gender dysphoria. Age limits included the terms youth, child, children, teenager*, and adolescen*. The combined search produced 654 articles of potential relevance. The resulting abstracts went through a tiered elimination system, and the remaining 15 articles, which presented quantitative data related to the prevalence of transgender youth and their mental health, were included in the present review. In addition to providing new estimates of the number of young people who identify as transgender (.17%-1.3%), studies since 2011 have shown that transgender youth have higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers. Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents. Recent research has demonstrated increased rates of psychiatric morbidity among transgender youth compared to their peers. Future work is needed to understand those youth who identify as gender nonbinary, improve methods to capture and understand diverse gender identities and related health disparities, and delineate the social determinants of such disparities.

Dutch-Flemish translation of nine pediatric item banks from the Patient-Reported Outcomes Measurement Information System (PROMIS)®

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS(®)) is a new, state-of-the-art assessment system for measuring patient-reported health and well-being of adults and children. It has the potential to be more valid, reliable, and responsive than existing PROMs. The items banks are designed to be self-reported and completed by children aged 8-18 years. The PROMIS items can be administered in short forms or through computerized adaptive testing. This paper describes the translation and cultural adaption of nine PROMIS item banks (151 items) for children in Dutch-Flemish.

METHODS

The translation was performed by FACITtrans using standardized PROMIS methodology and approved by the PROMIS Statistical Center. The translation included four forward translations, two back-translations, three independent reviews (at least two Dutch, one Flemish), and pretesting in 24 children from the Netherlands and Flanders.

RESULTS

For some items, it was necessary to have separate translations for Dutch and Flemish: physical function-mobility (three items), anger (one item), pain interference (two items), and asthma impact (one item). Challenges faced in the translation process included scarcity or overabundance of possible translations, unclear item descriptions, constructs broader/smaller in the target language, difficulties in rank ordering items, differences in unit of measurement, irrelevant items, or differences in performance of activities. By addressing these challenges, acceptable translations were obtained for all items.

CONCLUSION

The Dutch-Flemish PROMIS items are linguistically equivalent to the original USA version. Short forms are now available for use, and entire item banks are ready for cross-cultural validation in the Netherlands and Flanders.

Mental Health of Transgender Children Who Are Supported in Their Identities

OBJECTIVE

Transgender children who have socially transitioned, that is, who identify as the gender "opposite" their natal sex and are supported to live openly as that gender, are increasingly visible in society, yet we know nothing about their mental health. Previous work with children with gender identity disorder (GID; now termed gender dysphoria) has found remarkably high rates of anxiety and depression in these children. Here we examine, for the first time, mental health in a sample of socially transitioned transgender children.

METHODS

A community-based national sample of transgender, prepubescent children (n = 73, aged 3-12 years), along with control groups of nontransgender children in the same age range (n = 73 age- and gender-matched community controls; n = 49 sibling of transgender participants), were recruited as part of the TransYouth Project. Parents completed anxiety and depression measures.

RESULTS

Transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms.

CONCLUSIONS

Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.

Mode effects between computer self-administration and telephone interviewer-administration of the PROMIS(®) pediatric measures, self- and proxy report

OBJECTIVE

To test equivalence of scores obtained with the PROMIS(®) pediatric Depressive Symptoms, Fatigue, and Mobility measures across two modes of administration: computer self-administration and telephone interviewer-administration. If mode effects are found, to estimate the magnitude and direction of the mode effects.

METHODS

Respondents from an internet survey panel completed the child self-report and parent proxy-report versions of the PROMIS(®) pediatric Depressive Symptoms, Fatigue, and Mobility measures using both computer self-administration and telephone interviewer-administration in a crossed counterbalanced design. Pearson correlations and multivariate analysis of variance were used to examine the effects of mode of administration as well as order and form effects.

RESULTS

Correlations between scores obtained with the two modes of administration were high. Scores were generally comparable across modes of administration, but there were some small significant effects involving mode of administration; significant differences in scores between the two modes ranged from 1.24 to 4.36 points.

CONCLUSIONS

Scores for these pediatric PROMIS measures are generally comparable across modes of administration. Studies planning to use multiple modes (e.g., self-administration and interviewer-administration) should exercise good study design principles to minimize possible confounding effects from mixed modes.

Chronic Pain Assessment Tools for Cerebral Palsy: A Systematic Review

BACKGROUND AND OBJECTIVE

Chronic pain in children with cerebral palsy (CP) is underrecognized, leading to detriments in their physical, social, and mental well-being. Our objective was to identify, describe, and critique pediatric chronic pain assessment tools and make recommendations for clinical use for children with CP. Secondly, develop an evidence-informed toolbox to support clinicians in the assessment of chronic pain in children with disabilities.

METHODS

Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, and Embase databases were systematically searched by using key terms "chronic pain" and "clinical assessment tool" between January 2012 and July 2014. Tools from multiple pediatric health conditions were explored contingent on inclusion criteria: (1) children 1 to 18 years; (2) assessment focus on chronic pain; (3) psychometric properties reported; (4) written in English between 1980 and 2014. Pediatric chronic pain assessment tools were extracted and corresponding validation articles were sought for review. Detailed tool descriptions were composed and each tool underwent a formal critique of psychometric properties and clinical utility.

RESULTS

Of the retrieved 2652 articles, 250 articles met eligibility, from which 52 chronic pain assessment tools were retrieved. A consensus among interprofessional working group members determined 7 chronic pain interference tools to be of importance. Not all tools have been validated with children with CP nor is there 1 tool to meet the needs of all children experiencing chronic pain.

CONCLUSIONS

This study has systematically reviewed and recommended, through expert consensus, valid and reliable chronic pain interference assessment tools for children with disabilities.

Item-level informant discrepancies between children and their parents on the PROMIS(®) pediatric scales

OBJECTIVE

The study objective was to describe the individual item-level discrepancies between children ages 8-17 years and their parents for the PROMIS(®) pediatric scales. Contextual effects on item-level informant discrepancies for the pediatric pain interference items were further analyzed conditional on whether the child, the parent, or anyone else in the household experienced chronic pain.

METHODS

Parallel pediatric self-report and parent proxy-report items were completed by approximately 300 parent-child dyads depending on form assignment and individual nonresponse. Agreement between parent and child responses to individual items was measured using the polychoric correlation coefficient and weighted κ. The Chi-square test of symmetry was utilized for a comparison of the pattern of parent-child item discrepancies on the response scales, and the differences between the child and parent responses on the 1-5 item response scale are summarized .

RESULTS

A continuum of higher item-level parent-child discrepancies was demonstrated starting with peer relationships, anger, anxiety, and depressive symptoms, followed by progressively lower parent-child discrepancies for energy, fatigue, asthma impact, pain interference, upper extremity, and mobility items. Parent-child discrepancies for pain interference items were lower in the context of chronic pain either in the child or in the parent.

CONCLUSIONS

Parent-child item-level discrepancies were lower for more objective or visible items than for items measuring internal states or less observable items measuring latent variables such as peer relationships and fatigue. Future research should focus on the child and parent characteristics that influence domain-specific item-level discrepancies, and under what conditions item-level parent-child discrepancies predict child health outcomes.

Pediatric quality of life in children with otolaryngologic disease: what inventories are available and what is still needed?

PURPOSE OF REVIEW

Quality of life (QOL) is an important patient-oriented outcome in common disorders, particularly when one management strategy is not clearly superior to an alternative. This article reviews the recently published literature that evaluated QOL in children with common pediatric otolaryngologic problems.

RECENT FINDINGS

Among the 41 reviewed articles that used QOL as an outcome, 14 disease-specific QOL surveys and 12 generic QOL questionnaires were used. QOL instruments that had been validated in adults were frequently used in children without validation in pediatric populations. For children, parent-reported outcomes of caregiver concerns are often used as proxy measures of QOL for the child, and only a few QOL instruments asked the child to rate their own perception of their QOL. Several studies used nonvalidated QOL surveys as outcomes.

SUMMARY

QOL is being evaluated in an increasing number of pediatric otolaryngologic disorders. Although there are numerous surveys to measure generic pediatric QOL, validated disease-specific surveys for children are less common, especially those that utilize child self-report. The lack of disease-specific pediatric surveys for otolaryngologic disorders hampers the ability to document change or differences in patient-oriented outcomes with interventions.

Caregiver Quality of Life Is Related to Severity of Otitis Media in Children

OBJECTIVE

Otitis media (OM) in children is the most frequent reason for physician visits in developed countries and burdens caregivers, society, and the child. Our objective was to describe the impact of OM severity on parent/caregiver quality of life (QoL).

STUDY DESIGN

Multi-institutional prospective cross-sectional study.

SETTING

Otolaryngology, family, and pediatric practices.

SUBJECTS AND METHODS

Children 6 to 24 months old with and without a primary diagnosis of recurrent OM and their caregivers. Physicians provided patient history, and parents/caregivers completed a Family Information Form, the PedsQL Family Impact survey, the Patient Reported Outcomes Measurement Information System (PROMIS) survey, and the OM 6-item severity survey (OM-6).

RESULTS

A total of 2413 subjects were enrolled and data from 1208 patients and physician were analyzed. The average child age was 16 months, and 54% were male. The mean OM-6 score was 3.2. The mean PedsQL Family Impact score for parents was 66.9 from otolaryngology sites and 78.8 from pediatrics/family practice sites (P < .001). Higher (worse) OM-6 scores correlated significantly with worse PedsQL Family Impact scores (Pearson r = -0.512, P < .01). Similarly, increasing OM-6 scores strongly correlated with increased parental anxiety, depression, and fatigue, as well as decreased satisfaction (all P < .01).

CONCLUSIONS

Worse PedsQL Family Impact and PROMIS scores were highly correlated with elevated OM-6 scores, suggesting that severity of childhood OM significantly affects parent/caregiver QoL. Understanding the impact of a child's illness on parent/caregiver QoL can help physicians counsel patients and families and provide better family-centered, compassionate care.

Lack of physician-patient communication as a key factor associated with malpractice litigation in neonatal brachial plexus palsy

OBJECT

Perinatal disorders are prone to malpractice litigation. Neonatal brachial plexus palsy (NBPP) results from stretching the nerves in the perinatal period and may lead to paresis or paralysis and sensory loss in the affected arm. Little is known about the key factors associated with malpractice litigation by families of patients with NBPP and whether these factors reflect the practice environment or are inherent to the condition. In this study, the authors documented the percentage of families of NBPP patients at a specialty center that had filed a malpractice suit and described the key factors associated with that pursuit of legal action.

METHODS

The families/caregivers of 51 patients with NBPP who had presented to the University of Michigan Interdisciplinary Brachial Plexus Program participated in this study. A qualitative research design was applied using both a questionnaire to examine psychosocial factors and a dynamic tool to measure health outcomes from the patient perspective via parent proxy (Patient-Reported Outcomes Measurement Information System [PROMIS] assessment instruments). Statistical analysis included the Fisher exact test, chi-square test, and Student t-test. The study protocol was approved by the University of Michigan institutional review board.

RESULTS

Forty-seven percent of the families pursued malpractice litigation. In comparing patient families that had pursued legal action with those that had not, significant differences were revealed in the perception that the sustained birth injury was unnecessary (p = 0.002), the information received in the perinatal period was inadequate (p = 0.003), family concerns were ignored in the perinatal period (p = 0.005), and family concerns were not adequately addressed (p < 0.001). Sixty-six percent of the families received external advice to pursue legal action. The PROMIS survey revealed significant group differences in depressive symptoms (p = 0.008), fatigue (p = 0.02), pain (p = 0.01), and anger (p = 0.004). In contrast, the extent of NBPP was not associated with malpractice litigation (p = 0.18). Age, sex, and race were not significantly different between litigation and nonlitigation groups.

CONCLUSIONS

Physician-controllable factors, such as communication in the perinatal period, are associated with malpractice litigation in NBPP. The perceived level of global disability may affect the pursuit of malpractice litigation, whereas the isolated extent of nerve root involvement and/or upper extremity dysfunction are not significant factors in pursuing litigation. Identifying and ameliorating these factors within the practice environment may decrease the animosity between families and health care providers and improve overall outcome for patients with NBPP.

PROMIS Pediatric Peer Relationships Scale: development of a peer relationships item bank as part of social health measurement

OBJECTIVE

This study's objective was to develop a measure of social health using item response theory as part of the Patient Reported Outcomes Measurement Information System (PROMIS).

METHODS

After candidate items were generated from review of prior literature, focus groups, expert input, and cognitive interviews, items were administered to youth aged 8-17 as part of the PROMIS pediatric large scale testing. Exploratory and confirmatory factor analyses were used to assess dimensionality and to identify instances of local dependence. Items that met the unidimensionality criteria were subsequently calibrated using Samejima's Graded Response Model. Differential item functioning was examined by gender and age.

RESULTS

The sample included 3,048 youth who completed the questionnaire (51.8% female, 60% white, and 22.7% with chronic illness). The initial conceptualization of social function and sociability did not yield unidimensional item banks. Rather, factor analysis revealed dimensions contrasting peer relationships and adult relationships. The analysis also identified dimensions formed by responses to positively versus negatively worded items. The resulting 15-item bank measures quality of peer relationships and has strong psychometric characteristics as a full bank or an 8-item short form.

CONCLUSIONS

The PROMIS pediatric peer relationships scale demonstrates good psychometric characteristics and addresses an important aspect of child health.

PROMIS® Parent Proxy Report Scales for children ages 5-7 years: an item response theory analysis of differential item functioning across age groups

OBJECTIVE

The objective of the present study is to describe the extension of the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS(®)) pediatric parent proxy-report item banks for parents of children ages 5-7 years, and to investigate differential item functioning (DIF) between the data obtained from parents of 5-7-year-old children with the data obtained from parents of 8-17 year-old children in the original construction of the scales.

METHODS

Item response theory (IRT) analyses of DIF were conducted comparing data from the 5-7 age group with data from the established scales for ages 8-17 across 5 generic health domains (physical functioning, pain, fatigue, emotional health, and social health) and asthma.

RESULTS

IRT DIF analyses revealed that the majority of the items functioned similarly with responses from parents of younger and older children. A small number of items were removed from the item bank for younger children, and a few items that exhibited statistical DIF were retained in the pools with the caveat that they should not be used in studies that involve comparisons of younger children with older children.

CONCLUSIONS

The study confirms that most of the items in the PROMIS parent proxy-report item banks can be used with parents of children ages 5-7. It is anticipated that these new scales will have application for younger pediatric populations when pediatric self-report is not feasible.

Using Rasch rating scale model to reassess the psychometric properties of the Persian version of the PedsQL™ 4.0 Generic Core Scales in school children

BACKGROUND

Item response theory (IRT) is extensively used to develop adaptive instruments of health-related quality of life (HRQoL). However, each IRT model has its own function to estimate item and category parameters, and hence different results may be found using the same response categories with different IRT models. The present study used the Rasch rating scale model (RSM) to examine and reassess the psychometric properties of the Persian version of the PedsQL™ 4.0 Generic Core Scales.

METHODS

The PedsQL™ 4.0 Generic Core Scales was completed by 938 Iranian school children and their parents. Convergent, discriminant and construct validity of the instrument were assessed by classical test theory (CTT). The RSM was applied to investigate person and item reliability, item statistics and ordering of response categories.

RESULTS

The CTT method showed that the scaling success rate for convergent and discriminant validity were 100% in all domains with the exception of physical health in the child self-report. Moreover, confirmatory factor analysis supported a four-factor model similar to its original version. The RSM showed that 22 out of 23 items had acceptable infit and outfit statistics (<1.4, >0.6), person reliabilities were low, item reliabilities were high, and item difficulty ranged from -1.01 to 0.71 and -0.68 to 0.43 for child self-report and parent proxy-report, respectively. Also the RSM showed that successive response categories for all items were not located in the expected order.

CONCLUSIONS

This study revealed that, in all domains, the five response categories did not perform adequately. It is not known whether this problem is a function of the meaning of the response choices in the Persian language or an artifact of a mostly healthy population that did not use the full range of the response categories. The response categories should be evaluated in further validation studies, especially in large samples of chronically ill patients.

Development of six PROMIS pediatrics proxy-report item banks

Background

Pediatric self-report should be considered the standard for measuring patient reported outcomes (PRO) among children. However, circumstances exist when the child is too young, cognitively impaired, or too ill to complete a PRO instrument and a proxy-report is needed. This paper describes the development process including the proxy cognitive interviews and large-field-test survey methods and sample characteristics employed to produce item parameters for the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric proxy-report item banks.

Methods

The PROMIS pediatric self-report items were converted into proxy-report items before undergoing cognitive interviews. These items covered six domains (physical function, emotional distress, social peer relationships, fatigue, pain interference, and asthma impact). Caregivers (n = 25) of children ages of 5 and 17 years provided qualitative feedback on proxy-report items to assess any major issues with these items. From May 2008 to March 2009, the large-scale survey enrolled children ages 8-17 years to complete the self-report version and caregivers to complete the proxy-report version of the survey (n = 1548 dyads). Caregivers of children ages 5 to 7 years completed the proxy report survey (n = 432). In addition, caregivers completed other proxy instruments, PedsQL™ 4.0 Generic Core Scales Parent Proxy-Report version, PedsQL™ Asthma Module Parent Proxy-Report version, and KIDSCREEN Parent-Proxy-52.

Results

Item content was well understood by proxies and did not require item revisions but some proxies clearly noted that determining an answer on behalf of their child was difficult for some items. Dyads and caregivers of children ages 5-17 years old were enrolled in the large-scale testing. The majority were female (85%), married (70%), Caucasian (64%) and had at least a high school education (94%). Approximately 50% had children with a chronic health condition, primarily asthma, which was diagnosed or treated within 6 months prior to the

interview. The PROMIS proxy sample scored similar or better on the other proxy instruments compared to normative samples.

Conclusions

The initial calibration data was provided by a diverse set of caregivers of children with a variety of common chronic illnesses and racial/ethnic backgrounds. The PROMIS pediatric proxy-report item banks include physical function (mobility n = 23; upper extremity n = 29), emotional distress (anxiety n = 15; depressive symptoms n = 14; anger n = 5), social peer relationships (n = 15), fatigue (n = 34), pain interference (n = 13), and asthma impact (n = 17).