Psychological interventions for parents of children and adolescents with chronic illness

'Family first' - feasibility and pilot outcomes of a community intervention for families of children in recovery following brain injury

PURPOSE

Feasibility and pilot outcomes of a new community-based program for families of children with acquired brain injury (ABI) are presented. Interventions, delivered by home-visiting and teletherapy, were underpinned by problem-solving therapy, narrative meaning making, goal-directed interventions and community system psychoeducation.

METHODS

Eighty-three families of children, who had sustained an ABI before 12 years of age, had an average of 13 sessions of the 'Family First' (FF) intervention. A mixed-methods prospective design was employed. Feasibility was evaluated through measures of accessibility and acceptability. Goal attainment scaling and pre-post changes on standardized questionnaires assessed changes in psychosocial adjustment and quality of life.

RESULTS

Feasibility analyses suggested engagement and retention of often hard to reach families and children with high psychosocial needs. Qualitative analyses suggested themes related to the accessibility of a unique service ('Nothing else like this out there' and 'Accessible and flexible') which facilitated 'Empowerment' within a family context ('A family affair'). Promising changes on standardized scales of behavior problems, competencies and child and family quality of life were discerned. Increased goal attainment scores were observed.

CONCLUSION

The FF program showed feasibility and promise. It impacted positively on the lives of children and families and improved capacity in supporting systems.

A Dutch paediatric palliative care guideline: a systematic review and evidence-based recommendations for symptom treatment

BACKGROUND

Children with life-threatening and life-limiting conditions can experience high levels of suffering due to multiple distressing symptoms that result in poor quality of life and increase risk of long-term distress in their family members. High quality symptom treatment is needed for all these children and their families, even more so at the end-of-life. In this paper, we provide evidence-based recommendations for symptom treatment in paediatric palliative patients to optimize care.

METHODS

A multidisciplinary panel of 56 experts in paediatric palliative care and nine (bereaved) parents was established to develop recommendations on symptom treatment in paediatric palliative care including anxiety and depression, delirium, dyspnoea, haematological symptoms, coughing, skin complaints, nausea and vomiting, neurological symptoms, pain, death rattle, fatigue, paediatric palliative sedation and forgoing hydration and nutrition. Recommendations were based on evidence from a systematic literature search, additional literature sources (such as guidelines), clinical expertise, and patient and family values. We used the GRADE methodology for appraisal of evidence. Parents were included in the guideline panel to ensure the representation of patient and family values.

RESULTS

We included a total of 18 studies that reported on the effects of specific (non) pharmacological interventions to treat symptoms in paediatric palliative care. A few of these interventions showed significant improvement in symptom relief. This evidence could only (partly) answer eight out of 27 clinical questions. We included 29 guidelines and two textbooks as additional literature to deal with lack of evidence. In total, we formulated 221 recommendations on symptom treatment in paediatric palliative care based on evidence, additional literature, clinical expertise, and patient and family values.

CONCLUSION

Even though available evidence on symptom-related paediatric palliative care interventions has increased, there still is a paucity of evidence in paediatric palliative care. We urge for international multidisciplinary multi-institutional collaboration to perform high-quality research and contribute to the optimization of symptom relief in palliative care for all children worldwide.

Effects of comorbid asthma and eczema on child and family quality of life

Paediatric chronic health conditions are associated with poorer psychological wellbeing and quality of life for children and families. This study investigated differences in child and parent/family quality of life between families of children with asthma only, eczema only, or both asthma and eczema, and tested predictors of child and parent/family quality of life. A convenience sample of 106 families completed parent-report measures of child and parent/family quality of life, child emotional and behavioural difficulties, parent adjustment and parenting practices. Between-groups ANOVAs indicated no differences for child quality of life, whereas parent/family quality of life was worse for those with eczema only compared to asthma only. Multiple linear regression revealed that child emotional difficulties predicted worse child quality of life, whereas worse parent adjustment, child emotional difficulties and eczema only (compared to both asthma and eczema) predicted worse parent quality of life. Results suggest that families of children with eczema may be at particular risk for impaired parent/family quality of life. Interventions that take a family-centred approach to improving child and parent adjustment should be investigated as an adjunct to medical treatment to reduce the impact of chronic health conditions on quality of life for children and families.

Problem-Solving Skills Training for Parents of Children With Chronic Health Conditions: A Systematic Review and Meta-Analysis

Importance

Problem-solving skills training (PSST) has a demonstrated potential to improve psychosocial well-being for parents of children with chronic health conditions (CHCs), but such evidence has not been fully systematically synthesized.

Objective

To evaluate the associations of PSST with parental, pediatric, and family psychosocial outcomes.

Data Sources

Six English-language databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library), 3 Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang), gray literature, and references were searched from inception to April 30, 2023.

Study Selection

Randomized clinical trials (RCTs) that performed PSST for parents of children with CHCs and reported at least 1 parental, pediatric, or family psychosocial outcome were included.

Data Extraction and Synthesis

Study selection, data extraction, and quality assessment were conducted independently by 2 reviewers. Data were pooled for meta-analysis using the standardized mean difference (SMD) by the inverse variance method or a random-effects model. Subgroup analyses of children- and intervention-level characteristics were conducted.

Main Outcomes and Measures

The psychosocial outcomes of the parents, their children, and their families, such as problem-solving skills, negative affectivity, quality of life (QOL), and family adaptation.

Results

The systematic review included 23 RCTs involving 3141 parents, and 21 of these trials were eligible for meta-analysis. There was a significant association between PSST and improvements in parental outcomes, including problem-solving skills (SMD, 0.43; 95% CI, 0.27-0.58), depression (SMD, -0.45; 95% CI, -0.66 to -0.23), distress (SMD, -0.61; 95% CI, -0.81 to -0.40), posttraumatic stress (SMD -0.39; 95% CI, -0.48 to -0.31), parenting stress (SMD, -0.62; 95% CI, -1.05 to -0.19), and QOL (SMD, 0.45; 95% CI, 0.15-0.74). For children, PSST was associated with better QOL (SMD, 0.76; 95% CI, 0.04-1.47) and fewer mental problems (SMD, -0.51; 95% CI, -0.68 to -0.34), as well as with less parent-child conflict (SMD, -0.38; 95% CI, -0.60 to -0.16). Subgroup analysis showed that PSST was more efficient for parents of children aged 10 years or younger or who were newly diagnosed with a CHC. Significant improvements in most outcomes were associated with PSST delivered online.

Conclusions and Relevance

These findings suggest that PSST for parents of children with CHCs may improve the psychosocial well-being of the parents, their children, and their families. Further high-quality RCTs with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence.

Palliative care for children: methodology for the development of a national clinical practice guideline

BACKGROUND

Provision of paediatric palliative care for children with life-threatening or life-limiting conditions and their families is often complex. Guidelines can support professionals to deliver high quality care. Stakeholders expressed the need to update the first Dutch paediatric palliative care guideline with new scientific literature and new topics. This paper provides an overview of the methodology that is used for the revision of the Dutch paediatric palliative care guideline and a brief presentation of the identified evidence.

METHODS

The revised paediatric palliative care guideline was developed with a multidisciplinary guideline panel of 72 experts in paediatric palliative care and nine (bereaved) parents of children with life-threatening or life-limiting conditions. The guideline covered multiple topics related to (refractory) symptom treatment, advance care planning and shared-decision making, organisation of care, psychosocial care, and loss and bereavement. We established six main working groups that formulated 38 clinical questions for which we identified evidence by updating two existing systematic literature searches. The GRADE (CERQual) methodology was used for appraisal of evidence. Furthermore, we searched for additional literature such as existing guidelines and textbooks to deal with lack of evidence.

RESULTS

The two systematic literature searches yielded a total of 29 RCTs or systematic reviews of RCTs on paediatric palliative care interventions and 22 qualitative studies on barriers and facilitators of advance care planning and shared decision-making. We identified evidence for 14 out of 38 clinical questions. Furthermore, we were able to select additional literature (29 guidelines, two textbooks, and 10 systematic reviews) to deal with lack of evidence.

CONCLUSIONS

The revised Dutch paediatric palliative care guideline addresses many topics. However, there is limited evidence to base recommendations upon. Our methodology will combine the existing evidence in scientific literature, additional literature, expert knowledge, and perspectives of patients and their families to provide recommendations.

Burden of care and a sense of loneliness in caregivers of children with type 1 diabetes. a cross-sectional study

BACKGROUND

Treatment of type 1 diabetes is a process involving not only sick children, but also their caregivers.

AIM

To assess the burden of care and sense of loneliness in caregivers of children with type 1 diabetes. Also, an analysis was conducted of the connection between sociodemographic factors characterizing caregivers and the clinical factors characterizing sick children and between the burden of care and the sense of loneliness.

MATERIALS AND METHODS

The study included 125 caregivers of children with type 1 diabetes. In order to collect the research data, the Caregiver Burden Scale and the Revised UCLA Loneliness Scale were used.

RESULTS

In the research group, the total result in the caregiving burden scale was 2.14, which remains within the average burden level. Caregivers showed the highest burden level in the General Strain Subscale. The analysis showed that mothers experience a greater burden of care than fathers in the General Strain Subscale and that caregivers of younger children are more burdened with care within the Isolation and Disappointment Subscales. Moderate high degree of loneliness was shown in 4.8% of caregivers. A higher burden of care for caregivers of children with type 1 diabetes is accompanied by a higher sense of loneliness.

CONCLUSIONS

The results of this study may help healthcare professionals plan a holistic, family-centered care program that will take into account factors that increase the burden of care: younger age of the affected child, motherhood, caregiver unemployment, feelings of loneliness, lower education, caregiver unemployment, blood glucose meter measurements, and frequent night-time blood glucose measurements.

Self-care in children and young people with complex chronic conditions: a qualitative study using Emotional Text Mining

Objectives

To explore: (1) self-care behaviors in children and young people (range: 6 months-24 years) with complex chronic conditions, characterized by the diagnosis of a severe chronic condition, substantial family-identified needs, functional limitations associated with technology dependence, and intensive use of healthcare services; (2) the contribution to self-care of family members and other persons involved in the child's health and daily life context (e.g., health professionals and teachers), and (3) the principal factors that might have influenced the self-care process associated with developmental age.

Methods

A qualitative descriptive study was conducted in an Italian academic tertiary pediatric hospital between September 2020 and May 2021. Overall, 25 focus groups and 7 online interviews were conducted via videoconferencing. Textual data were analyzed using Emotional Text Mining to identify three levels of communication: the factors, the main themes (clusters), and the sub-themes.

Results

A total of 104 participants were enrolled, including 27 patients with complex chronic conditions (12 males, mean age = 11.1 ± 4.40), 33 parents, 6 siblings, 33 health professionals, and 5 teachers. Participants described the process of self-care through four main factors: "self-care", "external settings", "family", and "management". Five clusters (themes) were identified: (1) Self-care management (device; consulting); (2) Shift of agency (influencing factors; parents; school); (3) Self-care support (normal life and personal development; multidisciplinary support); (4) Daily self-care maintenance/monitoring; (5) Treatment adherence. Self-care management was mostly relevant for parents of children aged between 6 months and 3 years.

Conclusion

The self-care process varies according to the needs related to the specific developmental age and the evolution of the clinical condition over time. The contribution of the family, health professionals, and social networks is fundamental for adequate self-care. To help families manage the unstable condition of their children at home, it is necessary to strengthen support networks implement home care, and ensure continuity of care.

Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis

Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3-8 weeks' follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.

Cognitive Behavioral Therapy for Children With Headaches: Will an App Do the Trick?

Participants were enrolled into a pilot randomized-controlled 4-week trial comparing the efficacy and feasibility of app-based cognitive behavioral therapy (CBT) to a stretching program. Headache-related disability and quality of life were assessed using the Pediatric Migraine Disability Scale (PedMIDAS), Kidscree27, and Pediatric Quality of Life Inventory. Multivariable regression analysis were performed to assess the group effects in the presence of adherence and other covariates. Twenty participants completed the study. Adherence was significantly higher in the stretching than in the CBT app group (100% vs 54%, P < .034). When controlling for adherence and baseline scores, the stretching group showed greater reduction in PedMIDAS score (average: 29.2, P < .05) as compared to the CBT app group. However, in terms of the Quality-of-Life Indicators, pre- and postintervention raw scores were not significantly different between groups (P > .05). App-based CBT was not superior to a stretching program in reducing headache-related disability in a select population of pediatric headache patients. Future studies should assess if implementing features to the CBT app, like tailoring to pediatric age groups, would improve outcomes.

Stress and coping strategies of families of pediatric solid organ transplant recipients in times of pandemic

Objective

Pediatric solid organ transplantation (SOT) is a chronic condition that impacts the whole family system. The objective of this study is to evaluate psychopathology, family stress, and coping strategies in families of SOT recipients compared to families of healthy children and adolescents. Moreover, it analyzes if the stress related to the COVID-19 pandemic has had an additional impact on these families.

Methods

The sample was recruited between May and July 2021, during the fourth and fifth wave of the pandemic in Spain. It consisted of 102 families, 51 with a pediatric recipient who had undergone a SOT (liver, kidney, heart, or lung) and 51 healthy controls, matched by child age and gender. A primary caregiver from each family answered an online sociodemographic questionnaire and different tests to evaluate family stress, depression, anxiety, coping strategies, and effects of the pandemic on the family.

Results

Caregivers were mostly mothers (89.2%). Families of SOT recipients showed greater anxiety (U = 863.5, p = 0.003) and more total stress, stress related to childcare (t = -2.043; p = 0.045), and parent-child interaction stress (U = 355.5, p = 0.015). SOT families used more avoidance strategies, specifically denial (U = 889.5; p = 0.010) and abandonment of coping efforts (U = 1,013; p = 0.047), more religious strategies (U = 792.5; p = 0.031), and fewer social support coping strategies (t = 2.098; p = 0.038). No differences were found between groups in terms of exposure, impact, and distress more than 1 year after the start of the pandemic.

Conclusion

SOT families showed clinical levels of anxiety, more parent-child interaction stress, more difficulties in taking care of their child, more avoidance and religious strategies, and less use of social support strategies, even 4 years after transplantation. The pandemic did not have an additional differential effect on SOT families. Caregivers of SOT patients can benefit from psychological interventions focused on parents' mental health, parent-child connectedness, skill building, and social support aid groups, with attention to multiculturalism and promoting a better balance between caregivers. There is a need for family interventions that are maintained over time. Strategies that offer this support to families through digital resources can facilitate adjustment to chronic illness, especially in pandemic times.

Coping Strategies in Greek Parents of Children with Cancer

INTRODUCTION

Childhood cancer is a life-threatening, chronic condition and treatment may extent for several years. The diagnosis of cancer in children could stress intensely their parents.

AIM

To explore coping strategies utilized by Greek parents who have children with cancer.

MATERIAL AND METHODS

Eighty-five parents of children with cancer, admitted for treatment at the in-patient unit of a Paediatric Hospital in Athens completed a questionnaire with demographic and their children's disease related characteristics and the Family Crisis Oriented Personal Evaluation Scale.

RESULTS

Sixty mothers (70.6%) and 25 fathers (29.4%) completed the questionnaire. A percentage of 29.4% of the parents included in this study considered themselves anxious. Elementary or secondary school graduates scored higher in Seeking Spiritual Support (p = 0.013). Stay-at-home or unemployed parents scored lower in the subscale of Passive Appraisal (p = 0.012). Parents who were very well informed tended to exhibit more frequently passive appraisal behavior (p = 0.004). Parents whose child had Hodgkin's lymphoma scored higher in the subscale of Acquiring Social Support (p = 0.034). Statistical significance was found between parent's strategies of Seeking Spiritual Support and the gender (girls) (p = 0.036), as well as the treatment problems (p = 0.008) of hospitalized children.

CONCLUSIONS

This study may help health professionals understand Greek families' coping strategies when they have a child with cancer. Appropriate knowledge could significantly help them in the field of planning and implementation of personalized care in order to achieve optimal therapeutic outcomes.

Caregiving burden and special needs of parents in the care of their short-statured children - a qualitative approach

PURPOSE

To explore caregiving burden, health-related quality of life (HRQOL), stress, and individual resources of parents in the care of children with isolated growth hormone deficiency (IGHD) or idiopathic short stature (ISS).

METHODS

Focused interview analysis of previously, within the Quality of Life in Short Stature Youth (QoLISSY) project, conducted structured focus group discussions (n=7) with parents (n=33) of children with IGHD/ISS aged 4 to 18 years were performed.

RESULTS

26 out of the 33 parents reported mental stress due to their child's growth disorder. Social pressure and stigmatization were also mentioned as being demanding. Some parents reported having trouble with human growth hormone (hGH) treatment. Several parents wished for parent support groups with other like-minded parents of short-statured children.

CONCLUSION

For physicians, it is essential to understand the parents' caregiving burden, stress, and individual resources in caring for IGHD/ISS children. If an impaired HRQOL is detected, psychological intervention for these parents may be scheduled, and coping mechanisms may be discussed. Furthermore, it seems essential for parents to be educated by their healthcare provider about the possible side effects of hGH treatment or to know where to find evidence-based information about it.

A National Profile of Families and Caregivers of Children With Disabilities and/or Medical Complexity

OBJECTIVE

Provide an up-to-date description of the well-being of families and caregivers of children with disability and medical complexity at the national level.

METHODS

We performed a secondary analysis of the 2016-2019 National Survey of Children's Health and divided the sample based on a child's disability and medical complexity status: children with no special health care needs (non-CSHCN), children with special health care needs (CSHCN), CSHCN with significant disabilities (CSHCN-SD), and children with medical complexity (CMC). Outcomes included survey items assessing 1) caregiver emotional well-being, 2) family functioning, and 3) economic adversity. We conducted multivariable logistic regression analyses to examine associations between child disability and medical complexity status with study outcomes.

RESULTS

Among 131,774 survey responses, CSHCN-SD (weighted n = 4.2 million) and CMC (n =1.1 million) disproportionately reported adverse outcomes for every measure of well-being. Notably, caregivers of CSHCN-SD and CMC were more likely to report frequently feeling bothered (aOR 5.0 and 6.3, respectively) and angry (aOR 3.0 and 3.1) with their child than non-CSHCN caregivers. Families of CSHCN-SD and CMC had 40% lower odds of endorsing all aspects of family resilience and more likely to report three or more adverse childhood experiences (aOR 3.3 and 3.7) than non-CSHCN families. CSHCN-SD and CMC families were also more likely to experience difficulty covering basics (aOR, 2.6 and 3.3) and report caregivers changing jobs due to their child's care (aOR, 3.1 and 5.0).

CONCLUSIONS

Development and testing of interventions specifically targeting the well-being of CSHCN-SD and CMC families and caregivers is needed.

The Effects of a Web-Based Tool for Parents of Children With Juvenile Idiopathic Arthritis: Randomized Controlled Trial

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a group of autoinflammatory diseases that cause pain and disability if not controlled by treatment. Parenting a child with JIA is stressful for parents, who express concerns about their child's treatment and may experience anxiety and powerlessness concerning their child's illness. Parenting stress is greater in parents of children with chronic illness than in those with healthy children and is related to poorer psychological adjustment in both parents and children. It is therefore important to develop interventions to support parents. This paper reports the evaluation of a web-based tool that provides information and practical skills to help increase parents' confidence in managing their child's illness and reduce parenting stress.

OBJECTIVE

The aim of this study is to evaluate the benefits of a web-based tool (WebParC) for parents of children with recently diagnosed JIA.

METHODS

A multicentered randomized controlled trial was conducted at pediatric rheumatology centers in England. We recruited parents of children aged ≤12 years who had been diagnosed with JIA within the previous 6 months. They were randomized to the intervention (WebParC access plus standard care) or the control (standard care alone) and followed up 4 months and 12 months after randomization. Where both parents participated, they were randomized by household to the same trial arm. The WebParC intervention consists of information about JIA and its treatment plus a toolkit, based on cognitive behavioral therapy, to help parents develop skills to manage JIA-related issues. The primary outcome was the self-report Pediatric Inventory for Parents measure of illness-related parenting stress. The secondary outcomes were parental mood, self-efficacy, coping, effectiveness of participation in their child's health care, satisfaction with health care, and child's health-related quality of life.

RESULTS

A total of 203 households comprising 220 parents were randomized to the intervention (100/203, 49.3%) or control (103/203, 50.7%) arm. Follow-up assessments were completed by 65.5% (133/203) of the households at 4 months (intervention 60/100, 60%, and control 73/103, 70.9%) and 61.1% (124/203) of the households at 12 months (intervention 58/100, 58%, and control 66/103, 64.1%). A main effect of the trial arm was found on the Pediatric Inventory for Parents: the intervention participants reported less frequency (subscales communication F_1,120627=5.37; P=.02, and role function F_1,27203=5.40; P=.02) and difficulty (subscales communication F_1,2237=7.43; P=.006, medical care F_1,2907=4.04; P=.04, and role function F_1,821=4.37, P=.04) regarding illness-related stressful events than the control participants.

CONCLUSIONS

The WebParC website for parents of children with JIA reduced illness-related parenting stress. This web-based intervention offers a feasible preventive approach for parents of children with JIA and potentially could be adapted and evaluated for parents of children with other chronic illnesses.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 13159730; http://www.isrctn.com/ISRCTN13159730.

Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial

Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.

Child Welfare System Involvement Among Children With Medical Complexity

Children with medical complexity may be at elevated risk of experiencing child maltreatment and child welfare system involvement, though empirical data are limited. This study examined the extent of child welfare system involvement among children with medical complexity and investigated associated health and social factors. A retrospective chart review of children with medical complexity (N = 208) followed at a pediatric hospital-based complex care program in Canada was conducted. Descriptive statistics and odds ratios using logistic regression were computed. Results showed that nearly one-quarter (23.6%) had documented contact with the child welfare system, most commonly for neglect; of those, more than one-third (38.8%) were placed in care. Caregiver reported history of mental health problems (aOR = 3.19, 95%CI = 1.55-6.56), chronic medical conditions (aOR = 2.86, 95%CI = 1.09-7.47), and interpersonal violence or trauma (aOR = 17.58, 95%CI = 5.43-56.98) were associated with increased likelihood of child welfare system involvement, while caregiver married/common-law relationship status (aOR = 0.35, 95%CI = 0.16-0.74) and higher number of medical technology supports (aOR = 0.75, 95%CI = 0.57-0.99) were associated with decreased likelihood. Implications for intervention and prevention of maltreatment in children with high healthcare needs are discussed.

Treatment for Pediatric Functional Abdominal Pain: An Initial Examination of Reciprocal Associations Between Pain, Functional Impairment, and Parental Distress

OBJECTIVE

While cross-sectional studies underline that child and parent factors in pediatric chronic pain are reciprocally related, so far, little is known on their prospective relationship, especially in treatment contexts. This study aims to analyze directions of influence between child and parental outcomes using data from an intervention study.

METHODS

The sample covered 109 families with children aged 7-13 years diagnosed with functional abdominal pain (FAP). Child outcomes included pain and impairment, and parental outcomes covered caregiver-specific distress including both parental personal time burden (i.e., less time available for personal needs) and emotional burden due to child's pain (i.e., increased worries). Cross-lagged panel analyses examined the directions of the relations between child and parental outcomes across time (pretreatment T1, post-treatment T2, and 3-month follow-up and 12-month follow-up T3/T4).

RESULTS

First, a significant improvement over time in all measures was observed. Cross-lagged effects were found for less parental personal time burden at T2, predicting both less pain (β = -0.254, p = .004) and less impairment (β = -0.150, p = .039) at T3. Higher baseline pain was predictive for higher parental emotional burden after treatment (β = -0.130, p = .049) and, reversely, for less emotional burden at 12-month follow-up (β = 0.261, p = .004).

CONCLUSIONS

Addressing parental personal time burden in FAP treatment might possibly support the improvement on the child level. Replication of results in larger samples is warranted to gain more insight into the directions of influence and, in that way, to optimize treatment for pediatric FAP.

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial

Background

Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family.

Methods

Children aged 6–16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children’s and families’ self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted.

Discussion

The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021.

Trial registration

ClinicalTrials.govNCT04798859. Registered on March 15, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06048-8.

Analyzing Psychotherapy on Twitter: An 11-Year Analysis of Tweets From Major U.S. Media Outlets

BACKGROUND

The Internet has become the main source of information on health issues, and information now determines the therapeutic preferences of patients. For this reason, it is relevant to analyze online information discussing psychotherapy.

OBJECTIVE

To investigate tweets posted by 25 major US media outlets between 2009 and 2019 concerning psychotherapy.

METHODS

We investigated tweets posted by 25 major US media outlets about psychotherapy between January 2009 and December 2019 as well as the likes generated. In addition, we measured the sentiment analysis of these tweets.

RESULTS

Most of the tweets analyzed focused on Mindfulness (5,498), while a low number were related to Psychoanalysis (376) and even less to Cognitive-Behavioral Therapy (61). Surprisingly, Computer-supported therapy, Psychodynamic therapy, Systemic therapy, Acceptance and commitment therapy, and Dialectical behavior therapy did not generate any tweet. In terms of content, efficacy was the main focus of the posted tweets, receiving Cognitive-Behavioral Therapy and Mindfulness a positive appraisal.

CONCLUSIONS

US media outlets focused their interest on Mindfulness which may have contributed to the growing popularity in the past years of this therapeutic modality.

Evaluation of the parents' anxiety levels before and after the diagnosis of their child with a rare genetic disease: the necessity of psychological support

Background

The diagnosis of the rare genetic diseases has great importance in treating multisystemic conditions, preventing potential complications, and estimating disease risk for family members. The duration of obtaining genetic test results is varies. The demand to learn the diagnosis of a possible untreatable illness involves a struggle between uncertainty and a lifetime chronic disease. The current uncertainty of their child's condition and the long wait for a diagnosis may increase the parents' anxiety level and cause difficulties in the continuation of diagnostic procedures in some families. This study aimed to investigate the prediagnosis and postdiagnosis anxiety levels of parents who have a child with a rare genetic disease.

Method

The parents in this study, mothers or fathers, admitted their children to the Bezmialem Vakıf University Medical Genetics Clinic due to a suspected rare genetic disease (n = 40). Researchers created “The Sociodemographic Questionnaire” and used it to analyze the parents' sociodemographic status. In addition, they used the State-Trait Anxiety Inventory (STAI) to determine the anxiety levels of the parents.

Results

The state anxiety levels of parents decreased significantly after learning the diagnosis. However, there was no statistically significant decrease observed in trait anxiety levels.

Conclusion

Data from this study revealed that informing parents about their child's disease and properly explaining to them the expected difficulties might help to reduce their anxiety levels. Psychological support for parents is necessary to reduce their long-term stress, thus increasing the patient's compliance with treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02046-2.

Yoga, cognitive-behavioural therapy versus education to improve quality of life and reduce healthcare costs in people with endometriosis: a randomised controlled trial

INTRODUCTION

Endometriosis is a debilitating chronic inflammatory condition highly burdensome to the healthcare system. The present trial will establish the efficacy of (1) yoga and (2) cognitive-behavioural therapy (CBT), above (3) education, on quality of life, biopsychosocial outcomes and cost-effectiveness.

METHODS AND ANALYSIS

This study is a parallel randomised controlled trial. Participants will be randomly allocated to yoga, CBT or education. Participants will be English-speaking adults, have a diagnosis of endometriosis by a qualified physician, with pain for at least 6 months, and access to internet. Participants will attend 8 weekly group CBT sessions of 120 min; or 8 weekly group yoga sessions of 60 min; or receive weekly educational handouts on endometriosis. The primary outcome measure is quality of life. The analysis will include mixed-effects analysis of variance and linear models, cost-utility analysis from a societal and health system perspective and qualitative thematic analysis.

ETHICS AND DISSEMINATION

Enrolment in the study is voluntary and participants can withdraw at any time. Participants will be given the option to discuss the study with their next of kin/treating physician. Findings will be disseminated via publications, conferences and briefs to professional organisations. The University's media team will also be used to further disseminate via lay person articles and media releases.

TRIAL REGISTRATION NUMBER

ACTRN12620000756921p; Pre-results.

Acceptance and Commitment Therapy for Children with Special Health Care Needs and Their Parents: A Systematic Review and Meta-Analysis

Context: Acceptance and Commitment Therapy (ACT) is an emerging treatment for improving psychological well-being. Objective: To summarize research evaluating the effects of ACT on psychological well-being in children with special health care needs (SHCN) and their parents. Data Sources: An electronic literature search was conducted in PubMed, Web of Science, Ovid/EMBASE and PsycINFO (January 2000–April 2021). Study Selection: Included were studies that assessed ACT in children with SHCN (ages 0–17y) and/or parents of children with SHCN and had a comparator group. Data Extraction: Descriptive data were synthesized and presented in a tabular format, and data on relevant outcomes (e.g., depressive symptoms, stress, avoidance and fusion) were used in the meta-analyses to explore the effectiveness of ACT (administered independently with no other psychological therapy) compared to no treatment. Results: Ten studies were identified (child (7) and parent (3)). In children with SHCN, ACT was more effective than no treatment at helping depressive symptoms (standardized mean difference [SMD] = −4.27, 95% CI: −5.20, −3.34; p < 0.001) and avoidance and fusion (SMD = −1.64, 95% CI: −3.24, −0.03; p = 0.05), but not stress. In parents of children with SHCN, ACT may help psychological inflexibility (SMD = −0.77, 95% CI: −1.07, −0.47; p < 0.01). Limitations: There was considerable statistical heterogeneity in three of the six meta-analyses. Conclusions: There is some evidence that ACT may help with depressive symptoms in children with SHCN and psychological inflexibility in their parents. Research on the efficacy of ACT for a variety of children with SHCN and their parents is especially limited, and future research is needed.

Maternal Depressive Risk in Prenatal versus Postnatal Surgical Closure of Myelomeningocele: Associations with Parenting Stress and Child Outcomes

INTRODUCTION

Depressive risk is higher for mothers of infants with chronic medical conditions. The present study examined maternal depressive risk and associations with parent and child outcomes among mothers of young children who were randomized to either prenatal or postnatal surgical closure for myelomeningocele.

METHODS

Using the Management of Myelomeningocele Study database, maternal depressive risk was examined at 3 time points as follows: prior to birth, 12 months, and 30 months post birth. Separate multivariate analyses examined associations among change in depressive risk (between baseline and 30 months), parenting stress, and child outcomes at 30 months.

RESULTS

Mean scores were in the minimal depressive risk range at all the time points. Post birth depressive risk did not differ by prenatal versus postnatal surgery. Mean change scores reflected a decrease in depressive risk during the first 30 months. Only 1.1-4.5% of mothers reported depressive risk in the moderate to severe range across time points. Increased depressive risk during the first 30 months was associated with increased parenting stress scores and slightly lower child cognitive scores at 30 months.

CONCLUSION

Most mothers reported minimal depressive risk that decreased over time, regardless of whether their infant underwent prenatal or postnatal surgery. Only a small percentage of mothers endorsed moderate to severe depressive risk, but an increase in depressive risk over time was associated with higher parental stress and slightly lower child cognitive development.

Online psychosocial group intervention for parents: Positive effects on anxiety and depression

Objective

To evaluate the efficacy of an online psychosocial group intervention for parents of children with a chronic illness, in terms of anxiety and depression, and disease-related coping skills.

Methods

Parents (N = 73) participated in a parallel multicenter randomized controlled trial comparing an intervention group to a waitlist control group. In the group intervention Op Koers Online (English: On Track Online) parents learned how to use adaptive coping strategies taught with cognitive behavioral therapy and acceptance and commitment therapy techniques. Assessments (online questionnaires) took place at baseline (T0), 6-months (T1), and 12-months (T2) follow-up. Mixed-model analyses were performed to test the difference in change in outcomes between intervention (N = 34) and waitlist control group (N = 33).

Results

When compared with the waitlist control group, the intervention had a significant positive effect (p < .05) on changes in anxiety, depression, and total score T1 versus T0 (β = −.47 to −.51) and T2 versus T0 (β = −.39 to −.46), the coping skills open communication, relaxation, social support, acceptance, predictive control (β = .42–.88) and helplessness (β = −.47) T1 versus T0 and relaxation and positive thinking T2 versus T0 (β = .42–.53).

Conclusions

Parental anxiety and depression decreased, and use of adaptive coping skills improved after the intervention. The online character, the focus on parents themselves instead of on their child and the possibility for parents of children with rare illnesses to participate, are innovative and unique aspects of Op Koers Online for parents. The next step is to implement the intervention in clinical practice.

"it's a medical condition … you need to support as much as possible": a qualitative analysis of teachers' experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

Background

An increasing number of children with complex health needs are being educated in mainstream classes. CFS/ME is a complex and disabling condition, and there is little guidance on how primary school teachers can support younger children with this condition. To improve care, it is important to understand what these children need in the school setting, and the barriers and facilitators to teachers providing this support. The aims for this qualitative study were to explore teachers’ views about CFS/ME, their experiences of supporting a pupil with CFS/ME and their perspectives on the barriers and facilitators to providing support.

Methods

We recruited families from an NHS specialist paediatric CFS/ME service and families were eligible if the child was aged between 5 and 11 years and had a diagnosis of CFS/ME. We gained written consent/assent from families to invite the child’s teacher to participate in a qualitative interview. We contacted these teachers, gained written consent and then carried out semi-structured qualitative interviews. Interviews were audio-recorded, transcribed, anonymised and analysed thematically. Interviews took place between July 2018 and December 2018.

Results

We interviewed 11 teachers; their pupil’s age ranged from 5 to 11 years and school attendance ranged from 0 to 80%. Theme 1: Most teachers provided rich descriptions of their pupil’s CFS/ME; they consistently described cognitive dysfunction and significant fatigue, but beyond this the symptoms varied from one account to the next (from mobility problems, to aches and pains, digestive problems, headaches, nausea and hypersensitivity). These teachers noted the ripple effects on their pupil’s social, emotional and academic functioning. Two of the eleven teachers said that they did not observe symptoms of CFS/ME, expressing a degree of scepticism about the diagnosis. Theme 2: Teachers described a close relationship with their pupil. They said they understood the individual needs of the child and portrayed positive and proactive attitudes towards providing support. The type of support provided included facilitating rest breaks and limiting strenuous activities; using practical strategies to address cognitive, physical, social and emotional difficulties; maintaining a connection with the child during their absences from school; and encouraging the child to talk about their health and wellbeing. Teachers noted that receiving formal confirmation of the child’s diagnosis enabled them to put this support in place. Theme 3: The adaptations they described were often intuitive, rather than being based on a knowledge of CFS/ME. Teachers wanted more resources to increase their understanding of the condition and its management.

Conclusions

Primary school teachers want to provide effective support for children with CFS/ME. Clinical services should consider working in collaboration with teachers to equip them with evidence-based strategies for CFS/ME management in the primary school setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02461-7.

The Relationship between Stressors and Pain-Related Clinical Outcomes in Pediatric Chronic Pain Patients

Youth with chronic pain and youth who have experienced stressors are at risk for poor outcomes; however, little is known about the intersection of pain and stressors. This study aims to understand the prevalence of stressors among youth with chronic pain and the relationship between stressors and pain-related outcomes. Seven hundred and seventy youth with chronic pain aged 8–18 (M_age = 14.15 years, 70% female) reported pain characteristics, stressors, anxiety, disability, and quality of life. Most participants (82%) endorsed at least one stressor. A greater number of stressors was significantly related to greater anxiety and disability, and lower levels of quality of life. School stressors were significantly associated with functional disability; family, school, and peer stressors were significantly associated with anxiety and quality of life. Stressors are common in youth with chronic pain, and the presence of stressors is related to greater functional impairment. The results of this preliminary study using semi-structured clinical interviews suggest the importance of developing a validated measure that encompasses a wide variety of stressors for youth with pain. Future research on patient-reported stressors, relative intensity, and impact are needed.

The experience of living with a chronic disease in pediatrics from the mothers' narratives: The Clinical Interview on Parental Sense of Grip on the Disease

The Clinical Interview on the Sense of Grip on Chronic Disease has been administered to 68 mothers of children affected by Hereditary Angioedema (C1-Inh HAE), Type 1 Diabetes (T1D), Juvenile Rheumatoid Arthritis (JRA). The objectives are to detect general features of the experience of parenting children with chronic illness as well as the specificities of this experience related to the different conditions. Four Profiles of Sense of Grip were identified: Adempitive, Controlling, Reactive, Dynamic. The Sense of Grip Interview is an effective clinical tool for understanding the characteristics of the disease in daily life, which can help clinicians to encourage family adjustment to disease.

Matching Psychosocial Support Needs of Parents of a Child with a Chronic Illness to a Feasible Intervention

Objectives

Parents of children with a chronic illness (CI) are at risk for psychosocial problems. The aim of this study was to refine an existing face-to-face intervention into an online psychosocial group intervention for parents by (1) exploring which themes are important, (2) determine what type of intervention parents would like and (3) assess parents’ practical preferences.

Methods

Parents of children with a CI (0–18 years) were invited to complete an online questionnaire. To acquire more in-depth information, focus groups and telephone interviews were conducted. Descriptive statistics were used.

Results

272 parents (mean age = 43.1 years, 85% female) participated. Three focus groups (15 parents) and seven telephone interviews were conducted. Most important themes were: the CI of the child, family functioning, taking care of yourself, relationships with others and practical support. Parents preferred a group with parents of children in the same age category. At first, parents preferred face-to-face contact. After an explanation and demonstration of an online intervention, parents became more positive about online support, mostly because they could participate from home.

Conclusions for Practice

Parents have a need for psychosocial support focusing on different themes. Professionals should explain and demonstrate an online intervention to parents. Based on these results, Op Koers Online for parents was developed. An RCT to assess feasibility and effectiveness of the intervention is currently running.

How do parents deal with their children's chronic kidney disease? A qualitative study for identifying factors related to parent's adaptation

Background

Parents’ adaptation affects the health outcomes of children with chronic kidney diseases (CKD). Identifying factors that affect parents’ adaptation is necessary to understand their adaptation status. This study aims to explore factors related to the adaptation of parents who have children with CKD.

Methods

This was a qualitative study with a content analysis approach. Seventeen parents of children with CKD were selected by using purposive sampling. The leading researcher performed semi-structured, in-depth, face-to-face interviews to collect data. Conventional content analysis was used to analyze data.

Results

Two main categories extracted from the data were “adaptation facilitators” and “adaptation barriers.” Adaptation facilitators were supported by three sub-categories: “social support”, “family capability” and “spiritual beliefs”. Four sub-categories of “adaptation barriers” were revealed as: “family-related barriers,” “mental stress by others,” “the chronic nature of the disease,” and “unfavorable treatment conditions.”

Conclusions

Identifying the factors influencing parental adaptation helps the medical staff to make the necessary interventions to support the parents. According to this study, increasing parent access to the required information, supporting them financially and emotionally, and helping them identify support resources can facilitate their adaptation to their child’s chronic illness. Also, identifying and eliminating adaptation barriers can help parents deal better with their child’s chronic disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02170-4.

Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review

Background

The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years).

Objective

This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user’s experience of the digital intervention.

Methods

A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality.

Results

Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs) feedback and monitoring, shaping knowledge, repetition and substitution, and reward. Three papers included qualitative data on the user’s experience. We developed the following themes: parental involvement, connection with a health professional is important for engagement, technological affordances and barriers, and child-centered design.

Conclusions

Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (feedback and monitoring, shaping knowledge, repetition and substitution, and reward). This review suggests a model for improving the conceptualization and reporting of behavioral interventions involving children and parents.

Feasibility and Acceptance Testing of a Mobile Application Providing Psychosocial Support for Parents of Children and Adolescents With Chronic Pain: Results of a Nonrandomized Trial

Objective To conduct a single-arm pilot study assessing the feasibility and acceptability of a 30-day parent-focused mindfulness and psychosocial support mobile app intervention for parents of children with chronic pain. Methods Thirty parents completed the intervention, which included a mindfulness curriculum, peer support videos, and written psychoeducational content. Twelve healthcare providers also assessed the app and provided feedback. Feasibility was assessed by server-side documented usage on ≥50% of the days in the intervention period and completion of ≥70% of the mindfulness content. Parent and provider acceptance were assessed by ≥70% of participants rating each acceptance test question as ≥5 on a 7-point Likert scale. Parents completed measures of solicitousness, stress, mindful parenting, and resilience prior to and following the intervention. Results Feasibility results were mixed: parents completed mindfulness content on an average of 11.2 days during the intervention period, slightly under the pre-established criterion. However, parents completed an average of 72.1% of the content, which met feasibility criterion. Acceptance criteria were met for the majority of parent acceptance test questions and all of the provider acceptance test questions. Exploratory analyses of the psychosocial measures revealed significant decreases in parental solicitous behavior and perceived stress, and a significant increase in mindful parenting. Conclusions The current study extends the emerging body of research on mindfulness-based interventions for parents of children with chronic illness and suggests that it may be acceptable to deliver this content through a mobile device. Future research is needed to assess the intervention's efficacy compared to standard of care.

Mapping the evidence and gaps of interventions for pediatric chronic pain to inform policy, research, and practice: A systematic review and quality assessment of systematic reviews

Background: Reviews in pediatric chronic pain often focus on only one intervention or population, making it difficult for policymakers and decision makers to quickly synthesize knowledge to inform larger-scale policy and funding priorities. Aims: The aims of this study were to (1) create an evidence and gap map of interventions for pediatric chronic pain and (2) identify gaps between existing evidence and recently identified patient-oriented research priorities. Methods: We performed a systematic review of English-language peer-reviewed systematic reviews or clinical practice guidelines of pediatric chronic pain intervention published in the past 20 years. Database searches of Medline, Embase, PsycINFO, Web of Science, CINAHL, and SCOPUS were conducted inclusive to June 3, 2019. Review quality was assessed using the AMSTAR-2. Results: Of 4168 unique abstracts, 50 systematic reviews (including 2 clinical practice guidelines) crossing diverse pediatric chronic pain populations and intervention settings were included. One third were rated high quality, with half rated low to critically low quality. The largest proportion of reviews addressed psychological and pharmacological interventions, followed by interdisciplinary, other (e.g., dietary), and physical interventions. Most common outcomes included pain, physical, emotional, and role functioning and quality of life. Treatment satisfaction and adverse events were less common, with minimal report of sleep or economic factors. Most patient-oriented research priorities had not been investigated. Conclusions: Sufficient quality evidence is available to guide evidence-informed policies in pediatric chronic pain, most notably regarding psychological and pharmacological interventions. Numerous evidence gaps in patient-oriented research priorities and treatment outcomes should guide prioritization of research funds, as well as study aims and design.

Family Meal Frequency, Diet, and Family Functioning: A Systematic Review With Meta-analyses

OBJECTIVE

To examine the direction and magnitude of the relation between family meal frequency and dietary and family functioning outcomes in children (aged 2-18 years).

DESIGN

Systematic literature review with meta-analysis.

METHODS

Independent electronic searches, 1 for each outcome of interest, were conducted across 5 databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and PsycINFO. Studies were included if they were peer-reviewed and published in English in the US through December 2018.

MAIN OUTCOME MEASURES

Diet and family functioning.

RESULTS

Dietary outcomes showed some evidence of a positive association between family meal frequency and fruits, vegetables, fruits and vegetables, sugar-sweetened beverages, and the Healthy Eating Index. There was less clear evidence of this relation in snacks, fast food, and desserts. A positive association was found between family meal frequency or dinner family meal frequency and family functioning outcomes. All studies included had cross-sectional and longitudinal study designs.

CONCLUSIONS AND IMPLICATIONS

There is some evidence to show a positive relation between family meal frequency and dietary outcomes. There is stronger evidence for the relation with family functioning outcomes. Most articles included in the systematic reviews were excluded from meta-analysis owing to inadequate data and high methodological diversity across exposure and outcome variables.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Family Caregivers of Children With Medical Complexity: Health-Related Quality of Life and Experiences of Care Coordination

OBJECTIVE

To examine the association between care coordination experiences of family caregivers of children with medical complexity (CMC) and caregivers' health-related quality of life (HR-QOL).

METHODS

From July 2018 to July 2019, family caregivers of CMC completed an electronic survey (n = 136) at the time of initial contact with a regional complex care medical home. Information on caregiver HR-QOL and receipt of care coordination services were assessed using the Center for Disease Control's HR-QOL-14 measure and Family Experiences of Care Coordination questionnaire, respectively. Negative binomial regression, adjusted for caregiver and child characteristics, examined associations between caregiver HR-QOL and caregiver experiences of care coordination.

RESULTS

In the 30 days prior to initial contact, CMC caregivers reported a median of 3.5 mentally unhealthy days, 2 days felt depressed, 7 days felt anxious, and 16 days with insufficient sleep. Caregivers who had a knowledgeable, supportive care coordinator who advocates for their child reported significantly fewer days mentally unhealthy (incidence rate ratio [IRR], 0.46; 95% confidence interval [CI], 0.22-0.95), depressed (IRR, 0.44; 95% CI, 0.21-0.91), or anxious (IRR, 0.5; 95% CI, 0.29-0.85). Having a shared care plan was associated with significantly fewer days mentally unhealthy (IRR, 0.46; 95% CI, 0.23-0.93) or anxious (IRR, 0.53; 95% CI, 0.31-0.92). Having a written visit summary with appropriate content was associated with fewer days of insufficient sleep (IRR, 0.63; 95% CI, 0.43-0.93).

CONCLUSIONS

CMC family caregivers report experiencing mentally unhealthy days and negative mental symptom days. The experience of specific care coordination activities was associated with higher caregiver mental HR-QOL.

Caregivers' Sensemaking of Children's Hereditary Angioedema: A Semiotic Narrative Analysis of the Sense of Grip on the Disease

Background and aims: In pediatrics receiving a diagnosis of a chronic condition is a matter that involves caregivers at first. Beyond the basic issues of caring for the physical condition of the ill child, how caregivers face and make sense of the disease orients and co-constructs their children’s sensemaking processes of the disease itself. The aim of this article is to explore the experience of a rare chronic illness, a pediatric case of Hereditary Angioedema (HAE) from the caregivers’ perspective. Hereditary angioedema is characterized by subcutaneous swellings that can involve internal as well as external mucosal tissues and is highly variable and unpredictable in terms of severity, frequency, and where it occurs.

A qualitative narrative semiotic analysis of n. 28 maternal narratives on their children’s disease experience. Narratives were collected by an ad hoc interview on three domains of the disease experience: (A) interpretation of disease variability, (B) dialogical processes, and (C) management of the disease. Subsequently, we executed a TwoStep cluster analysis for categorical data to detect cross-sectional profiles of the maternal sensemaking processes of the disease.

Results: The coding grid was built analyzing the characteristics of the narrative links that orient the connection between the elements of the experience within each domain: (A) the connection among events, for the domain of disease variability interpretation, (B) the connection between self and other, for the dialogue domain, and (C) the connection among sensemaking and actions, for the disease management domain. Results from the cluster analysis show three narrative profiles: (1) adempitive; (2) reactive; (3) dynamic.

Discussion: Profiles will be discussed in light of the general conceptual framework of the Sense of Grip on the Disease (SoGoD) highlighting the importance of those sensemaking processes which, instead of relying on a coherent and closed interpretation of the disease, are characterized by a degree of tolerance for uncertainty and the unknown.

Electronic Health Interventions for Preventing and Treating Negative Psychological Sequelae Resulting From Pediatric Medical Conditions: Systematic Review

BACKGROUND

Pediatric medical conditions have the potential to result in challenging psychological symptoms (eg, anxiety, depression, and posttraumatic stress symptoms [PTSS]) and impaired health-related quality of life in youth. Thus, effective and accessible interventions are needed to prevent and treat psychological sequelae associated with pediatric medical conditions. Electronic health (eHealth) interventions may help to meet this need, with the capacity to reach more children and families than in-person interventions. Many of these interventions are in their infancy, and we do not yet know what key components contribute to successful eHealth interventions.

OBJECTIVE

The primary objective of this study was to conduct a systematic review to summarize current evidence on the efficacy of eHealth interventions designed to prevent or treat psychological sequelae in youth with medical conditions.

METHODS

MEDLINE (PubMed) and PsycINFO databases were searched for studies published between January 1, 1998, and March 1, 2019, using predefined search terms. A total of 2 authors independently reviewed titles and abstracts of search results to determine which studies were eligible for full-text review. Reference lists of studies meeting eligibility criteria were reviewed. If the title of a reference suggested that it might be relevant for this review, the full manuscript was reviewed for inclusion. Inclusion criteria required that eligible studies (1) had conducted empirical research on the efficacy of a Web-based intervention for youth with a medical condition, (2) had included a randomized trial as part of the study method, (3) had assessed the outcomes of psychological sequelae (ie, PTSS, anxiety, depression, internalizing symptoms, or quality of life) in youth (aged 0-18 years), their caregivers, or both, (4) had included assessments at 2 or more time points, and (5) were available in English language.

RESULTS

A total of 1512 studies were reviewed for inclusion based on their title and abstracts; 39 articles qualified for full-text review. Moreover, 22 studies met inclusion criteria for the systematic review. Of the 22 included studies, 13 reported results indicating that eHealth interventions significantly improved at least one component of psychological sequelae in participants. Common characteristics among interventions that showed an effect included content on problem solving, education, communication, and behavior management. Studies most commonly reported on child and caregiver depression, followed by child PTSS and caregiver anxiety.

CONCLUSIONS

Previous research is mixed but suggests that eHealth interventions may be helpful in alleviating or preventing problematic psychological sequelae in youth with medical conditions and their caregivers. Additional research is needed to advance understanding of the most powerful intervention components and to determine when and how to best disseminate eHealth interventions, with the goal of extending the current reach of psychological interventions.

Parent Pain Cognitions and Treatment Adherence in Juvenile Idiopathic Arthritis

OBJECTIVE

Given the high levels of pain and low rates of treatment adherence in children with juvenile idiopathic arthritis (JIA) and their families, this study sought to examine the relationship between parent pain cognitions (i.e., pain catastrophizing, fear of pain) and treatment adherence, and how barriers to treatment (e.g., forgetting treatments, children resisting injections) may be implicated in this relationship.

METHODS

Parents of children under 18 years of age who have been diagnosed with JIA were recruited to complete an online survey. In total, 221 parents (93% mothers) of children aged 2-17 years (M = 11.10, SD = 4.25) took part, completing questions regarding their pain cognitions, perceived barriers to treatment, and their child's arthritis treatment adherence ability.

RESULTS

Hierarchical regressions demonstrated that both pain cognitions (i.e., pain catastrophizing and fear of pain) were related to a decrease in parent-reported treatment adherence, however, pain catastrophizing was no longer significant when fear of pain was added to the model. The presence of treatment barriers partially mediated the relationship between fear of pain and treatment adherence, above and beyond the alternate model proposed.

CONCLUSION

These results suggest that parent pain catastrophizing and fears of pain are related to a greater difficulty following treatment plans, possibly in part because of barriers parents experience that preclude adherence. Given these findings, the identification and management of parent pain cognitions is critical to improving treatment adherence and outcomes for children with JIA and their families.

Recognizing and Effectively Managing Hypermobility-Related Conditions

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

The association of depression, anxiety, and stress with caring for a child with Congenital Zika Syndrome in Brazil; Results of a cross-sectional study

BACKGROUND

Zika virus (ZIKV) infection in pregnancy can cause microcephaly and a wide spectrum of severe adverse outcomes, collectively called "Congenital Zika Syndrome" (CZS). Parenting a child with disabilities can have adverse mental health impacts, but these associations have not been fully explored in the context of CZS in Brazil.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study was undertaken in Recife and Rio de Janeiro, including 163 caregivers of a child with CZS (cases) and 324 caregivers with an unaffected child (comparison subjects), identified from existing studies. The primary caregiver, almost always the mother, was interviewed using a structured questionnaire to collect information on: depression, anxiety, and stress (Depression, Anxiety, and Stress Scale-DASS-21), social support (Medical Outcomes Study Social Support Scale-MOS-SSS), and socio-demographic data. Data was collected May 2017-January 2018. Ethical standards were adhered to throughout the research. A high proportion of mothers reported experiencing severe or extremely severe levels of depression (18%), anxiety (27%) and stress (36%). Mothers of children with CZS were more likely to experience symptoms of depression, anxiety andstress, compared to mothers of comparison children. These associations were more apparent among mothers living in Rio de Janeiro. These differences were reduced after adjustment for socio-economic status and social support. Among mothers of children with CZS, low social support was linked to higher levels of depression, anxiety and stress, but there was no association with socio-economic status.

CONCLUSIONS/SIGNIFICANCE

Depression, anxiety and stress were very common among mothers of young children in Brazil, regardless of whether they were parenting a child with disabilities. Mothers of children with CZS may be particularly vulnerable to poor mental health, and this association may be buffered through better social support.

Improving health, wellbeing and parenting skills in parents of children with special health care needs and medical complexity - a scoping review

Background

Parenting children with special health care needs can be challenging particularly if children have complex conditions. Parents may struggle to manage their child’s health and their own emotions, contributing to poorer health outcomes for the family. Frequent healthcare contact presents opportunities to intervene, but current evidence review is limited. This review scopes and synthesizes interventions to improve health, wellbeing and parenting skills.

Methods

Using formal scoping review methodology MEDLINE, EMBASE, PsycINFO, CINAHL, The Cochrane Library, ERIC, ASSIA, HMIC and OpenGrey were searched to February 2017. Citations were double screened according to predetermined eligibility criteria. Data were extracted and synthesized on study design, population, measurement tools, and results.

Results

Sixty-five studies from 10,154 citations were included spanning parenting programs, other parent behavior change interventions, peer support, support for hospital admission and discharge and others. Interventions for parents of children with a wide range of conditions were included. These targeted a broad selection of parent outcomes, delivered by a wide variety of professionals and lay workers. Most studies reported positive outcomes. No serious adverse events were noted but issues identified included group and peer relationship dynamics, timing of interventions in relation to the child’s disease trajectory, the possibility of expectations not fulfilled, and parent’s support needs following intervention. Children with medical complexity were not identified explicitly in any studies.

Conclusions

The range of interventions identified in this review confirms that parents have significant and diverse support needs, and are likely to benefit from a number of interventions targeting specific issues and outcomes across their child’s condition trajectory. There is much scope for these to be provided within existing multi-disciplinary teams during routine health care contacts. Careful tailoring is needed to ensure interventions are both feasible for delivery within routine care settings and relevant and accessible for parents of children across the complexity spectrum. Further review of the existing literature is needed to quantify the benefits for parents and assess the quality of the evidence. Further development of interventions to address issues that are relevant and meaningful to parents is needed to maximize intervention effectiveness in this context.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1648-7) contains supplementary material, which is available to authorized users.

Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain

Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

The Role of Compassion and Mindfulness in Building Parental Resilience When Caring for Children With Chronic Conditions: A Conceptual Model

Compassion- and mindfulness-based interventions (CMBIs) and therapies hold promise to support parent resilience by enabling adaptive stress appraisal and coping, mindful parenting, and perhaps crucially, self-compassion. These contemplative modalities have recently been expanded to parents of children with chronic illness, building on successful applications for adults facing stress, chronic pain, or mental illness, and for healthcare professionals in response to caregiver burnout resulting from their work. The design and adaptation of interventions and therapies require a conceptual model of parent resilience in the context of childhood chronic illness that integrates mindfulness and compassion. The objective of this paper is to propose and describe such a model. First, we review the need for parent support interventions for this population. Second, we introduce a Model of Compassion, Mindfulness, and Resilience in Parental Caregiving. We highlight the mindful parenting approaches, guiding theories for adaptive coping, and family resilience frameworks that informed our model. Third, we describe a case of a parent to illustrate a practical application model. Finally, we outline future directions for intervention development and research to examine the impact of CMBIs on parent resilience.

A systematic review of the association between coping strategies and quality of life among caregivers of children with chronic illness and/or disability

Background

Parents of children with chronic illness have reported decreased psychological and physical quality of life (QoL) relative to parents of children without such illness, which may be associated with the extent of complexity involved in the caregiving role. Given that coping strategies have been reported to influence QoL, our goal was to synthesize existing research about the association between coping strategies and QoL in caregivers of children with chronic illness. We were particularly interested in whether coping strategies may mediate the association between caregiving complexity and QoL, or may modify the association.

Methods

We developed an electronic search strategy to identify relevant citations in Medline, EMBASE, PsycINFO and CINAHL. Two reviewers independently assessed retrieved citations against pre-specified inclusion criteria in two stages of screening. One reviewer abstracted data on study characteristics, methods to address confounding, measurement tools, risk of bias, and results with respect to associations of interest. A second reviewer validated extracted data. We summarized results narratively.

Results

2602 citations were screened and 185 full-text articles reviewed. The 11 articles that met inclusion criteria addressed 5 diseases and included a total of 2155 caregivers. Ten of the 11 included studies were cross-sectional. We identified some evidence that coping was associated with QoL: in three studies, coping strategies considered to be adaptive were positively associated with psychological QoL while in one study, maladaptive strategies were negatively associated with psychological QoL. Only two studies considered coping as a potential mediating variable in the association between caregiving complexity and parental QoL, with inconsistent findings and challenges in interpreting cross-sectional associations. No studies considered coping as a moderating variable. The variability among instruments used to measure key constructs, particularly coping strategies, made it difficult to synthesize results.

Conclusions

We found that coping strategies may be associated with psychological QoL among parents of children with chronic illness. We also identified important research gaps related to the consistent and clear measurement of coping strategies and their prospective association with QoL. Understanding how coping strategies are associated with QoL is important to inform the development of interventions to support families of children with chronic illness.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1587-3) contains supplementary material, which is available to authorized users.

Posttraumatic stress and health-related quality of life in parents of children with cardiac rhythm devices

PURPOSE

Studies have shown a high prevalence of post-traumatic stress disorders (PTSD) among parents of children with life-threatening diseases. However, it is yet unknown whether parents of children with cardiac rhythm device develop posttraumatic stress symptoms or even PTSD.

METHODS

This cross-sectional investigation is part of a comprehensive single-center study of long-term medical and psychosocial outcomes in pediatric patients with pacemaker (PM) and implantable cardioverter defibrillator (ICD). 69 patients (78%) were included in the study, with the participation of 69 mothers and 57 fathers. Parents completed the Posttraumatic Diagnostic Scale and Medical Outcomes Study Short Form-36 item questionnaire. Child's medical data was collected retrospectively from patients' hospital records.

RESULTS

At assessment, the patients (39% females) were on average 11.2 years old. The predominant device type was PM in 56 cases (81%). The mean time since device implantation was 6.3 years (SD = 4.3). Full heart-disease related PTSD was diagnosed in one mother and no father, while partial heart-disease-related PTSD was diagnosed in 3 mothers (4%) and 2 fathers (4%). Parental HRQoL-especially regarding the mental health dimension-was affected in both parents. In both parents, total PTSD symptom severity scores were a significant predictor for mental health summary scores after controlling for child age at implantation, presence of other non-cardiac disease in the child, parental age, and presence of own chronic disease.

CONCLUSIONS

Special attention should be given to parental PTSD symptoms in the clinical follow-up of PM and ICD patients as some parents might probably benefit from psychological support.

Risk severity moderated effectiveness of pain treatment in adolescents

Background and aims A targeted pain program may prevent the progression and subsequent occurrence of chronic pain in adolescents. This study tested the effectiveness of a new acceptance and commitment therapy -based pain management intervention, using physical and psychological functions as the outcomes. The objective was also to determine whether Pediatric Pain Screening Tool risk profiles function as outcome moderator in the current sample. A valid screening tool would enable the program development. Methods Thirty-two consecutive adolescent patients (13-17 years old) with idiopathic recurrent musculoskeletal pain completed the study. The intervention comprised acceptance and commitment therapy-oriented multidisciplinary treatment. Pediatric Pain Screening Tool, pain frequency, functional disability, school attendance, physical endurance, depressive symptoms, and catastrophizing coping style were measured before treatment (baseline) and again at 6 and 12 months after the initiation of treatment. To test the effectiveness of the new program, we also determined whether the original risk classification of each patient remained constant during the intervention. Results The intervention was effective for high-risk patients. In particular, the pain frequency decreased, and psychosocial measures improved. In post-intervention, the original risk classification of seven patients in the high-risk category changed to medium-risk. PPST classification acted as a moderator of the outcome of the current program. Conclusions The categorization highlighted the need to modify the program content for the medium-risk patients. The categorization is a good tool to screen adolescent patients with pain. Implications The results support using the Pediatric Pain Screening Tool in developing rehabilitation program for pediatric musculoskeletal pain patients. According to the result, for adolescent prolonged musculoskeletal pain patients the use of ACT-based intervention program is warranted.

An open/pilot trial of cognitive behavioral therapy in Turkish patients with refractory chronic migraine

Cognitive behavioral therapy (CBT) for pain management is a therapy that aims to modify thoughts and behavior to be more realistic and balanced. There are limited number of studies to assess the efficacy of CBT for patients with pharmacotherapy-resistant chronic migraine in our population. We aimed to invstigate the effects of CBT for patients with refractory chronic migraine on pain attack frequency, disability, severity, anxiety and depression. Fourteen patients with refractory chronic migraine who were referred from the headache clinic to the psychiatry department and regularly attended CBT sessions at least once every 2 weeks for at least 6 months, were included in the study. After 2 sessions of psychiatric evaluation, the subjects had 12 40-min CBT sessions and were given relaxation exercises. The Hamilton depression and anxiety inventories, visual analogue scale for assessing the severity of pain, and the Migraine disability assessment (MIDAS) test were used before and after CBT. The mean Hamilton depression scores before and after CBT were 29.07 ± 7.74 and 14.21 ± 7.7, respectively (p < 0.0001). The mean Hamilton anxiety scores before and after CBT were 26.8 ± 11.7 and 11.7 ± 2.6, respectively (p < 0.0001). The mean VAS scores before and after CBT were 8.07 ± 0.91 and 3.71 ± 1.32, respectively (p < 0.0001). The mean MIDAS scores before and after CBT were 55.5 ± 20.4 and 20.12 ± 16.6, respectively (p < 0.0001). Our results showed that CBT had made a statistically significant difference on pain severity, number of migraine attacks and disability in patients with refractory chronic migraine. CBT should be considered in this patient group.

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.

OBJECTIVES

To determine the efficacy of psychological therapies delivered remotely compared to waiting list, treatment as usual, or active control treatments, for the management of chronic pain in children and adolescents.

SEARCH METHODS

We searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents with chronic pain. We searched for chronic pain conditions including, but not exclusive to, headache, recurrent abdominal pain, musculoskeletal pain, and neuropathic pain. We also searched online trial registries, reference sections, and citations of included studies for potential trials.

SELECTION CRITERIA

We included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting-list control. We considered blended treatments, which used a combination of technology and up to 30% face-to-face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.

DATA COLLECTION AND ANALYSIS

We combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and satisfaction with treatment as a secondary outcome. We considered outcomes at two time points: first immediately following the end of treatment (known as 'post-treatment'), and second, any follow-up time point post-treatment between three and 12 months (known as 'follow-up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.

MAIN RESULTS

We found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta-analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.Headache conditionsFor headache pain conditions, we found headache severity was reduced post-treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low-quality evidence). No effect was found at follow-up (very low-quality evidence). There were no effects of psychological therapies delivered remotely for disability post-treatment (standardised mean difference (SMD) -0.16, 95% CI -0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow-up (both very low-quality evidence). Similarly, no effect was found for the outcomes of depression (SMD -0.04, 95% CI -0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD -0.08, 95% CI -0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post-treatment, or follow-up (both very low-quality evidence).Mixed chronic pain conditionsWe did not find any beneficial effects of psychological therapies for reducing pain intensity post-treatment for mixed chronic pain conditions (SMD -0.90, 95% CI -1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow-up. There were no beneficial effects of psychological therapies delivered remotely for disability post-treatment (SMD -0.28, 95% CI -0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow-up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI -0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI -0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post-treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow-up. We judged the evidence for all outcomes to be very low quality.All conditionsAcross all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.

AUTHORS' CONCLUSIONS

There are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post-treatment. For the remaining outcomes there was either no beneficial effect at post-treatment or follow-up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies for parents of children and adolescents with chronic illness aim to improve parenting behavior and mental health, child functioning (behavior/disability, mental health, and medical symptoms), and family functioning.This is an updated version of the original Cochrane Review (2012) which was first updated in 2015.

OBJECTIVES

To evaluate the efficacy and adverse events of psychological therapies for parents of children and adolescents with a chronic illness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and trials registries for studies published up to July 2018.

SELECTION CRITERIA

Included studies were randomized controlled trials (RCTs) of psychological interventions for parents of children and adolescents with a chronic illness. In this update we included studies with more than 20 participants per arm. In this update, we included interventions that combined psychological and pharmacological treatments. We included comparison groups that received either non-psychological treatment (e.g. psychoeducation), treatment as usual (e.g. standard medical care without added psychological therapy), or wait-list.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcomes post-treatment and at first available follow-up. Primary outcomes were parenting behavior and parent mental health. Secondary outcomes were child behavior/disability, child mental health, child medical symptoms, and family functioning. We pooled data using the standardized mean difference (SMD) and a random-effects model, and evaluated outcomes by medical condition and by therapy type. We assessed risk of bias per Cochrane guidance and quality of evidence using GRADE.

MAIN RESULTS

We added 21 new studies. We removed 23 studies from the previous update that no longer met our inclusion criteria. There are now 44 RCTs, including 4697 participants post-treatment. Studies included children with asthma (4), cancer (7), chronic pain (13), diabetes (15), inflammatory bowel disease (2), skin diseases (1), and traumatic brain injury (3). Therapy types included cognitive-behavioural therapy (CBT; 21), family therapy (4), motivational interviewing (3), multisystemic therapy (4), and problem-solving therapy (PST; 12). We rated risk of bias as low or unclear for most domains, except selective reporting bias, which we rated high for 19 studies due to incomplete outcome reporting. Evidence quality ranged from very low to moderate. We downgraded evidence due to high heterogeneity, imprecision, and publication bias.Evaluation of parent outcomes by medical conditionPsychological therapies may improve parenting behavior (e.g. maladaptive or solicitous behaviors; lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.28, 95% confidence interval (CI) -0.43 to -0.13; participants = 664; studies = 3; SMD -0.21, 95% CI -0.37 to -0.05; participants = 625; studies = 3; I² = 0%, respectively, low-quality evidence), chronic pain post-treatment and follow-up (SMD -0.29, 95% CI -0.47 to -0.10; participants = 755; studies = 6; SMD -0.35, 95% CI -0.50 to -0.20; participants = 678; studies = 5, respectively, moderate-quality evidence), diabetes post-treatment (SMD -1.39, 95% CI -2.41 to -0.38; participants = 338; studies = 5, very low-quality evidence), and traumatic brain injury post-treatment (SMD -0.74, 95% CI -1.25 to -0.22; participants = 254; studies = 3, very low-quality evidence). For the remaining analyses data were insufficient to evaluate the effect of treatment.Psychological therapies may improve parent mental health (e.g. depression, anxiety, lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.21, 95% CI -0.35 to -0.08; participants = 836, studies = 6, high-quality evidence; SMD -0.23, 95% CI -0.39 to -0.08; participants = 667; studies = 4, moderate-quality evidence, respectively), and chronic pain post-treatment and follow-up (SMD -0.24, 95% CI -0.42 to -0.06; participants = 490; studies = 3; SMD -0.20, 95% CI -0.38 to -0.02; participants = 482; studies = 3, respectively, low-quality evidence). Parent mental health did not improve in studies of children with diabetes post-treatment (SMD -0.24, 95% CI -0.90 to 0.42; participants = 211; studies = 3, very low-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent mental health.Evaluation of parent outcomes by psychological therapy typeCBT may improve parenting behavior post-treatment (SMD -0.45, 95% CI -0.68 to -0.21; participants = 1040; studies = 9, low-quality evidence), and follow-up (SMD -0.26, 95% CI -0.42 to -0.11; participants = 743; studies = 6, moderate-quality evidence). We did not find evidence for a beneficial effect for CBT on parent mental health at post-treatment or follow-up (SMD -0.19, 95% CI -0.41 to 0.03; participants = 811; studies = 8; SMD -0.07, 95% CI -0.34 to 0.20; participants = 592; studies = 5; respectively, very low-quality evidence). PST may improve parenting behavior post-treatment and follow-up (SMD -0.39, 95% CI -0.64 to -0.13; participants = 947; studies = 7, low-quality evidence; SMD -0.54, 95% CI -0.94 to -0.14; participants = 852; studies = 6, very low-quality evidence, respectively), and parent mental health post-treatment and follow-up (SMD -0.30, 95% CI -0.45 to -0.15; participants = 891; studies = 6; SMD -0.21, 95% CI -0.35 to -0.07; participants = 800; studies = 5, respectively, moderate-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent outcomes.Adverse eventsWe could not evaluate treatment safety because most studies (32) did not report on whether adverse events occurred during the study period. In six studies, the authors reported that no adverse events occurred. The remaining six studies reported adverse events and none were attributed to psychological therapy. We rated the quality of evidence for adverse events as moderate.

AUTHORS' CONCLUSIONS

Psychological therapy may improve parenting behavior among parents of children with cancer, chronic pain, diabetes, and traumatic brain injury. We also found beneficial effects of psychological therapy may also improve parent mental health among parents of children with cancer and chronic pain. CBT and PST may improve parenting behavior. PST may also improve parent mental health. However, the quality of evidence is generally low and there are insufficient data to evaluate most outcomes. Our findings could change as new studies are conducted.