Determining patient needs: A partnership with South Carolina Advocates for Epilepsy (SAFE)

PURPOSE

The purpose of this study was to collaborate with a community partner to administer a current needs assessment of persons with epilepsy (PWE) and determine the types of resources that PWE would like to access through the community partner.

METHODS

A self-report needs assessment survey was administered to caregivers and PWE across the state of South Carolina during a community partner educational workshop (n=20) and via secure software distributed through an email link (n=54).

KEY FINDINGS

The most frequently reported challenges (>50%) were concerns about finding time to participate in epilepsy community activities, the personal safety of the PWE, finding social connections or social support, finding mental or behavioral health services, and work concerns. However, top ranked concerns centered on personal safety (27.8%), lack of insurance/not enough money to pay for epilepsy treatment (15.3%), and difficulty with daily management of epilepsy (13.9%). Participants reported likely engagement with the epilepsy community partner via in-person meetings, over the phone, and through social media contacts; however, there were differences between PWE and caregivers regarding preferences for communication. Almost 60% endorsed that they would likely participate in a brief program to learn skills to manage their epilepsy daily.

SIGNIFICANCE

Persons with epilepsy in South Carolina continue to have many unmet needs and would access resources, if available, from a state-wide epilepsy community partner via various modes of communication.

Psychometric validation of the Pediatric Symptom Checklist-17 in a pediatric population with epilepsy: A methods study

OBJECTIVE

The purpose of this study was to address critical gaps in behavioral health care of youth with epilepsy by examining the utility of a brief, well-validated screening instrument, the PSC-17, in a pediatric population with epilepsy.

METHOD

One hundred eighty-seven caregivers of youth with epilepsy ages 2-17years completed the PSC-17 for their child/adolescent during a routine epilepsy visit. Demographic and seizure information was abstracted from electronic medical record review.

RESULTS

Confirmatory factor analyses for the PSC-17 revealed an acceptable fit with the 3-factor model, χ(2) (116 [N=187]=204.54, p<0.001, CFI=0.90, TLI=0.88, RMSEA=0.064, SRMSR=0.078). Scale level reliabilities were excellent (0.72-0.85). Interscale correlations were moderate (0.48-0.69). Approximately 1/5th of the sample met clinical cut-offs for the total score of behavioral health concerns. However, an additional 20% of the sample had at least one elevated subscale score despite the total score being in the normative/nonclinical range.

SIGNIFICANCE

The PSC-17 is a brief, free behavioral health screening tool with adequate to strong validity, reliability, and clinical utility for pediatric populations with epilepsy. Clinicians should consider using the 3 PSC-17 subscale scores instead of the total score to guide referrals for further evaluation as the subscales may provide a more accurate picture of functioning in particular domains.

Psychological Interventions for Vaccine Injections in Children and Adolescents: Systematic Review of Randomized and Quasi-Randomized Controlled Trials

BACKGROUND

This systematic review evaluated the effectiveness of psychological interventions for reducing vaccination pain and related outcomes in children and adolescents.

DESIGN/METHODS

Database searches identified relevant randomized and quasi-randomized controlled trials. Data were extracted and pooled using established methods. Pain, fear, and distress were considered critically important outcomes.

RESULTS

Twenty-two studies were included; 2 included adolescents. Findings showed no benefit of false suggestion (n=240) for pain (standardized mean difference [SMD] -0.21 [-0.47, 0.05]) or distress (SMD -0.28 [-0.59, 0.11]), or for use of repeated reassurance (n=82) for pain (SMD -0.18 [-0.92, 0.56]), fear (SMD -0.18 [-0.71, 0.36]), or distress (SMD 0.10 [-0.33, 0.54]). Verbal distraction (n=46) showed reduced distress (SMD -1.22 [-1.87, -0.58]), but not reduced pain (SMD -0.27 [-1.02, 0.47]). Similarly, video distraction (n=328) showed reduced distress (SMD -0.58 [-0.82, -0.34]), but not reduced pain (SMD -0.88 [-1.78, 0.02]) or fear (SMD 0.08 [-0.25, 0.41]). Music distraction demonstrated reduced pain when used with children (n=417) (SMD -0.45 [-0.71, -0.18]), but not with adolescents (n=118) (SMD -0.04 [-0.42, 0.34]). Breathing with a toy (n=368) showed benefit for pain (SMD -0.49 [-0.85, -0.13]), but not fear (SMD -0.60 [-1.22, 0.02]); whereas breathing without a toy (n=136) showed no benefit for pain (SMD -0.27 [-0.61, 0.07]) or fear (SMD -0.36 [-0.86, 0.15]). There was no benefit for a breathing intervention (cough) in children and adolescents (n=136) for pain (SMD -0.17 [-0.41, 0.07]).

CONCLUSIONS

Psychological interventions with some evidence of benefit in children include: verbal distraction, video distraction, music distraction, and breathing with a toy.

Psychosocial Interventions Pre and Post Bariatric Surgery

Despite positive results overall, a substantial number of patients experience poor long-term outcomes following bariatric surgery. One reason for variability in weight loss may be difficulty in making and sustaining changes in dietary intake and physical activity; post-surgery binge eating has also been associated with poorer weight outcomes. In this paper, we review available evidence on adjunctive psychosocial interventions for bariatric surgery patients. Although the literature is limited, evidence suggests that bariatric surgery patients may benefit from a comprehensive approach targeting diet, activity and psychological factors. We think the optimal time to initiate adjunctive intervention is after surgery, but before significant weight regain has occurred. Adaptive interventions incorporating advances in technology may prove to be effective for promoting behavioural self-management and psychosocial adjustment following bariatric surgery. For some patients, pharmacotherapy and reoperation may also play a role in a personalized approach to post-surgery care.

Behavioral predictors of medication adherence trajectories among youth with newly diagnosed epilepsy

OBJECTIVE

This study aimed to identify psychosocial predictors of two-year antiepileptic drug (AED) adherence trajectories among youth with newly diagnosed epilepsy, controlling for known demographic and medical factors.

METHOD

This study is part of a large, prospective, longitudinal observational study of AED adherence and medical outcomes in youth with newly diagnosed epilepsy. Parents completed questionnaires of psychosocial and family functioning at one month and one year following diagnosis. Chart review and questionnaires were used to collect medical variables and seizure outcomes. Previously established two-year AED adherence trajectories (Severe Early Nonadherence, Variable Nonadherence, Moderate Nonadherence, High Adherence) were used as the outcome variable.

RESULTS

Participants were 91 parents of youth with epilepsy (7.3±2.8years of age; 60% male) and their families. Early (one month following diagnosis) predictors of two-year adherence trajectories included socioeconomic status, epilepsy knowledge, family problem-solving, and family communication. Significant predictors one year following diagnosis included socioeconomic status, parent fears and concerns, and parent life stress.

CONCLUSION

There are modifiable parent and family variables that predict two-year adherence trajectories above and beyond known medical (e.g., seizures, side effects) factors. Psychosocial interventions delivered at key points during the course of epilepsy treatment could have a positive impact on adherence outcomes.

Obesity in Childhood Cancer Survivors: Call for Early Weight Management

A high prevalence of obesity and cardiometabolic conditions has been increasingly recognized in childhood cancer survivors. In particular, survivors of pediatric acute lymphoblastic leukemia have been found to be at risk of becoming overweight or obese early in treatment, with increases in weight maintained throughout treatment and beyond. Nutrition plays an important role in the etiology of obesity and cardiometabolic conditions and is among the few modifiable factors that can prevent or delay the early onset of these chronic conditions. However, nutritional intake in childhood cancer survivors has not been adequately examined and the evidence is built on data from small cohorts of survivors. In addition, the long-term impact of cancer diagnosis and treatment on survivors' nutritional intake as well as how survivors' nutritional intake is associated with chronic health conditions have not been well quantified in large-scale studies. Promoting family-based healthy lifestyles, preferably at a sensitive window of unhealthy weight gain, is a priority for preventing the early onset of obesity and cardiometabolic conditions in childhood cancer survivors.

Systematic Review: A Reevaluation and Update of the Integrative (Trajectory) Model of Pediatric Medical Traumatic Stress

OBJECTIVE

The objective of this systematic review is to reevaluate and update the Integrative Model of Pediatric Medical Traumatic Stress (PMTS; Kazak et al., 2006), which provides a conceptual framework for traumatic stress responses across pediatric illnesses and injuries.

METHODS

Using established systematic review guidelines, we searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and PubMed (producing 216 PMTS papers published since 2005), extracted findings for review, and organized and interpreted findings within the Integrative Model framework.

RESULTS

Recent PMTS research has included additional pediatric populations, used advanced longitudinal modeling techniques, clarified relations between parent and child PMTS, and considered effects of PMTS on health outcomes. Results support and extend the model's five assumptions, and suggest a sixth assumption related to health outcomes and PMTS.

CONCLUSIONS

Based on new evidence, the renamed Integrative Trajectory Model includes phases corresponding with medical events, adds family-centered trajectories, reaffirms a competency-based framework, and suggests updated assessment and intervention implications.

Comparison of childhood cancer survivors' nutritional intake with US dietary guidelines

BACKGROUND

Despite improved survival, childhood cancer survivors experience significantly elevated risk of premature mortality and serious morbidity due to chronic health conditions. Poor diet quality can exacerbate chronic health conditions in the survivors but their nutritional intake has not been adequately studied.

PROCEDURE

We assessed the Healthy Eating Index 2010 (HEI-2010) in 22 survivors of pediatric acute lymphoblastic leukemia and lymphoma (median age = 11.7 years) and compared survivors' dietary intake to the 2010 Dietary Guidelines for Americans. Dietary data were collected using repeated 24 hr dietary recalls over a 1-year period, which were averaged to estimate habitual intake.

RESULTS

The mean HEI-2010 in childhood cancer survivors was 52.7, about 50 percent of the maximum score. Long-term survivors (time from diagnosis ≥10 years) had a significantly lower HEI-2010 than recent survivors (time from diagnosis <5 years) (β = -11.5, 95% CI: -22.1, -0.9, P = 0.047). For individual food groups and nutrients, survivors had a particularly poor adherence to green vegetables and beans, total vegetables, and whole fruits. None of the survivors met the guidelines for dietary fiber and potassium intake. Only 4%, 19%, 24%, and 29% met the guidelines for vitamin D, sodium, calcium, and saturated fat intake. The average intake in relative to the recommended intake was 32% for vitamin D, 50% for potassium, 63% for fiber, and 85% for calcium, but was 115% for saturated fat and 143% for sodium.

CONCLUSIONS

Childhood cancer survivors, in particular long-term survivors, have a poor adherence to the US dietary guidelines.

Growth patterns during and after treatment in patients with pediatric ALL: A meta-analysis

BACKGROUND

Survivors of pediatric acute lymphoblastic leukemia (ALL) have a significantly higher body mass index (BMI) than their peers. Understanding the critical time periods in which patients with pediatric ALL are vulnerable to unhealthy weight gain will lay the groundwork for developing effectively timed interventions.

PROCEDURE

We determined the growth patterns of patients with pediatric ALL during and after treatment through the conduct of a systematic review and meta-analysis. A search of MEDLINE, Scopus, and Web of Science was performed from its inception through May 2014. Studies met the inclusion criteria if they included at least 10 patients of pediatric ALL, and longitudinally assessed BMI at diagnosis and at least one time point after diagnosis

RESULTS

Twenty-one studies met the inclusion criteria for the systematic review and 16 were included in meta-analysis. The mean increase in BMI z-score during treatment in 1,514 patients with pediatric ALL was 0.81 (95% CI: 0.25-1.38). Specifically, patients experienced substantial weight gain in early treatment (Δ = 0.41, 95% CI: -0.34, 1.17) and again during maintenance (Δ = 0.34, 95% CI:-0.22, 0.90). The mean increase in BMI z-score ranged between 0.52 and 0.89 beyond treatment completion. Subgroup analyses found unhealthy weight gain occurred regardless of patients' receipt of cranial radiation therapy, sex, and, weight status at diagnosis.

CONCLUSIONS

Patients with pediatric ALL experience unhealthy weight gain early in treatment, and increases in weight are maintained beyond treatment completion. Preventing early onset of obesity is a priority for improving the care and outcomes for patients with pediatric ALL.

Health care charges for youth with newly diagnosed epilepsy

OBJECTIVES

To estimate first-year health care charges for youth with newly diagnosed epilepsy seen within an interdisciplinary pediatric epilepsy team and examine demographic, clinical, and psychosocial predictors of annual charges.

METHODS

Retrospective chart review was conducted to extract medical, hospital, and physician billing data from the year following an epilepsy diagnosis for 258 patients (aged 2-18 years) seen in a New Onset Seizure Clinic between July 2011 and December 2012. Descriptive statistics were used to estimate per-patient total first-year charges and health care utilization patterns (e.g., hospitalizations, emergency department visits, outpatient visits). Univariate analyses examined differences in health care charges between demographic, clinical, and psychosocial factors. Predictors of health care charges were examined using hierarchical multiple regression analysis.

RESULTS

The estimated per-patient total first-year health care charge was $20,084 (95% confidence interval [CI] $16,491-$23,677). Charges were higher for patients who reported having seizures since diagnosis ($25,509; 95% CI $20,162-$30,856) and were associated with more antiepileptic drug side effects (r = 0.18; 95% CI 0.03-0.32). Controlling for demographic and clinical factors, poorer baseline health-related quality of life was associated with higher per-patient health care charges (B = -445.40; 95% CI -865 to -25).

CONCLUSIONS

The economic impact of pediatric epilepsy in the year following diagnosis is substantial. Cost reduction efforts would be optimized by improving seizure control and targeting health-related quality of life, an outcome amenable to behavioral intervention.

Healthcare Reform and Preparing the Future Clinical Child and Adolescent Psychology Workforce

The healthcare environment is undergoing important changes for both patients and providers, in part due to the Patient Protection and Affordable Care Act (ACA). Ultimately the healthcare delivery system will function very differently by the end of this decade. These changes will have important implications for the education, training, scientific inquiry, and practice of clinical child and adolescent psychologists. In this article we provide a brief description of the fundamental features of the ACA, with a specific focus on critical components of the act that have important, specific implications for clinical child and adolescents psychologists. We then provide recommendations to help position our field to thrive in the evolving healthcare environment to help facilitate further awareness and promote discussion of both challenges and opportunities that face our field in this evolving health care environment.

Systematic Review on Intensive Interdisciplinary Pain Treatment of Children With Chronic Pain

BACKGROUND AND OBJECTIVE

Pediatric debilitating chronic pain is a severe health problem, often requiring complex interventions such as intensive interdisciplinary pain treatment (IIPT). Research is lacking regarding the effectiveness of IIPT for children. The objective was to systematically review studies evaluating the effects of IIPT.

METHODS

Cochrane, Medline/Ovid, PsycInfo/OVID, PubMed, PubPsych, and Web of Science were searched. Studies were included if (1) treatment was coordinated by ≥3 health professionals, (2) treatment occurred within an inpatient/day hospital setting, (3) patients were <22 years, (4) patients experienced debilitating chronic pain, (5) the study was published in English, and (6) the study had ≥10 participants at posttreatment. The child's pain condition, characteristics of the IIPT, and 5 outcome domains (pain intensity, disability, school functioning, anxiety, depressive symptoms) were extracted at baseline, posttreatment, and follow-up.

RESULTS

One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta-analysis was conducted separately on pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive symptoms. The positive effects were maintained at short-term follow-up. Findings demonstrated extreme heterogeneity.

CONCLUSIONS

Effects in nonrandomized treatment studies cannot be attributed to IIPT alone. Because of substantial heterogeneity in measures for school functioning and anxiety, meta-analyses could not be computed. There is preliminary evidence for positive treatment effects of IIPT, but the small number of studies and their methodological weaknesses suggest a need for more research on IIPTs for children.

Family Beliefs and Interventions in Pediatric Pain Management

Whether a child has to endure a procedure that incurs acute pain or a child has chronic pain, the impact on the family, especially parents, can be profound. Parents need to be active members of their child's health care team; however, they are often ill equipped to cope with either acute pain stressors or longstanding chronic pain in their children. This article provides an overview of acute and chronic pain, the impact of parent factors on pediatric pain, parental assessments of parent functioning, and parent-based interventions for pediatric pain management. Case examples are used to illustrate the treatments presented.

Lessons Learned From a Randomized Controlled Trial of a Family-Based Intervention to Promote School Functioning for School-Age Children With Sickle Cell Disease

OBJECTIVE

Tested a family-based group problem-solving intervention, "Families Taking Control," (FTC) to improve school functioning and health-related quality of life (HRQL) for children with sickle cell disease.

METHOD

Children and caregivers completed questionnaires assessing HRQL and school functioning and children completed performance-based measures of IQ and achievement at baseline and 6 months later. Families were randomized to the intervention (FTC, n = 42) or delayed intervention control (DIC, n = 41) group. FTC involved a full-day workshop followed by 3 booster calls.

RESULTS

There were no differences between FTC completers (n = 24) and noncompleters (n = 18). FTC group (n = 24) and DIC group (n = 38) did not differ significantly on primary outcomes at follow-up: number of formal academic and disease-related accommodations, individualized education plan/504 service plan, school absences, school HRQL, or academic skills.

CONCLUSIONS

Although families found FTC to be acceptable, there were no intervention effects. Challenges of the trial and implications for future research are discussed.

Cognitive mediators of treatment outcomes in pediatric functional abdominal pain

OBJECTIVES

Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain.

MATERIALS AND METHODS

Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children.

RESULTS

Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents' solicitous responses to their child's pain symptoms. Reductions in parents' perceived threat regarding their child's pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children's catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes.

DISCUSSION

Results suggest that reductions in reports of children's pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

Comparing Self-Reported Infant Safe Sleep From Community- and Health Care–Based Settings

Objective: To compare self-reported safe sleep data from a community social service agency and primary care centers. Design, Settings, and Participants: Cross-sectional Pregnancy Risk Assessment Monitoring System (PRAMS)–based survey data from a community social service agency and survey data from primary care centers were compared using descriptive statistics. There were 166 community survey respondents, average age of 25 years (SD = 5.4 years), and 79 primary care center respondents, average age of 24 years (SD = 5.4 years). Two binary logistic regressions were performed to examine the association between demographic differences and safe sleep position/bed sharing. Results: Safe sleep position responses did not differ significantly between the community-based (n = 126, 85%) and primary care center–based (n = 62, 79%) samples, χ2(1) = 0.79, P = .372. Reported bed sharing was significantly higher in the community sample (n = 54, 36%) than the health care center sample (n = 4, 5%), Fisher’s exact test, P< .001. Black race was determined to be significantly associated with increased unsafe sleep positioning (OR = 2.86, P = .022). The community center cohort was the only significant predictor of bed sharing (OR = 25.40, P = .002). Conclusion:Differences in reported safe sleep environments may be due to knowledge variances of safe sleep guidelines, or clinic-based respondents may have been more likely to provide socially desirable responses. The comparison data further highlight the need for continued targeted effort to improve safe sleep behaviors to improve infant health outcomes.

Technology-assisted Interventions for Parents of Young Children: Emerging Practices, Current Research, and Future Directions

Technology can potentially expand the reach and cut the costs of providing effective, evidence-based interventions. This paper reviews existing publications that describe the application and evaluation of technology-assisted interventions for parents of young children. A broad review of the early childhood literature revealed 48 studies describing technology-assisted parent education and interventions. Across these studies, multiple forms of technology were used, including web-based platforms, discussion forums, mobile devices, and video conferencing. Results are described moving from feasibility and acceptability of technology-based delivery systems to more rigorous evaluations examining their impact on parent and child outcomes. Potential exists for technology to deliver interventions to parents. Limitations are discussed including differential acceptability and elevated attrition associated with internet-only intervention delivery.

Costs of Development and Maintenance of an Internet Program for Teens with Type 1 Diabetes

Many adolescents with type 1 diabetes (T1D) have difficulty completing self-management tasks within the context of their social environments. Group-based approaches to psycho-educational support have been shown to prevent declines in glucose control, but are challenging to implement due to youths' many activities and costs. A novel solution is providing psycho-educational support via the internet. The purpose of this study is to describe the cost of developing and maintaining two internet psycho-educational programs, both of which have been shown to improve health outcomes in adolescents with T1D. We calculated actual costs of personnel and programming in the development of TEENCOPE^™ and Managing Diabetes, two highly interactive programs that were evaluated in a multi-site clinical trial (n=320). Cost calculations were set at U.S. dollars and converted to value for 2013 as expenses were incurred over 6 years. Development costs over 1.5 years totaled $324,609, with the majority of costs being for personnel to develop and write content in a creative and engaging format, to get feedback from teens on content and a prototype, and IT programming. Maintenance of the program, including IT support, a part-time moderator to assure safety of the discussion board (0.5-1 hour/week), and yearly update of content was $43,845/year, or $137.00 per youth over 4.5 years. Overall, program and site development were relatively expensive, but the program reach was high, including non-white youth from 4 geographically distinct regions. Once developed, maintenance was minimal. With greater dissemination, cost-per-youth would decrease markedly, beginning to offset the high development expense.

Non-adherence in children with asthma reviewed: The need for improvement of asthma care and medical education

Adherence to daily inhaled corticosteroid therapy is a key determinant of asthma control. Therefore, improving adherence to inhaled corticosteroids is the most effective method through which healthcare providers can help children with uncontrolled asthma. However, identifying non-adherent patients is difficult, and electronic monitoring is the only reliable method to assess adherence. (Non-)adherence is a complex behavioural process influenced by many interacting factors. Intentional barriers to adherence are common; driven by illness perceptions and medication beliefs, patients and parents deliberately choose not to follow the doctor's recommendations. Common non-intentional barriers are related to family routines, child-raising issues, and to social issues such as poverty. Effective interventions improving adherence are complex, because they take intentional and non-intentional barriers to adherence into account. There is evidence that comprehensive, guideline-based asthma self-management programmes can be successful, with excellent adherence and good asthma control. Patient-centred care focused on healthcare provider-patient/parent collaboration is the key factor determining the success of guided self-management programmes. Such care should focus on shared decision-making as this has been shown to improve adherence and healthcare outcomes. Current asthma care falls short because many physicians fail to adhere to asthma guidelines in their diagnostic approach and therapeutic prescriptions, and because of the lack of application of patient-centred health care. Increased awareness of the importance of patient-centred communication and increased training in patient-centred communication skills of undergraduates and experienced attending physicians are needed to improve adherence to daily controller therapy and asthma control in children with asthma.

Growth of Secure Messaging Through a Patient Portal as a Form of Outpatient Interaction across Clinical Specialties

OBJECTIVE

Patient portals are online applications that allow patients to interact with healthcare organizations. Portal adoption is increasing, and secure messaging between patients and healthcare providers is an emerging form of outpatient interaction. Research about portals and messaging has focused on medical specialties. We characterized adoption of secure messaging and the contribution of messaging to outpatient interactions across diverse clinical specialties after broad portal deployment.

METHODS

This retrospective cohort study at Vanderbilt University Medical Center examined use of patient-initiated secure messages and clinic visits in the three years following full deployment of a patient portal across adult and pediatric specialties. We measured the proportion of outpatient interactions (i.e., messages plus clinic visits) conducted through secure messaging by specialty over time. Generalized estimating equations measured the likelihood of message-based versus clinic outpatient interaction across clinical specialties.

RESULTS

Over the study period, 2,422,114 clinic visits occurred, and 82,159 unique portal users initiated 948,428 messages to 1,924 recipients. Medicine participated in the most message exchanges (742,454 messages; 78.3% of all messages sent), followed by surgery (84,001; 8.9%) and obstetrics/gynecology (53,424; 5.6%). The proportion of outpatient interaction through messaging increased from 12.9% in 2008 to 33.0% in 2009 and 39.8% in 2010 (p<0.001). Medicine had the highest proportion of outpatient interaction conducted through messaging in 2008 (23.3% of outpatient interactions in medicine). By 2010, this proportion was highest for obstetrics/gynecology (83.4%), dermatology (71.6%), and medicine (56.7%). Growth in likelihood of message-based interaction was greater for anesthesiology, dermatology, obstetrics/gynecology, pediatrics, and psychiatry than for medicine (p<0.001).

CONCLUSIONS

This study demonstrates rapid adoption of secure messaging across diverse clinical specialties, with messaging interactions exceeding face-to-face clinic visits for some specialties. As patient portal and secure messaging adoption increase beyond medicine and primary care, research is needed to understand the implications for provider workload and patient care.

A new method for assessing content validity in model-based creation and iteration of eHealth interventions

Background

The advent of eHealth interventions to address psychological concerns and health behaviors has created new opportunities, including the ability to optimize the effectiveness of intervention activities and then deliver these activities consistently to a large number of individuals in need. Given that eHealth interventions grounded in a well-delineated theoretical model for change are more likely to be effective and that eHealth interventions can be costly to develop, assuring the match of final intervention content and activities to the underlying model is a key step. We propose to apply the concept of “content validity” as a crucial checkpoint to evaluate the extent to which proposed intervention activities in an eHealth intervention program are valid (eg, relevant and likely to be effective) for the specific mechanism of change that each is intended to target and the intended target population for the intervention.

Objective

The aims of this paper are to define content validity as it applies to model-based eHealth intervention development, to present a feasible method for assessing content validity in this context, and to describe the implementation of this new method during the development of a Web-based intervention for children.

Methods

We designed a practical 5-step method for assessing content validity in eHealth interventions that includes defining key intervention targets, delineating intervention activity-target pairings, identifying experts and using a survey tool to gather expert ratings of the relevance of each activity to its intended target, its likely effectiveness in achieving the intended target, and its appropriateness with a specific intended audience, and then using quantitative and qualitative results to identify intervention activities that may need modification. We applied this method during our development of the Coping Coach Web-based intervention for school-age children.

Results

In the evaluation of Coping Coach content validity, 15 experts from five countries rated each of 15 intervention activity-target pairings. Based on quantitative indices, content validity was excellent for relevance and good for likely effectiveness and age-appropriateness. Two intervention activities had item-level indicators that suggested the need for further review and potential revision by the development team.

Conclusions

This project demonstrated that assessment of content validity can be straightforward and feasible to implement and that results of this assessment provide useful information for ongoing development and iterations of new eHealth interventions, complementing other sources of information (eg, user feedback, effectiveness evaluations). This approach can be utilized at one or more points during the development process to guide ongoing optimization of eHealth interventions.

Psoriasis in childhood: effective strategies to improve treatment adherence

Psoriasis is a relatively common chronic inflammatory skin disease in children for which there is no cure. Most children have mild disease that can be managed with topical therapy as opposed to phototherapy or systemic therapy. Despite the mild presentation of psoriasis in most children, the disease can have a significant impact on quality of life due to the need for ongoing treatment, the frequently visible nature of the cutaneous manifestations, and the social stigma that is associated with psoriasis. Adherence to treatment, in particular topical therapy, is often poor in adults and compromises response to therapy and medical provider management strategies. Multiple factors that may contribute to nonadherence in adults with psoriasis have been identified, including lack of education on the disease and expectations for management, issues related to ease of use and acceptability of topical medications, and anxiety regarding possible medication side effects. There is currently no published data on adherence in the pediatric psoriasis population; however, poor adherence is often suspected when patients fail to respond to appropriate therapy. General strategies used to assess adherence in other pediatric disease populations can be applied to children with psoriasis, and interventions that reflect experience in other chronic dermatologic disorders such as atopic dermatitis may also be helpful for medical providers caring for children with psoriasis.

Concordant parent-child reports of anxiety predict impairment in youth with functional abdominal pain

BACKGROUND

Functional abdominal pain (FAP) is associated with significant anxiety and impairment. Prior investigations of child anxiety in youth with FAP are generally limited by small sample sizes, based on child report, and use lengthy diagnostic tools. It is unknown whether a brief anxiety-screening tool is feasible, whether parent and child reports of anxiety are congruent, and whether parent and child agreement of child anxiety corresponds to increased impairment. The purpose of this investigation was to examine anxiety characteristics in youth with FAP using parent and child reports. Parent-child agreement of child anxiety symptoms was examined in relation to pain and disability.

METHODS

One hundred patients with FAP (8-18 years of age) recruited from pediatric gastroenterology clinics completed measures of pain intensity (Numeric Rating Scale) and disability (Functional Disability Inventory). Patients and caregivers both completed a measure of child anxiety characteristics (Screen for Child Anxiety and Related Disorders).

RESULTS

Clinically significant anxiety symptoms were more commonly reported by youth (54%) than their parents (30%). Panic/somatic symptoms, generalized anxiety, and separation anxiety were most commonly endorsed by patients, whereas generalized anxiety, separation anxiety, and school avoidance were most commonly reported by parents. The majority (65%) of parents and children agreed on the presence (26%) or absence (39%) of clinically significant anxiety. Parent-child agreement of clinically significant anxiety was related to increased impairment.

CONCLUSIONS

A brief screening instrument of parent and child reports of anxiety can provide clinically relevant information for comprehensive treatment planning in children with FAP.

Parent-teacher agreement on ADHD symptoms across development

Parent-teacher agreement on attention-deficit/hyperactivity disorder (ADHD) symptom ratings ranges from low to moderate. Most studies evaluating parent-teacher agreement have not assessed measurement invariance across raters. Hence, it is unclear whether discordance across raters is due to differing ADHD constructs across raters or other factors (e.g., subjective differences across raters). Additionally, the effect of development on parent-teacher agreement is relatively unknown. To address these limitations, the present study used parent and teacher ADHD ratings from a large (N = 6,659) developmentally diverse (ages 4-17) sample. Using exploratory structural equation modeling on half the sample, and then confirmatory factor analysis (CFA) on the other half of the sample, confirmed a 2-factor structure with significant cross-loadings for the 18 ADHD symptoms. CFA invariance analyses demonstrated that the 2-factor symptom structure was similar across raters and age groups. After confirming measurement invariance, the correlation between latent factors within and across raters was examined for each age group as well as across age groups. Parents reported greater severity of ADHD symptoms than did teachers, and both parents and teachers reported higher levels of hyperactivity/impulsivity in younger children than in older children and consistent levels of inattention across development. Finally, correlations between parent-teacher ratings of like factors were weak for inattention and moderate-strong for hyperactivity/impulsivity, and the magnitude of parent-teacher agreement did not vary across development. In conclusion, while parent and teacher ratings of ADHD behaviors are only weakly to moderately correlated, each reporter provides unique and valid clinical information as it relates to ADHD symptom presentation.

Depression screening in pediatric epilepsy: evidence for the benefit of a behavioral medicine service in early detection

Despite the increased risk and prevalence of depression in youth with epilepsy, only one-third receive mental health services. Untreated depression can contribute to negative outcomes and increased health-care utilization and medical cost. Proactive behavioral medicine screening may facilitate identification of depressive symptoms and necessary interventions in efforts to optimize behavioral health and health-related quality of life (HRQOL). Primary study aims included the examination of 1) rates of self-reported depression in youth with epilepsy, 2) differences in depression by demographic and medical variables, 3) the impact of depression on HRQOL, and 4) changes in depression and suicidal ideation following a behavioral medicine consultation. As part of routine clinic care over a 24-month period, youth with epilepsy of 7-17years of age completed the Children's Depression Inventory-Second Edition. Parents completed the PedsQL. A chart review was conducted to ascertain demographics, medical variables, and behavioral medicine visits and recommendations. A subsample with Time 1 and Time 2 depression data was examined. Time 1 participants included 311 youth with epilepsy (Mage=11.9years, 50% female, 84% Caucasian, 46.0% with localization-related epilepsy, 71.0% with seizure control in the past 3months). Elevated depression was identified in 23% of youth, with 14% endorsing suicidal ideation. Depression significantly varied by age, antiepileptic drug, and insurance. After controlling for seizure status, HRQOL worsened with elevated depression. Depression significantly decreased from Time 1 to Time 2 (n=159), particularly for those referred for behavioral medicine services at Time 1. Systematic assessment and early detection of depression and/or suicidal ideation in youth with epilepsy can improve HRQOL and decrease depression. Depression screening can be implemented through clinic-based behavioral medicine services.

Recent Updates on the Efficacy of Group Based Treatments for Pediatric Obesity

BACKGROUND

There is limited research on optimal treatment formats for childhood obesity. Group-based interventions are popular, but it is unclear whether outcomes can be obtained without an additional individual component.

AIM

To examine statistically and clinically significant outcomes of recent group-based and mixed-format (group + Individual) pediatric obesity interventions.

METHODS

Effect sizes and magnitudes of weight change were calculated for studies published between January 2013 and September 2014.

RESULTS

Approximately half of the group-based studies reviewed produced significant results compared to control, and effect sizes were small. Mixed-format studies were less likely to include a control group, but those that did evidenced medium to large effects. Magnitudes of weight change post-intervention were generally greater in mixed-format studies than group-only studies.

CONCLUSIONS

Recent studies in pediatric obesity interventions suggest including an individual component in a group-based intervention produces optimal outcomes. Future research should directly compare group-only and mixed formats to confirm this observation.

Design and rationale for NOURISH-T: a randomized control trial targeting parents of overweight children off cancer treatment

Approximately 40% of off-treatment pediatric cancer survivors (PCS) are overweight or obese, which increases their risk for negative long-term physical health complications. Consistent with the Institute of Medicine's (IOM) emphasis on patients transitioning from treatment to cancer survivorship and increasing long-term healthy behaviors in these survivors, we plan to conduct a pilot RCT to address the increasing overweight/obesity rates among PCS by targeting their caregivers as agents for PCS behavior change. We plan to focus on parents' behaviors, attitudes and roles in promoting healthier eating and physical activity (PA) in PCS and adapt an evidence-informed, manualized parent intervention - NOURISH - found to be effective for parents of overweight and obese children and adolescents in reducing child and adolescent BMI. We plan to adapt NOURISH for caregivers of 5-12 year old PCS (6 months-4 years off active cancer treatment). Our pilot feasibility RCT - NOURISH-T (Nourishing Our Understanding of Role modeling to Improve Support for Healthy Transitions) evaluates: 1) the preliminary efficacy of NOURISH-T for PCS, compared with an Enhanced Usual Care (EUC) control condition, and 2) factors to consider to improve future adaptations of the intervention. The project will enroll caregivers of PCS at two pediatric oncology clinics into the 6-week intervention (or EUC) with assessments occurring pre- and post-6 weeks of intervention, and at a 4-month follow-up.

Improved but still impaired: symptom-impairment correspondence among youth with attention-deficit hyperactivity disorder receiving community-based care

OBJECTIVE

To explore correspondences between the trajectories of symptoms and impairments in youth with attention-deficit hyperactivity disorder (ADHD) being treated by in primary care settings.

METHODS

Parents of youth (n = 1976) rated their child's symptoms of inattention and hyperactivity/impulsivity, and impairment across a variety of domains. Multilevel models were estimated to characterize the trajectories of symptoms and impairment and to determine whether changes in symptom dimension trajectories corresponded to changes in impairment trajectories over time.

RESULTS

Results indicated that symptom dimensions initially improved, then leveled off, and then decreased minimally. However, impairment domains remained largely stable (i.e., neither improved nor worsened). Improvement in inattention symptoms were associated with improved ratings of writing impairment, and improved ratings of hyperactivity/impulsivity symptoms were associated with improved relationship with peers.

CONCLUSIONS

Youths with ADHD who are treated by their community pediatrician tend to initially improve in their symptom presentation, although this symptom reduction plateaus and is not associated with corresponding improvements in most areas of impairment.

Treatment of overweight and obesity in children and youth: a systematic review and meta-analysis

BACKGROUND

Childhood obesity is a public health concern. One-third of North American children and youth are overweight or obese. We reviewed the evidence of behavioural and pharmacological weight-management interventions on body mass index (BMI), BMI z-score and the prevalence of overweight and obesity in children and youth.

METHODS

We updated the search of a previous review. We searched 4 databases up to August 2013. We included randomized trials of primary care-relevant behavioural (diet, exercise, lifestyle) and pharmacological (orlistat) interventions for treating overweight and obesity in children and youth aged 2-18 years if 6-month post-baseline data were provided for BMI, BMI z-score or prevalence of overweight and obesity. In addition, we examined secondary health outcomes such as lipid and glucose levels, blood pressure, quality of life and physical fitness. We included any study reporting harms. We performed meta-analyses when possible, and we examined the features of interventions that showed benefits.

RESULTS

Thirty-one studies (29 behavioural, 2 pharmacological and behavioural) were included. Both intervention types showed a significant effect on BMI or BMI z-score in favour of treatment (behavioural: standardized mean difference [SMD] -0.54, 95% confidence interval [CI] -0.73 to -0.36; orlistat plus behavioural: SMD -0.43, 95% CI -0.60 to -0.25). Studies reported no significant difference between groups in the likelihood of reduced prevalence of overweight or overweight and obesity. Pooled estimates for blood pressure and quality of life showed significant benefits in favour of treatment (systolic blood pressure mean difference [MD] -3.42, 95% CI -6.65 to -0.29; diastolic blood pressure MD -3.39, 95% CI -5.17 to -1.60; quality of life MD 2.10, 95% CI 0.60 to 3.60). Gastrointestinal difficulties were more common in youth taking orlistat than in the control group (risk ratio 3.77, 95% CI 2.56 to 5.55). We saw much variability across efficacious interventions.

INTERPRETATION

Low- to moderate-quality evidence suggests behavioural treatments are associated with a medium effect in terms of reduced BMI or BMI z-score compared with a small effect shown by combined pharmacological-behavioural interventions. Future research should evaluate active weight maintenance interventions in adolescents with longer follow-up and examine the effectiveness of combined pharmacological and behavioural interventions.

REGISTRATION

PROSPERO no. CRD42012002754.

Addressing Item-Level Missing Data: A Comparison of Proration and Full Information Maximum Likelihood Estimation

Often when participants have missing scores on one or more of the items comprising a scale, researchers compute prorated scale scores by averaging the available items. Methodologists have cautioned that proration may make strict assumptions about the mean and covariance structures of the items comprising the scale (Schafer & Graham, 2002 ; Graham, 2009 ; Enders, 2010 ). We investigated proration empirically and found that it resulted in bias even under a missing completely at random (MCAR) mechanism. To encourage researchers to forgo proration, we describe a full information maximum likelihood (FIML) approach to item-level missing data handling that mitigates the loss in power due to missing scale scores and utilizes the available item-level data without altering the substantive analysis. Specifically, we propose treating the scale score as missing whenever one or more of the items are missing and incorporating items as auxiliary variables. Our simulations suggest that item-level missing data handling drastically increases power relative to scale-level missing data handling. These results have important practical implications, especially when recruiting more participants is prohibitively difficult or expensive. Finally, we illustrate the proposed method with data from an online chronic pain management program.

Patient-reported outcomes in clinical practice

Patient-reported outcome (PRO) measurement plays an increasingly important role in health care and understanding health outcomes. PROs are any report of a patient's health status that comes directly from the patient, and can measure patient symptoms, patient function, and quality-of-life. PROs have been used successfully to assess impairment in a clinical setting. Use of PROs to systematically quantify the patient experience provides valuable data to assist with clinical care; however, initiating use of PROs in clinical practice can be daunting. Here we provide suggestions for implementation of PROs and examples of opportunities to use PROs to tailor individual patient therapy to improve patient outcomes, patient-physician communication, and the quality of care for hematology/oncology patients.

Understanding Barriers to Early Intervention Services for Preterm Infants: Lessons From Two States

OBJECTIVE

To explore existing barriers and challenges to Early Intervention (EI) referral, enrollment, and service provision for very low birth weight (VLBW; <1500 g) infants.

METHODS

We conducted 10 focus groups with parents of VLBW children (n = 44) and 32 interviews with key informants from EI (n = 7), neonatal intensive care units (n = 17), and outpatient clinics (n = 8) at 6 sites in 2 states. We used grounded theory to identify themes about gaps in services.

RESULTS

Both parents and providers found EI helpful. However, they also identified gaps in the current EI system at the levels of eligibility, referral, family receptivity, and service provision and coordination with medical care. Inadequate funding and variable procedures for evaluation may affect children's eligibility. Referrals can be missed as a result of simple oversight or communication failure among hospitals, EI, and families; referral outcomes often are not formally tracked. Families may not be receptive to services as a result of wariness of home visits, social stressors, denial about potential developmental delays, or lack of understanding of the benefits of EI. Once a child is deemed eligible, services may be delayed or terminated early, and EI providers may have little specialized training. Communication and coordination with the child's medical care team is often limited.

CONCLUSIONS

Systemic barriers, including funding and staffing issues, state and federal regulations, and communication with families and medical providers, have led to gaps in the EI system. The chronic care model may serve as a framework for integrating community-based interventions like EI with medical care for VLBW children and other vulnerable populations.

Evidence update on the treatment of overweight and obesity in children and adolescents

Childhood obesity is associated with increased medical and psychosocial consequences and mortality and effective interventions are urgently needed. Effective interventions are urgently needed. This article reviews the evidence for psychological treatments of overweight and obesity in child and adolescent populations. Studies were identified through searches of online databases and reference sections of relevant review articles and meta-analyses. Treatment efficacy was assessed using established criteria, and treatments were categorized as well-established, probably efficacious, possibly efficacious, experimental, or of questionable efficacy. Well-established treatments included family-based behavioral treatment (FBT) and Parent-Only Behavioral Treatment for children. Possibly efficacious treatments include Parent-Only Behavioral Treatment for adolescents, FBT-Guided Self-Help for children, and Behavioral Weight Loss treatment with family involvement for toddlers, children, and adolescents. Appetite awareness training and regulation of cues treatments are considered experimental. No treatments are considered probably efficacious, or of questionable efficacy. All treatments considered efficacious are multicomponent interventions that include dietary and physical activity modifications and utilize behavioral strategies. Treatment is optimized if family members are specifically targeted in treatment. Research supports the use of multicomponent lifestyle interventions, with FBT and Parent-Only Behavioral Treatment being the most widely supported treatment types. Additional research is needed to test a stepped care model for treatment and to establish the ideal dosage (i.e., number and length of sessions), duration, and intensity of treatments for long-term sustainability of healthy weight management. To improve access to care, the optimal methods to enhance the scalability and implementability of treatments into community and clinical settings need to be established.

Risk for suicidal ideation and attempt among a primary care sample of adolescents engaging in nonsuicidal self-injury

One in five adolescents in the United States has engaged in nonsuicidal self-injury (NSSI), one in eight have had serious thoughts of suicide, and one in 25 have attempted suicide. Research suggests that NSSI may increase risk for suicide attempt, yet little is known about the relationship between NSSI and suicidal ideation or attempts. In a primary care setting, 1,561 youth aged 14-24 years completed a brief, comprehensive, mental health screen as part of a routine well visit to determine which factors were most likely to predict suicidal ideation and attempt among youth engaging in NSSI. Results of recursive partitioning revealed that current depression and history of alcohol use best differentiated youth engaging in NSSI with low versus high risk for suicidal ideation and attempts. This simple algorithm is presented as a clinical screening tool that might aid medical providers in determining which youth would benefit from more intensive assessment and intervention.

Variability in ADHD care in community-based pediatrics

BACKGROUND

Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report.

METHODS

Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined.

RESULTS

Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors.

CONCLUSIONS

There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.

Self-management education for cystic fibrosis

BACKGROUND

Self-management education may help patients with cystic fibrosis and their families to choose, monitor and adjust treatment requirements for their illness, and also to manage the effects of illness on their lives. Although self-management education interventions have been developed for cystic fibrosis, no previous systematic review of the evidence of effectiveness of these interventions has been conducted.

OBJECTIVES

To assess the effects of self-management education interventions on improving health outcomes for patients with cystic fibrosis and their caregivers

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register (date of the last search: 22 August 2013).We also searched databases through EBSCO (CINAHL; Psychological and Behavioural Sciences Collection; PsychInfo; SocINDEX) and Elsevier (Embase) and handsearched relevant journals and conference proceedings (date of the last searches: 01 February 2014 ).

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials or controlled clinical trials comparing different types of self-management education for cystic fibrosis or comparing self-management education with standard care or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias. Three authors extracted data.

MAIN RESULTS

Four trials (involving a total of 269 participants) were included. The participants were children with cystic fibrosis and their parents or caregivers in three trials and adults with cystic fibrosis in one trial. The trials compared four different self-management education interventions versus standard treatment: (1) a training programme for managing cystic fibrosis in general; (2) education specific to aerosol and airway clearance treatments; (3) disease-specific nutrition education; and (4) general and disease-specific nutrition education. Training children to manage cystic fibrosis in general had no statistically significant effects on weight after six to eight weeks, mean difference -7.74 lb (i.e. 3.51 kg) (95% confidence interval -35.18 to 19.70). General and disease-specific nutrition education for adults had no statistically significant effects on: pulmonary function (forced expiratory volume at one second), mean difference -5.00 % (95% confidence interval -18.10 to 8.10) at six months and mean difference -5.50 % (95% confidence interval -18.46 to 7.46) at 12 months; or weight, mean difference - 0.70 kg (95% confidence interval -6.58 to 5.18) at six months and mean difference -0.70 kg (95% confidence interval -6.62 to 5.22) at 12 months; or dietary fat intake scores, mean difference 1.60 (85% confidence interval -2.90 to 6.10) at six months and mean difference 0.20 (95% confidence interval -4.08 to 4.48) at 12 months. There is some limited evidence to suggest that self-management education may improve knowledge in patients with cystic fibrosis but not in parents or caregivers. There is also some limited evidence to suggest that self-management education may result in positively changing a small number of behaviours in both patients and caregivers.

AUTHORS' CONCLUSIONS

The available evidence from this review is of insufficient quantity and quality to draw any firm conclusions about the effects of self-management education for cystic fibrosis. Further trials are needed to investigate the effects of self-management education on a range of clinical and behavioural outcomes in children, adolescents and adults with cystic fibrosis and their caregivers.

Feasibility and impact of multidisciplinary training of an evidence-based intervention within a pediatric psychiatry consultation service

OBJECTIVE

To train clinicians on a multidisciplinary pediatric consultation-liaison (CL) psychiatry service to administer an evidence-based intervention, biofeedback-assisted relaxation training (BART), in the inpatient medical setting and obtain their opinions about BART's utility and feasibility in the CL setting.

METHODS

Attendings and trainees on a multidisciplinary pediatric CL service received 3 h of BART training and completed a 10-item questionnaire designed to assess opinions about BART at two time points: after training but prior to using the intervention with patients and again 3 months after implementing the intervention in their clinical practice.

RESULTS

Nineteen clinicians administered BART with 28 patients across the study period, and clinicians rated BART positively after training and significantly more positively after utilizing BART in the clinical setting. From post-training to post-implementation, trainees reported significant increases in their opinions that BART increased parent and patient receptiveness to psychiatric consultation (p<0.05) and attendings reported significant increases in their opinions that BART enhanced clinical intervention (p<0.05).

CONCLUSIONS

BART training on a multidisciplinary CL service was well received by clinicians and patients and may enhance psychiatry trainees' repertoire of cognitive-behavioral and evidence-based interventions.

Medication adherence in the transition of adolescent kidney transplant recipients to the adult care

Non-adherence is common in adolescent and young adult kidney transplant recipients, leading to adverse graft outcomes. The aim of this study was to determine whether adherence to immunosuppressant medications changes during transition from a pediatric to an adult program within the same transplant center. Adherence was assessed for a period of two yr before and two yr after the transfer. Subtherapeutic trough levels of serum tacrolimus and level variability were used as measures of adherence. Twenty-five patients were transitioned between 1996 and 2011 at the median age of 22.3 [IQR 21.6-23.0] yr. Young adults 21-25 yr of age (n = 26) and non-transitioned adolescents 17-21 yr of age (currently followed in the program, n = 24 and those that lost their grafts prior to the transfer, 22) formed the comparison groups. In the transitioned group, adherence prior to the transfer was not significantly different from the adherence after the transfer (p = 0.53). The rate of non-adherence in the group of non-transitioned adolescents who lost their grafts (68%) was significantly higher than in the transitioned group (32%, p = 0.01). In the group of young adults, adherence was not significantly different from the transitioned group (p = 0.27). Thus, transition was not associated with differences in medication adherence in this single-center study. Large-scale studies are needed to evaluate the national data on medication adherence after transfer.

Adolescent rumination syndrome

Rumination syndrome is the non-purposeful regurgitation of recently ingested food from the stomach to the mouth, where it is either expelled or reswallowed. Adolescent rumination syndrome (ARS) is a rare condition of which many physicians are unaware. Patients often are misdiagnosed or undergo costly testing, and as a result, diagnosis and treatment are often delayed. While ARS is not life-threatening, it does have medical and emotional effects on the patient and the patient's family. Diagnosis of ARS is based upon the Rome III diagnostic criteria. Antroduodenal manometry, while not required for a diagnosis, can be helpful to confirm the diagnosis. The pathogenesis of this disorder is complex and not well understood. However, because of its behavioral component, treatment of ARS requires a multidisciplinary approach that includes both medical management of symptoms and implementation of strategies that address behavioral, psychological, and general quality-of-life components of the disorder.