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

Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions

BACKGROUND

Cerebral palsy (CP), the most common physical disability of childhood, is often accompanied by a range of comorbidities including pain. Pain is highly prevalent in children and young people with CP, yet has been poorly understood, inaccurately assessed, and inadequately managed in this vulnerable population. This narrative review presents recent research advances for understanding and managing pain in children and young people with CP, focusing on chronic pain, and highlights future research directions.

MAIN BODY

Pain prevalence rates in CP vary due to different methodologies of studies. Recent systematic reviews report up to 85% of children experience pain; higher in older children, females, and those with dyskinesia and greater motor impairment. Research examining the lived experience perspectives of children and their families demonstrate that even those with mild motor impairments have pain, children want to self-report pain where possible to feel heard and believed, and management approaches should be individualized. Notably, many children with cognitive and communication impairments can self-report their pain if adjustments are provided and they are given a chance. Past inadequacies of pain assessment in CP relate to a focus on pain intensity and frequency with little focus on pain interference and coping, a lack of tools appropriate for the CP population, and an assumption that many children with cognitive and/or communication limitations are unable to self-report. Recent systematic reviews have identified the most reliable and valid assessment tools for assessing chronic pain. Many were not developed for people with CP and, in their current form, are not appropriate for the spectrum of physical, communication, and cognitive limitations seen. Recently, consensus and co-design in partnership with people with lived experience and clinicians have identified tools appropriate for use in CP considering the biopsychosocial framework. Modifications to tools are underway to ensure feasibility and applicability for the spectrum of abilities seen.

CONCLUSION

Recent research advances have improved our understanding of the prevalence, characteristics and lived experience of chronic pain, and refined assessment methods in children and young people with CP. However, the very limited evidence for effective and novel management of chronic pain in this population is where research should now focus.

Cross-sectional and longitudinal changes in body composition, anxiety, and depression in a clinical sample of adolescents with anorexia nervosa

OBJECTIVE

Eating disorders among children and adolescents have increased in prevalence, and mortality rates for anorexia nervosa are among the highest for any psychiatric disorder. Our current study aimed to (a) examine the cross-sectional relationship between body composition and anxiety/depressive symptoms among 97 adolescents and young adults who have been diagnosed with anorexia nervosa, (b) examine the longitudinal changes in body composition and anxiety/depressive symptoms over three months (from baseline to follow-up visit), and (c) examine the longitudinal relationship between change in body composition and change in anxiety/depression over three months.

METHOD

A retrospective chart review was conducted within an interdisciplinary eating disorder clinic between August 2019 and December 2021. In total, 97 adolescents aged 11-20 years old with diagnoses of anorexia nervosa were included in the analyses. Body composition data were collected at each visit along with parent- and youth-report measures of symptoms of anxiety/depression symptoms.

RESULTS

Findings indicated adolescents demonstrated some improvement in body composition, as well as parent-reported reductions in anxiety/depression symptoms. Based on parent reports, increased BMI percentile was associated with improvements in anxiety/depression symptoms. On the other hand, youth did not report significant changes in anxiety/depressive symptoms. Additionally, there were no associated improvements with body composition measures, which may be associated with continued body dissatisfaction or symptoms of anxiety and depression predating the eating disorder.

CONCLUSIONS

These results suggest the importance of including interventions addressing depression, anxiety, and body image as part of treatment.

Patient-Reported Outcomes to Describe Global Health and Family Relationships in Pediatric Weight Management

Background: Patient-reported outcomes (PROs) can assess chronic health. The study aims were to pilot a survey through the PEDSnet Healthy Weight Network (HWN), collecting PROs in tertiary care pediatric weight management programs (PWMP) in the United States, and demonstrate that a 50% enrollment rate was feasible; describe PROs in this population; and explore the relationship between child/family characteristics and PROs. Methods: Participants included 12- to 18-year-old patients and parents of 5- to 18-year-olds receiving care at PWMP in eight HWN sites. Patient-Reported Outcomes Measurement Information System (PROMIS®) measures assessed global health (GH), fatigue, stress, and family relationships (FR). T-score cut points defined poor GH or FR or severe fatigue or stress. Generalized estimating equations explored relationships between patient/family characteristics and PROMIS measures. Results: Overall, 63% of eligible parents and 52% of eligible children enrolled. Seven sites achieved the goal enrollment for parents and four for children. Participants included 1447 children. By self-report, 44.6% reported poor GH, 8.6% poor FR, 9.3% severe fatigue, and 7.6% severe stress. Multiple-parent household was associated with lower odds of poor GH by parent proxy report [adjusted odds ratio (aOR) 0.69, 95% confidence interval (CI) 0.55-0.88] and poor FR by self-report (aOR 0.36, 95% CI 0.17-0.74). Parents were significantly more likely to report that the child had poor GH and poor FR when a child had multiple households. Conclusions: PROs were feasibly assessed across the HWN, although implementation varied by site. Nearly half of the children seeking care in PWMP reported poor GH, and family context may play a role. Future work may build on this pilot to show how PROs can inform clinical care in PWMP.

Parent-child agreement on health-related quality of life: the role of perceived consequences of the child's chronic illness

OBJECTIVE

We aimed to assess the parent-child agreement on various domains of health-related quality of life (HRQoL) in a Hungarian pediatric sample. We examined the associations of demographic, illness-specific factors and the perceived consequences of the illness with the parent-child disagreement.

DESIGN

A cross-sectional study was carried out with child-parent pairs in a heterogeneous pediatric sample (n = 259).

OUTCOME MEASURES

Child and parent versions of Kidscreen-52 and the consequences scale of the Revised Illness Perception Questionnaire (IPQ-R) were applied. We used intraclass correlation coefficients to measure agreement. We computed directional discrepancies as dyadic indexes and applied them in multinomial regression analysis to identify factors influencing agreement.

RESULTS

Agreement between children and parents on the KIDSCREEN-52 instrument was moderate to good (ICC = 0.41 to 0.66). Significant (p < 0.005) parent-child disagreement was observed on 6 out of 10 dimensions of HRQoL: Parents rated their children's well-being lower on Physical Well-being, Psychological Well-being, Parent Relations and Home Life, Social Support and Peers, and Financial Resources scales and rated higher on Moods and Emotions compared to child-reported HRQoL. Both parent's and child's higher perceived illness consequences made disagreement significantly more likely on various domains.

CONCLUSIONS

Direction of disagreement may draw attention to potentially vulnerable domains of the child's well-being, like moods and emotions and self-perception.

Natural History of Pediatric Hand and Wrist Ganglion Cysts: Longitudinal Follow-Up of a Prospective, Dual-Center Cohort

PURPOSE

This investigation describes the outcomes of pediatric ganglion cysts in a prospective cohort that elected not to undergo cyst aspiration or surgical treatment. Our primary aim was to investigate the rate of spontaneous resolution over time among the subset of patients who did not undergo specific treatments.

METHODS

Children (aged ≤18 years) who presented to the clinic with ganglion cysts of the hand or wrist were enrolled in a prospective two-center registry between 2017 and 2021. Enrolled subjects who never elected to undergo cyst aspiration or surgical treatment were analyzed. The data collected included age, sex, cyst location and laterality, hand dominance, Wong-Baker pain scale scores, and Patient-Reported Outcome Measurement Information System upper-extremity scores. Follow-up surveys were completed for up to 5 years.

RESULTS

A total of 157 cysts in 154 children, with an average age of 9.4 years and a female-to-male ratio of 1.4:1, were eligible. The most common ganglion location was dorsal wrist (67/157, 42.7%), followed by volar wrist (49/157, 31.2%), the flexor tendon sheath (29/157, 18.5%), and the extensor tendon synovial lining (8/157, 5.1%). The average follow-up duration was 2.5 years after initial presentation to the clinic, and 63.1% (99/157) of the patients responded to follow-up surveys. Among them, 62.6% (62/99) of cysts spontaneously resolved; the resolution rates ranged from 51.9% of volar wrist ganglions to 81% of flexor tendon sheath cysts, with an average time to resolution of 14.1 months after cyst presentation. Cysts were more likely to resolve in the hand than in the wrist (84.0% vs 55.4%, respectively). Cysts present for >12 months at initial evaluation were less likely to resolve spontaneously (41.2% vs 67.1%).

CONCLUSIONS

Of children who elected not to undergo aspiration or surgical treatment, approximately two-thirds of families reported that their child's ganglion cyst resolved spontaneously. Cysts that resolve spontaneously usually do so within 2 years of presentation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Chronic pain interference assessment tools for children and adults who are unable to self-report: A systematic review of psychometric properties

AIM

To identify and evaluate psychometric properties of assessment tools for assessing pain interference in children, adolescents, and adults with chronic pain and the inability to self-report.

METHOD

The protocol was registered with PROSPERO (CRD42022310102). A search was run in MEDLINE, Embase, and PsycInfo (29th March 2022) to identify articles reporting psychometric properties of pain interference assessment tools for children, adolescents, and adults with chronic pain and the inability to objectively self-report pain. Retrieved studies were reviewed by two authors (MGS, LCF) and study quality was assessed using COSMIN.

RESULTS

Psychometric properties of 10 pain interference tools were assessed from 33 studies. The Paediatric Pain Profile (PPP) had low-quality evidence for content validity and internal consistency with children and adolescents who are unable to self-report. No tools for adults had evidence for content validity and internal consistency. No tool had evidence for all nine psychometric properties.

INTERPRETATION

The PPP is recommended for pain interference assessment in children and adolescents with chronic pain and the inability to self-report. Few tools are available for adults. Three tools for children (Patient-Reported Outcome Measurement Information System Pediatric Proxy Pain Interference Scale; Bath Adolescent Pain Questionnaire for Parents; modified Brief Pain Inventory-Proxy [mBPI]) and three tools for adults (Doloplus-2; Patient-Reported Outcome Measurement Information System Pain Interference Scale-proxy; Brief Pain Inventory-proxy) are promising but require further investigation.

Pediatric Preanesthesia Anxiety and Factors of Family Satisfaction

PURPOSE

Pediatric patients scheduled for procedures with anesthesia experience stress and feelings of anxiety, but frequently lack the opportunity to report their feelings. Pediatric patient anxiety may be related to internal (patient perceptions/emotions) or external (demographic/family knowledge/satisfaction) factors. The purpose of the study was to explore patient reports of anxiety in young school-age through adolescent ages, and factors of family satisfaction before a scheduled procedure with anesthesia.

DESIGN

Cross-sectional, descriptive, and correlational.

METHODS

A voluntary survey including family-report of patient age and past anesthesia, type of procedure, family satisfaction factors (knowledge of anesthesia; perioperative concerns), and patient-report of anxiety with a visual analog scale (0-10) was offered to eligible families at their preanesthesia clinic appointment.

FINDINGS

Completed surveys from 80 families (mean age of patient = 12 years; range 7-17 years) showed legally authorized guardians (LAGs) felt the preanesthesia visit helped them understand anesthesia information, but they also had concerns, such as complications and pain. Patient anxiety ratings ranged from 0 to 10 (M = 3.3, SD = 3.1), and were slightly higher for patients 11 years and younger (M = 3.8; SD = 3.4). Anxiety ratings were not significantly correlated with other factors measured.

CONCLUSIONS

Pediatric patients, ages 7-17, report preanesthesia anxiety levels ranging from "not at all" to "worst imaginable," unrelated to demographic or family factors. Family members have perioperative concerns that need to be addressed before scheduled procedures. There is an impetus for improvement in psychosocial assessment and health care team collaboration to meet needs in a family-centered preanesthesia care model.

Patient-reported outcome instruments for assessing the involvement of children and adolescents with type 1 diabetes in their treatment: a scoping review protocol

OBJECTIVE

The objective of this review is to identify available patient-reported outcome instruments used to assess the involvement of children and adolescents with type 1 diabetes in their treatment. Specifically, this review will examine the content, structure, and application of these instruments.

INTRODUCTION

It is considered meaningful to involve children and adolescents living with a chronic health condition, such as type 1 diabetes, in their own treatment. Despite a growing interest in patient involvement within pediatric health care, including the use of patient-reported outcomes, only a few patient-reported outcome instruments have been developed and are used to evaluate the experiences of children and adolescents with type 1 diabetes of being involved in their own treatment.

INCLUSION CRITERIA

This scoping review will examine patient-reported outcome instruments used to assess the experiences of children and adolescents (11 to 18 years of age) with type 1 diabetes of being involved in their own care. Patient-reported outcome instruments measuring parents' or clinicians' experiences of involvement will be excluded.

METHODS

The proposed review will follow JBI guidelines and all stages will involve 2 or more reviewers. PubMed, Embase, CINAHL, PsycINFO, JSTOR, and MedNar will be searched without limitations on the year or language of publication. Literature that is not written in English will be translated. Data extraction, charting, and analysis will be guided by a template developed for this review that focuses on the content, structure, and application of the patient-reported outcome instruments. Any modifications to the extraction template will be detailed in the review, and data will be presented in a descriptive format.

Checking IN: Development, Acceptability, and Feasibility of a Pediatric Electronic Distress Screener

Objective

Chronic illness in children and adolescents is associated with significant stress and risk of psychosocial problems. In busy pediatric clinics, limited time and resources are significant barriers to providing mental health assessment for every child. A brief, real-time self-report measure of psychosocial problems is needed.

Methods

An electronic distress screening tool, Checking IN, for ages 8-21 was developed in 3 phases. Phase I used semi-structured cognitive interviews (N = 47) to test the wording of items assessing emotional, physical, social, practical, and spiritual concerns of pediatric patients. Findings informed the development of the final measure and an electronic platform (Phase II). Phase III used semi-structured interviews (N = 134) to assess child, caregiver and researcher perception of the feasibility, acceptability, and barriers of administering Checking IN in the outpatient setting at 4 sites.

Results

Most patients and caregivers rated Checking IN as "easy" or "very easy" to complete, "feasible" or "somewhat feasible," and the time to complete the measure as acceptable. Most providers (n = 68) reported Checking IN elicited clinically useful and novel information. Fifty-four percent changed care for their patient based on the results.

Conclusions

Checking IN is a versatile and brief distress screener that is acceptable to youth with chronic illness and feasible to administer. The summary report provides immediate clinically meaningful data. Electronic tools like Checking IN can capture a child's current psychosocial wellbeing in a standardized, consistent, and useful way, while allowing for the automation of triaging referrals and psychosocial documentation during outpatient visits.

A critical evaluation of the content validity of patient-reported outcome measures assessing health-related quality of life in children with cancer: a systematic review

BACKGROUND

With increasing survival rates in pediatric oncology, the need to monitor health-related quality of life (HRQOL) is becoming even more important. However, available patient-reported outcome measures (PROMs) have been criticized. This review aims to systematically evaluate the content validity of PROMs for HRQOL in children with cancer.

METHODS

In December 2021, a systematic literature search was conducted in PubMed. PROMs were included if they were used to assess HRQOL in children with cancer and had a lower age-limit between 8 and 12 years and an upper age-limit below 21 years. The COSMIN methodology for assessing the content validity of PROMs was applied to grade evidence for relevance, comprehensiveness, and comprehensibility based on quality ratings of development studies (i.e., studies related to concept elicitation and cognitive interviews for newly developed questionnaires) and content validity studies (i.e., qualitative studies in new samples to evaluate the content validity of existing questionnaires).

RESULTS

Twelve PROMs were included. Due to insufficient patient involvement and/or poor reporting, the quality of most development studies was rated 'doubtful' or 'inadequate'. Few content validity studies were available, and these were mostly 'inadequate'. Following the COSMIN methodology, evidence for content validity was 'low' or 'very low' for almost all PROMs. Only the PROMIS Pediatric Profile had 'moderate' evidence. In general, the results indicated that the PROMs covered relevant issues, while results for comprehensiveness and comprehensibility were partly inconsistent or insufficient.

DISCUSSION

Following the COSMIN methodology, there is scarce evidence for the content validity of available PROMs for HRQOL in children with cancer. Most instruments were developed before the publication of milestone guidelines and therefore were not able to fulfill all requirements. Efforts are needed to catch up with methodological progress made during the last decade. Further research should adhere to recent guidelines to develop new instruments and to strengthen the evidence for existing PROMs.

Disagreement between mothers' and fathers' rating of health-related quality of life in children with cancer

PURPOSE

Serial assessment of health condition based on self-report made by children and their proxies has consistently shown a lack of congruence. The study explored the discrepancies between mother's, father's, and children's reports on health-related quality of life (HRQOL) during the first two months of pediatric cancer treatment.

METHODS

In this cohort study, children and parents completed the generic and cancer-specific Pediatric Quality-of-Life Inventory (PedsQL) questionnaires at initial diagnosis and in the subsequent months. Evaluation of discrepancies included intraclass correlations between mother-child and father-child dyads at different domain levels.

RESULTS

Thirty-six children with a diagnosis of cancer between May 2020 and November 2021 and their parents were included in this study. At diagnosis, mother-child dyads showed better agreement on more domains of the PedsQL Generic Core Scale than father-child dyads; moderate agreement persisted for both parents at subsequent time points on the physical domain. The disease-specific PedsQL Cancer Module revealed moderate and better agreement for mother-child dyads during active cancer therapy. In particular, agreement of mother-child dyads was pronounced for domains such as worry (0.77 [95% CI 0.52-0.89, P < 0.001]), whereas fathers tended to overestimate the child's symptom burden for most of the remaining domains of the PedsQL Cancer Module.

CONCLUSION

This cohort study shows that both parent proxy reports can provide valid information on child's HRQOL, but that fathers tend to overestimate, particularly for non-observable domains. Proxy reports derived from mothers more closely agreed with children's HRQOL and might be more weighted, if there is uncertainty between parents.

Using the Parent Risk Screening Measure (PRISM) to Assess Pain-Related Risk Factors in Parents of Youth Seeking Treatment for Acute Musculoskeletal Pain

OBJECTIVES

The Parent Risk Screening Measure (PRISM) rapidly assesses parent distress, psychosocial function, and behaviors associated with child pain-related dysfunction in parents of youth with chronic pain. Recognizing the importance of parent pain-related cognitions and responses to pain during the acute pain period, the current study examined the utility of the PRISM in screening parents of youth with acute pain.

METHODS

Participants were 175 parent-youth dyads taking part in a larger study examining risk and resilience in youth with acute musculoskeletal pain. Parents completed the PRISM and a battery of measures reporting on their child's pain-related disability and cognitions and behaviors in response to their child's pain. Youth reported on their pain, pain-related disability, pain-related fear, catastrophizing, and pain self-efficacy.

RESULTS

PRISM total scores ( M =2.55, SD=2.77) were correlated with many parent and child report measures (eg, protectiveness, catastrophizing, and pain-related fear), with higher scores associated with greater symptoms. Using published PRISM cutoffs, 86.9% of parents were classified as low and 13.13% as elevated risk. t tests revealed significant differences between elevated and low-risk groups on several measures. Moreover, youth of parents in the elevated risk group were more likely to meet clinical cutoffs on pain catastrophizing and fear avoidance measures.

DISCUSSION

Findings suggest the PRISM is useful in screening for parent distress and behaviors associated with elevated pain symptomatology in a pediatric acute musculoskeletal pain sample. The important next steps are to identify the ideal time for administering the PRISM and to examine the associations among PRISM scores and pain outcomes over time.

Translation and linguistic validation of the DISABKIDS chronic generic module into simplified Chinese (DCGM-37) for use among children with cancer

PURPOSE

To develop a simplified Chinese version of the DISABKIDS chronic generic module-37 (DCGM-37), and to test the translated measures in children with cancer by employing a cognitive interviewing technique.

DESIGN AND METHODS

The English version of DCGM-37 was translated forward and backward into simplified Chinese by bilingual translators, following the guidelines from its copyright holders, which also involved a cultural adaptation component. Twelve Chinese children aged 8-18 years and eight parents were cognitively interviewed.

RESULTS

The findings support the relevance, comprehensibility, and efficacy of the Chinese version. Consideration was given, and improvements were made, to the language, cultural concerns, and content, which improved functionality and increased validation. The patients/caregivers understood the instructions, questions, and answer choices. Some revisions, however, were made to address patient/caregiver feedback obtained through cognitive interviews. Conceptually and semantically, the simplified Chinese version of the DCGM-37 version was identical to the original. Conclusions The simplified Chinese version of the DCGM-37 was semantically and conceptually equivalent to the English version. Chinese children aged 8 to 18 years were able to comprehend this instrument.

CONCLUSIONS

The simplified Chinese version of the DCGM-37 was semantically and conceptually equivalent to the English version. Chinese children aged 8 to 18 years were able to comprehend this instrument and express their experiences and feelings about their life.

PRACTICE IMPLICATIONS

The simplified Chinese version of the DCGM-37 was translated, and cross-cultural adaptation and validation were performed. Chinese children found the tool easy to use and were able to express their experiences and feelings about their health-related quality of life.

Factors Associated With Quality of Life in Children Receiving Pediatric Palliative Care

CONTEXT

Since pediatric palliative care (PPC) aims to improve the health-related quality of life (HRQoL) of children with life-limiting conditions (LLC), assessment of their HRQoL and identification of its determinants is crucial.

OBJECTIVES

To examine the clinical and family factors associated with HRQoL of children with LLC METHODS: This was a cross-sectional study of 136 pediatric patients with LLC who were enrolled in the PPC services at Seoul National University Hospital in South Korea. Patients' HRQoL was measured using the Pediatric Quality of Life 4.0. Clinical and family characteristics were gathered from the medical records and PPC registry database.

RESULTS

Most children with LLC have a poor HRQoL at their enrollment for PPC services with significant variation in their total HRQoL scores according to the diagnostic categories. Patients with nonmalignant conditions showed significantly lower HRQoL scores than patients with malignancy. Lower HRQoL scores were associated with more caregiver depressive symptoms. In a multivariable regression model, total HRQoL scores of patients were significantly associated with diagnostic categories and caregiver's depressive symptoms after controlling for other clinical and family variables. Physical health summary scores were significantly associated with diagnostic categories and caregiver depressive symptoms. Psychosocial health summary scores were significantly associated with diagnostic categories, patient location, and caregiver's depressive symptoms.

CONCLUSION

The HRQoL of children with LLC receiving PPC differed among underlying disease categories. Lower HRQoL was associated with more caregiver depressive symptoms. These findings suggest the needs for optimized intervention in palliative care for children with nonmalignant conditions and family-centered intervention to address caregivers' psychosocial problems.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children

PURPOSE

Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort.

METHODS

A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores.

RESULTS

A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores.

CONCLUSIONS

Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

What patient factors and Patient-Reported Outcomes Measurement Information System domains are associated with worse pain coping in pediatric orthopaedic patients in the United States?

We sought to better understand the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) mobility, pain interference (PI) and depressive symptoms scores, as well as determine what patient factors and PROMIS domains were associated with worse pain coping (PROMIS PI), in a pediatric orthopaedic population. Between 27 August 2015 and 30 April 2019, new pediatric orthopaedic patients 18 years or younger (or their guardians as a proxy) were asked to complete PROMIS mobility, PI and depressive symptoms domains at an academic medical center pediatric orthopaedic clinic. Pearson correlation coefficients (r) were calculated between each PROMIS domain. Linear multivariate regression analysis was used to determine patient characteristics and PROMIS domains associated with presenting PROMIS PI scores. There was a strong-moderate correlation between PROMIS mobility and PI (r = -0.66, P < 0.001), while the correlation between PROMIS mobility and depressive symptoms was moderate-poor (r = -0.38, P < 0.001). There was a moderate correlation between PROMIS depressive symptoms and PI (r = 0.54, P < 0.001). In multivariate linear regression analysis, female gender (β = 0.82, P < 0.001), self-reported black race (β = 0.94, P < 0.001), Medicaid insurance (β = 0.82, P < 0.001) and worsening depressive symptoms (β = 0.33, P < 0.001) were associated with worse pain coping mechanisms, while increasing mobility (β = -0.47, P < 0.001) was associated with better pain coping mechanisms. Poor mobility and worse depressive symptoms are associated with worse pain coping mechanisms. Additionally, Medicaid insurance status, black race and female gender are also associated with worse physical limitations secondary to pain.

Comparison of child self-report and parent proxy-report of symptoms: Results from a longitudinal symptom assessment study of children with advanced cancer

PURPOSE

This report represents a subanalysis of data from a primary study and addresses a gap in understanding the similarities and differences of symptom reporting between children with advanced cancer and their parents. The objectives of this subanalysis were to (1) compare reports of symptom prevalence, symptom burden, and symptom frequency, severity, and distress between groups of children and adolescents and their parents, and (2) describe concordance of symptom reports within individual child-parent dyads.

DESIGN AND METHODS

Forty-six children with relapsed, refractory, or progressive cancer and their parents from five pediatric cancer centers prospectively reported symptoms every 2 weeks for up to 61 weeks. The abbreviated Pediatric Quality of Life and Evaluation of Symptoms Technology-Memorial Symptom Assessment Scales were used to measure symptom prevalence, frequency, severity, and distress.

RESULTS

Children and parents reported pain, fatigue, nausea, and sleeping difficulties as the most frequently occurring symptoms. With the exception of shortness of breath, parents reported symptom prevalence more often than children. The differences in parent reports were statistically significant for fatigue, nausea, lack of appetite, feeling nervous, and sadness. Parents reported higher symptom burden scores compared to children for all individual symptoms except shortness of breath. Children reported higher scores for 19 of 32 possible symptom frequency, severity, and distress ratings. Children's scores were higher for frequency and severity, while parents' scores were higher for distress. Sleeping difficulties, pain, nausea, and diarrhea demonstrated the highest concordance, while feeling nervous, sadness, irritability, and fatigue yielded the lowest concordance between children's and parents' symptom reports.

PRACTICE IMPLICATIONS

Eliciting the symptom experience from the child, when appropriate, rather than a parent proxy is best practice given evidence supporting the overestimation of symptom prevalence by parents and underestimation of symptom frequency and severity for some symptoms. When proxy raters must be used, pediatric nurses should educate proxy raters regarding symptom assessment, and assess and tend to symptoms that may not exhibit visual cues. Pediatric nurses should conduct a comprehensive symptom assessment and evaluate beyond the presence of symptoms and include an assessment of frequency, severity, and distress for physical and psychological symptoms to optimize symptom management strategies.

Pediatric measure of participation short forms version 2.0: development and evaluation

DESIGN

Mixed methods cohort study.

OBJECTIVES

To develop and assess psychometric properties of the pediatric measure of participation (PMoP) short forms (SF) version 2.0.

SETTING

Secondary analyses of data collected from 381 children with spinal cord injury (SCI) of at least 3-month duration living in the community, and 322 parents of children with SCI at three pediatric orthopedic hospitals in the United States.

METHODS

Mixed methods iterative process to customize SF based on, highly relevant items, age and school analysis of item distributions; ceiling and floor effects; internal consistency and group-level reliability; correlation of SF scores with scores derived from the total item bank; and assessment of the degree to which item difficulty matched the abilities of children in the sample.

RESULTS

PMoP SF V2.0 mean T scores ranged from 47.59 to 51.23. Overall, mean scores were somewhat higher for older children and parent respondents. Group-level reliability values ranged from 0.66 to 0.79; Cronbach's alpha values ranged from 0.79 to 0.90; ICC values ranged from 0.89 to 0.95. Pearson Correlations ranged from 0.80 to 0.95, showing good to strong correlation between scores from the SFs and total item bank for each domain. Test information function demonstrated that score estimates will be less precise at higher ends of the scale.

CONCLUSIONS

PMoP SFs V2.0 contain items relevant to participation among children with SCI, and are tailored for four age groups and school status. They are recommended for use when computer adaptive testing (CAT) is not possible.

Phenotyping peripheral neuropathic pain in male and female adolescents: pain descriptors, somatosensory profiles, conditioned pain modulation, and child-parent reported disability

ABSTRACT

Neuropathic pain (NeuP) can be difficult to diagnose and manage in children. Data regarding prevalence and sex-dependent differences are limited, and more detailed phenotyping is needed. This observational cohort study recruited adolescents (10-17 years) with NeuP or complex regional pain syndrome (CRPS). After pain history and NeuP questionnaires, quantitative sensory testing was performed. Individual z-score plots were calculated with body-region control measures and matched to mechanism-related sensory profiles (sensory loss, thermal hyperalgesia, and mechanical hyperalgesia). Conditioned pain modulation was assessed with pressure pain threshold and a contralateral cold conditioning stimulus, and meaningful conditioned pain modulation defined as twice the standard error of measurement. Patients and parents completed validated questionnaires for child quality of life (QoL), pain catastrophizing, and self-reported anxiety/depression. Males (n = 23) and females (n = 43) with NeuP (n = 52) or CRPS (n = 14) reported moderate-severe pain with neuropathic sensory descriptors. Mixed patterns of sensory gain/loss at pain sites were not sex-dependent. Thermal hyperalgesia was common in both NeuP and CRPS, whereas sensory loss occurred only with NeuP and in a smaller proportion than adult cohorts. Conditioned pain modulation was inhibitory in 54%, facilitatory in 14%, and nonresponders had variable cold conditioning sensitivity. Males and females reported marked impairment of QoL, increased emotional distress, and pain catastrophising. Child-parent QoL scores correlated, but catastrophizing scores were discordant when parents or adolescents reported higher anxiety/depression. NeuP in adolescents is associated with significant pain, physical impairment, and psychosocial impairment. Quantifying alterations in somatosensory profiles, descending modulation, child and parent psychological function will inform individualized therapy and stratification for future clinical trials.

Reflection on modern methods: planned missing data designs for epidemiological research

Taking advantage of the ability of modern missing data treatments in epidemiological research (e.g. multiple imputation) to recover power while avoiding bias in the presence of data that is missing completely at random, planned missing data designs allow researchers to deliberately incorporate missing data into a research design. A planned missing data design may be done by randomly assigning participants to have missing items in a questionnaire (multiform design) or missing occasions of measurement in a longitudinal study (wave-missing design), or by administering an expensive gold-standard measure to a random subset of participants while the whole sample is administered a cheaper measure (two-method design). Although not common in epidemiology, these designs have been recommended for decades by methodologists for their benefits-notably that data collection costs are minimized and participant burden is reduced, which can increase validity. This paper describes the multiform, wave-missing and two-method designs, including their benefits, their impact on bias and power, and other factors that must be taken into consideration when implementing them in an epidemiological study design.

Considerations to Support Use of Patient-Reported Outcomes Measurement Information System Pediatric Measures in Ambulatory Clinics

OBJECTIVE

To identify challenges to the use of Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric measures in the ambulatory pediatric setting and possible solutions to these challenges.

STUDY DESIGN

Eighteen semistructured telephone interviews of health system leaders, measurement implementers, and ambulatory pediatric clinicians were conducted. Five coders used applied thematic analysis to iteratively identify and refine themes in interview data.

RESULTS

Most interviewees had roles in leadership or the implementation of patient-centered outcomes; 39% were clinicians. Some had experience using PROMIS clinically (44%) and 6% were considering this use. Analyses yielded 6 themes: (1) selection of PROMIS measures, (2) method of administration, (3) use of PROMIS Parent Proxy measures, (4) privacy and confidentiality of PROMIS responses, (5) interpretation of PROMIS scores, and (6) using PROMIS scores clinically. Within the themes, interviewees illuminated specific unique considerations for using PROMIS with children, including care transitions and privacy.

CONCLUSIONS

Real-world challenges continue to hamper PROMIS use. Ongoing efforts to disseminate information about the integration of PROMIS measures in clinical care is critical to impacting the health of children.

Agreement between proxy- and self-report scores on PROMIS health-related quality of life domains in pediatric burn survivors: a National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

PURPOSE

To examine agreement between pediatric burn survivor self- and caregiver proxy-report on multiple PROMIS domains and examine factors associated with differences between self- and proxy-reports.

METHODS

Children 8-17 years of age and their caregivers completed PROMIS measures (physical function, depression, peer relationships, pain interference, and anger) between 6 months and 15 years after injury. Self- and proxy-report scores were compared using Wilcoxon sign rank test, Cohen's effect size, and intraclass correlation coefficients (ICC) and by agreement across severity of symptoms based on recommended cutoffs. Ordinary least squares regression analyses examined child- (self-report score, age, gender, and ethnicity) and proxy-related (relationship to child) factors associated with score differences.

RESULTS

Two hundred and seventy four child-caregiver pairs completed the PROMIS measures. Mean child age was 13.0 (SD:3) years. Caregivers reported significantly worse scores than the child on physical function, pain, and anger (all p ≤ 0.01). The effect sizes were small across all domains except physical function. Similarly, ICCs were all of moderate agreement. The percentage of dyads in agreement by severity groups was high with only 5%-9% of pairs discordant. Only higher self-report score was associated (all p < 0.05) with greater differences across all domains in regression analyses.

CONCLUSIONS

This study supports the use of pediatric proxy PROMIS depression, physical function, peer relationships, pain interference, and anger scales in pediatric burn patients. Although agreement was moderate to good, assessing proxy-report alone as a surrogate should only be considered when self-report is not possible or practical. Caregivers typically report slightly worse severity of symptoms than children across all domains.

Caregiver-Child Discrepancies in Reports of Child Emotional Symptoms in Pediatric Chronic Pain

OBJECTIVE

Pediatric chronic pain evaluation includes self-reports and/or caregiver proxy-reports across biopsychosocial domains. Limited data exist on the effects of caregiver-child discrepancies in pediatric pain assessment. In children with chronic pain, we examined associations among discrepancies in caregiver-child reports of child anxiety and depressive symptoms and child functional impairment.

METHODS

Participants were 202 children (Mage=14.49 ± 2.38 years; 68.8% female) with chronic pain and their caregivers (95.5% female). Children and caregivers completed the Revised Child Anxiety and Depression Scale (RCADS) and RCADS-Parent, respectively. Children also completed the Functional Disability Inventory. Mean difference tests examined caregiver-child discrepancies. Moderation analyses examined whether associations between child self-reported anxiety and depressive symptoms and functional impairment varied as a function of caregiver proxy-report.

RESULTS

Children reported more anxiety and depressive symptoms compared with their caregivers' proxy-reports (Z = -4.83, p < .001). Both informants' reports of child anxiety and depressive symptoms were associated with child functional impairment (rs = .44, rs = .30, p < .001). Caregiver proxy-report moderated associations between child-reported anxiety and depressive symptoms and functional impairment (B = -0.007, p = .003). When caregiver proxy-report was low, child self-reported anxiety and depressive symptoms were positively related to functional impairment (B = 0.28, SE = 0.07, 95% CI [0.15, 0.41], p < .001).

CONCLUSIONS

Discrepant caregiver-child perceptions of child anxiety and depressive symptoms may be associated with functioning in children with chronic pain, especially when caregivers report less child internalizing symptoms. These findings highlight the need for further examination of the effects of caregiver-child discrepancies on pediatric chronic pain outcomes and may indicate targets for intervention.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial

BACKGROUND

Perioperative enhanced recovery protocols (ERPs) have been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but evidence for pediatric populations is lacking. The study is designed to evaluate the adoption, effectiveness, and generalizability of a 21-element ERP, adapted for pediatric surgery.

METHODS

The multicenter study is a stepped-wedge, cluster-randomized, pragmatic clinical trial that will evaluate the effectiveness of the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention while also assessing site-specific adaptations, implementation fidelity, and sustainability. The target patient population is pediatric patients, between 10 and 18 years old, who undergo elective gastrointestinal surgery. Eighteen (N = 18) participating sites will be randomly assigned to one of three clusters with each cluster, in turn, being randomly assigned to an intervention start period (stepped-wedge). Each cluster will participate in a Learning Collaborative, using the National Implementation Research Network's five Active Implementation Frameworks (AIFs) (competency, organization, and leadership), as drivers of facilitation of rapid-cycle adaptations and implementation. The primary study outcome is hospital length of stay, with implementation metrics being used to evaluate adoption, fidelity, and sustainability. Additional clinical outcomes include opioid use, post-surgical complications, and post-discharge healthcare utilization (clinic/emergency room visits, telephone calls to clinic, and re-hospitalizations), as well as, assess patient- and parent-reported health-related quality of life outcomes. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

DISCUSSION

The study provides a unique opportunity to accelerate the adoption of ERPs across 18 US pediatric surgical centers and to evaluate, for the first time, the effect of a pediatric-specific ENRICH-US intervention on clinical and implementation outcomes. The study design and methods can serve as a model for future pediatric surgical quality improvement implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04060303 . Registered on 07 August 2019.

Patient-Reported and Parent Proxy-Reported Outcomes in Pediatric Medical Specialty Clinical Settings: A Systematic Review of Implementation

OBJECTIVE

Youth with chronic illness are at higher risk for psychosocial difficulties, leading to a call for screening via patient-reported outcomes (PROs). The purpose of the current review is to summarize PRO implementation in pediatric medical specialty settings. A literature review of PRO implementation in these settings, conceptual issues, value and approach, legal and ethical concerns, as well as a case example of PROA in type 1 diabetes are presented.

METHODS

A systematic review was conducted to identify relevant articles published since the most recent Journal of Pediatric Psychology Special Issue on Evidence-Based Assessment in Pediatric Psychology (2008).

RESULTS

Thirty-two articles were identified and reviewed. The majority of studies reported that PROA was feasible, did not disrupt clinic flow, identified psychosocial issues warranting intervention, and was acceptable to families and providers. Response to elevated scores and impact on behavioral health referrals varied.

CONCLUSION

While many evidenced-based assessment measures are well-validated within pediatric chronic illness groups, the literature regarding implementation of PROs is still emerging. Research findings are promising, with PROs being feasible, acceptable, and leading to increased discussion of psychosocial issues when integrated into pediatric medical settings. Additional research is needed to evaluate the longitudinal impact of PROs and the optimal manner of responding to assessment data, particularly when clinically-elevated. Ultimately, identifying psychosocial issues in pediatric medical settings can promote optimal health and well-being of youth with chronic illness and their families.

Agreement Between Child Self-report and Caregiver-Proxy Report for Symptoms and Functioning of Children Undergoing Cancer Treatment

IMPORTANCE

Adult patients are considered the best reporters of their own health-related quality of life (HRQOL). Self-report in pediatrics has been challenged by a limited array of valid measures. Caregiver report is therefore often used as a proxy for child report.

OBJECTIVES

To examine the degree of alignment between child and caregiver proxy report for Patient-Reported Outcomes Measurement Information System (PROMIS) HRQOL domains among children with cancer and to identify factors associated with better child and caregiver-proxy congruence.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter cohort study, children with a first cancer diagnosis and their caregivers completed surveys at 2 time points: within 72 hours preceding treatment initiation (T1) and during follow-up (T2), when symptom burden was expected to be higher (eg, 7-17 days later for chemotherapy). Data were collected from October 26, 2016, to October 5, 2018, at 9 pediatric oncology hospitals. Five hundred eighty children (aged 7-18 years) and their caregivers were approached; 482 child-caregiver dyads completed surveys at T1 (response rate 83%), and 403 completed surveys at T2 (84% of T1 participants). Data were analyzed from July 1, 2019, to April 22, 2020.

EXPOSURES

Participants received up-front cancer treatment, including chemotherapy and radiotherapy.

MAIN OUTCOMES AND MEASURES

Congruence between child self-report and caregiver-proxy report of PROMIS pediatric domains of mobility (physical functioning), pain interference, fatigue, depressive symptoms, anxiety, and psychological stress.

RESULTS

Of the 482 dyads included in the analysis, 262 children (54%) were male (mean [SD] age, 12.9 [3.4] years), 80 (17%) were Black, and 71 (15%) were Hispanic. Intraclass correlations between child self-report and caregiver proxy report showed moderate agreement for mobility (0.57 [95% CI, 0.50-0.63]) and poor agreement for symptoms (range, 0.32 [95% CI, 0.24-0.41] for fatigue to 0.42 [95% CI, 0.34-0.50] for psychological stress). Children reported lower symptom burden and higher mobility than caregivers reported. In a multivariable model adjusted for child and parent sociodemographic factors and the caregiver's own self-reported HRQOL, caregivers reported the child's mobility score 6.00 points worse than the child's self-report at T2 (95% CI, -7.45 to -4.51), exceeding the PROMIS minimally important difference of 3 points. Caregivers overestimated the child's self-reported symptom levels, ranging from 5.79 (95% CI, 3.99-7.60) points for psychological stress to 13.69 (95% CI, 11.60-15.78) points for fatigue. The caregiver's own self-reported HRQOL was associated with the magnitude of difference between child and caregiver scores for all domains except mobility; for example, for fatigue, the magnitude of difference between child and caregiver-proxy scores increased by 0.21 (95% CI, 0.13-0.30) points for each 1-point increase in the caregiver's own fatigue score.

CONCLUSIONS AND RELEVANCE

This study found that caregivers consistently overestimated symptoms and underestimated mobility relative to the children themselves. These results suggest that elicitation of the child's own report should be pursued whenever possible.

Assessment of pediatric asthma exacerbation with the use of new PROMIS measures

OBJECTIVE

Patient reported outcome measures, such as the Patient Reported Outcomes Measurement Information System (PROMIS) may be used to assess patient functioning for asthma and aid in understanding the impact of asthma exacerbation. These domains may be utilized as endpoints in clinical trials and to guide clinical care. The purpose of this study was to determine psychometric properties of the new PROMIS measures for children with asthma, at baseline and with exacerbation.

METHODS

We conducted a cross-sectional analysis of children with acute asthma exacerbation or at baseline health. Psychometric properties of validity (using known groups and correlation) and reliability (using Cronbach's alpha and IRT) for the new PROMIS measures were determined.

RESULTS

Our study included 220 subjects, 102 were enrolled during an acute exacerbated state. Cronbach's alpha and IRT reliability was greater or equal to 0.75. Our subjects experiencing an acute exacerbated state reported worse T-scores for pain related domains: pain behavior 45.7 vs 53.5 (p < 0.001), pain quality sensory 44.4 vs 48.5 (p < 0.005), pain quality affective 42.5 vs 51.3 (p < 0.001), and physical stress experience 60.5 vs 65.4 (p < 0.001); and asthma impact 47.9 vs 61.0 (p < 0.001), than subjects at baseline. Child and parent-proxy agreement ranged from 35% to 56%.

CONCLUSIONS

The new Pediatric PROMIS domains are valid and reliable for use in children with asthma, for both child-reported and parent-proxy reported outcomes. It was determined that children with acute asthma exacerbation have worse patient reported outcomes (PROs) for the new pain related domains and asthma impact.

Patient-reported outcomes in paediatric cancer survivorship: a qualitative study to elicit the content from cancer survivors and caregivers

OBJECTIVES

Content elucidation for patient-reported outcomes (PROs) in paediatric cancer survivorship is understudied. We aimed to compare differences in the contents of five PRO domains that are important to paediatric cancer survivorship through semistructured interviews with paediatric cancer survivors and caregivers, and identified new concepts that were not covered in the item banks of the Patient-Reported Outcomes Measurement Information System (PROMIS).

DESIGN

Semistructured interviews to collect qualitative PRO data from survivors and caregivers.

SETTING

A survivorship care clinic of a comprehensive cancer centre in the USA.

PARTICIPANTS

The study included 51 survivors (<18 years old) and 35 caregivers who completed interviews between August and December 2016. Content experts coded the transcribed interviews into 'meaningful concepts' per PROMIS item concepts and identified new concepts per a consensus. Frequencies of meaningful concepts used by survivors and caregivers were compared by Wilcoxon rank-sum test.

RESULTS

For pain and meaning and purpose, 'Hurt a lot' and 'Purpose in life' were top concepts for survivors and caregivers, respectively. For fatigue and psychological stress, 'Needed to sleep during the day'/'Trouble doing schoolwork' and 'Felt worried' were top concepts for survivors, and 'Felt tired' and 'Felt distress'/'Felt stressed' for caregivers. Survivors reported more physically relevant contents (eg, 'Hard to do sport/exercise'; 0.78 vs 0.23, p=0.007) for pain, fatigue and stress, whereas caregivers used more emotionally relevant concepts (eg, 'Too tired to enjoy things I like to do'; 0.31 vs 0.05, p=0.025). Both groups reported positive thoughts for meaning and purpose (eg, 'Have goals for myself'). One (psychological stress, meaning and purpose) to eleven (fatigue) new concepts were generated.

CONCLUSIONS

Important PRO contents in the form of meaningful concepts raised by survivors and caregivers were different and new concepts emerged. PRO measures are warranted to include survivorship-specific items by accounting for the child's and the caregiver's viewpoints.

Psychometric evaluation of the pediatric applied cognition scale in pediatric hematology/oncology

Pediatric patients with hematology and oncology conditions often experience disease- and treatment-related neurocognitive deficits. Well-validated screening tools are critical for identifying patients experiencing cognitive impairments. The Pediatric Applied Cognition scale (PAC) Short Form, developed by the National Institutes of Health, assesses attention and memory concerns. The current study is the first to examine the psychometrics of the PAC in pediatric patients with hematology/oncology conditions. Pediatric patients (n = 222) and caregivers completed the PAC and self-report measures of psychosocial and academic functioning. Results revealed strong internal consistency for the Child (α = 0.81-0.89) and Parent (α = 0.92-0.95) PAC. More cognitive concerns on the Child/Parent PAC were associated with greater psychosocial concerns (e.g. anxiety, depression, and fatigue) and lower reported school grades. The Parent PAC incrementally predicted child reported symptoms of depression, mobility concerns, and school grades beyond the Child PAC. Overall, the PAC Short Form may be useful as an indicator of general academic and psychosocial concerns. Further research validating the PAC in relation to performance-based neurocognitive outcomes and academic achievement is needed in children treated for hematology/oncology conditions.

Performance of Pediatric PROMIS CATs in Children With Upper Extremity Fractures

Background: This study was designed to quantify the performance of the pediatric Patient-Reported Outcome Measurement Information System (PROMIS) when delivered as part of routine care to children with upper extremity (UE) fractures. Methods: This cross-sectional study analyzed 964 new pediatric patients presenting with an UE fracture. All patients completed PROMIS computer adaptive tests for pain interference, peer relationships, UE function, and mobility domains at clinic registration. PROMIS was completed by parent-proxy (n = 418) for 5- to 7-year-olds and self-reported by 8- to 10-year-olds (n = 546). PROMIS score distributions were defined, and Pearson correlations assessed the interrelation between PROMIS domains. Student's t tests compared mean PROMIS scores between parent-proxy and self-completion groups. Results: UE scores indicated the greatest average impairment of all PROMIS domains. However, 13% of patients reached the UE score ceiling indicating maximal UE function. UE scores and mobility scores had a strong positive correlation while UE scores had a moderate negative correlation with pain interference. In all patients, peer relationships were, at most, very weakly correlated with any other PROMIS domain. After grouping by fracture type, parent-proxy completion estimated worse UE function, more pain interference, and worse peer relationship. Conclusions: Pediatric PROMIS UE function scores capture impairment from UE fractures but do have a strong positive correlation with pediatric PROMIS Mobility, which assesses lower extremity function. Among children with UE fractures, parent-proxy completion of pediatric PROMIS appears associated with worse scores on most PROMIS domains.

An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy

Importance

Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population.

Objective

To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives.

Design, Setting, and Participants

A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016.

Main Outcomes and Measures

The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention.

Results

The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy.

Conclusions and Relevance

This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy.

Level of Evidence

NA.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Do Urban Minority Parents and Children Agree on Asthma Symptoms with Exercise, Worries, and Confidence in Disease Management?

OBJECTIVE

Providers commonly rely on parent reports of a child's asthma symptoms; however, children as young as 7 years can report on their own health. Our study compared parent and child reports of asthma symptoms with exercise, worries about developing an asthma attack, and confidence in disease management.

METHODS

We recruited children ages 7 to 10 years with asthma from 4 Bronx, NY, schools, as well as their parents. The parents and children completed interview surveys with parallel questions regarding perceived asthma symptoms, asthma-related worries, and confidence in disease management. We used McNemar tests for paired data to compare parent and child responses.

RESULTS

We analyzed data for 105 parent-child pairs. Mean child age was 8.5 years (standard deviation, 0.99); 53% were male, and 82% were Hispanic. Children were more likely than their parents to report ever having an exercise-induced asthma attack (85% vs 48%; P < .001) and that they "worry a lot" about developing an asthma attack during exercise (63% vs 45%; P = .01). Children felt more confident about using an inhaler correctly (76% of the children were "very sure" vs 60% of the parents; P = .009) and were more likely to report having an inhaler available in case of an attack (38% of the children were "very sure" vs 20% of the parents; P = .003).

CONCLUSIONS

In this school-based sample of urban children with asthma, we found disagreement between parent and child reports of symptoms with exercise, worry about developing an attack, and confidence in medication use. These findings suggest that including child reports during history taking could help providers identify children in need of enhanced asthma management.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chronic harsh parenting and anxiety associations with fear circuitry function in healthy adolescents: A preliminary study

Previous studies have reported altered fear circuitry function during fear conditioning in highly anxious individuals and in adults with a history of severe childhood adversity; less is known regarding younger populations and more common forms of adversity. We investigated fear circuitry functioning in healthy youths with histories of high (HH) or low (LH) chronic harsh parenting and high (HA) or low (LA) anxiety levels. 84 youths aged 13-16 performed an fMRI fear conditioning task. HH displayed decreased selective medial temporal lobe deactivations to CS+> CS- relative to LH. In addition, we found less amygdala-insula connectivity in HH vs LH. Interestingly, we observed distinct patterns of anxiety differences in amygdala-rostral ACC connectivity and subjective fear ratings depending on harsh parenting levels, suggesting a history of harsh parenting is linked with unique neural and behavioral anxious manifestations, which are different from anxiety manifestations in a context of low adversity.

The association of age, literacy, and race on completing patient-reported outcome measures in pediatric oncology

PURPOSE

Age is often used to determine when children can begin completing patient-reported outcome (PRO) instruments or transition to adult instruments. This study's purpose was to determine relationships between literacy, age, and race and their influence on a child's ability to understand and complete a PRO instrument.

METHODS

The Wide Range Achievement Test was used to evaluate literacy in children and young adults with cancer, participating in a cognitive interview for the Pediatric PRO-CTCAE instrument. 140 participants (7-20 years) were recruited from 8 sites. Logistic regression and multivariable liner regression were used to examine relationships among key variables.

RESULTS

Higher literacy scores were significantly associated with fewer PRO-CTCAE items being identified as "hard to understand" (p = 0.017). Literacy scores increased with age, but older participants were more likely to fall behind expected reading levels compared with US norms. A 1-year increase in age was associated with a 19% increase in the likelihood for being below the expected WRAT word reading score (OR 1.19; 95% CI 1.06-1.33, p = 0.003). No associations were found between race and literacy.

CONCLUSIONS

Wide variations in literacy were noted across age groups. All participants were able to complete the Pediatric PRO-CTCAE, although most 7 year olds (63%) required reading assistance. Those with lower literacy skills were able to understand items suggesting that multiple factors may be involved in comprehension (developmental stage, concentration, vocabulary, or prior health experiences). Risk for falling below expected literacy levels increased with age implying a need for literacy consideration for cancer patients.

Quality and Correlates of Peer Relationships in Youths with Chronic Pain

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

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

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

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level I, prognostic study.

Impact of pediatric cancer on family relationships

Little is known about the impact of cancer on family relationships from the perspective of the pediatric cancer patient and their sibling(s). This study assessed and compared children's experiences of family relationships in patients receiving active cancer therapy, those who have completed therapy, and siblings. A cross‐sectional study of children with cancer and their siblings aged 8–17 years old was conducted. Children completed the PROMIS Pediatric Family Relationships short form and the Depressive Symptoms, Anxiety, and Peer Relationships short forms. The Mann–Whitney test assessed differences in Family Relationships scores between therapy groups, while the Wilcoxon signed‐rank test assessed differences between patients and siblings. An actor–partner interdependence model (APIM) was used to assess how patient and sibling variables were associated with their own and each others’ family relationships. Two hundred and sixty‐five children completed the assessments. Siblings of patients on‐therapy had worse family relationships than patients on‐therapy (P = 0.015). Family relationships of patients off‐therapy did not differ from their siblings or the patients on‐therapy. Family relationships scores did not differ between the sibling cohorts. The APIM found patient family relationships were impaired when their own peer relationships decreased and when either their own or their siblings had increased depressive symptoms. Sibling family relationships were impaired when their own depression increased, and when the patient counterpart was female, younger age, had less depressive symptoms, more anxiety or a diagnosis of leukemia/lymphoma (compared to solid tumor). Based on these findings, increased psychosocial resources for patients and siblings of children undergoing cancer therapy may be warranted.

Parents' and Child's Concussion History as Predictors of Parental Attitudes and Knowledge of Concussion Recognition and Response

Background:

Parents’ knowledge of and attitudes toward concussions are often vital factors that affect care for injured adolescent athletes. It is important to understand the role that parents’ personal experiences with concussions play with regard to current concussion knowledge and attitudes so that clinicians may tailor their educational approaches.

Purpose/Hypothesis:

The purpose of this study was to determine an association between parents’ personal experiences and their child’s experiences with concussions as well as parental concussion knowledge and attitudes. We hypothesized that parents who have personally experienced symptoms or have a child who has experienced symptoms would have better knowledge and more favorable attitudes toward concussions.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Parents of youth sport athletes (N = 234 [82 male, 144 female, 8 unreported]; mean age, 44.0 ± 6.3 years) completed a prevalidated survey for concussion knowledge (maximum score possible, 29) and attitudes (maximum score possible, 49). Higher scores indicated better knowledge and more favorable attitudes toward concussive injuries. Parents reported the frequency of concussion diagnoses and/or experiences of concussion-related symptoms and whether their child had suffered a diagnosed concussion or experienced concussion symptoms (yes/no). Spearman rank correlation and multivariable regression were used to examine the association between experience of symptom clusters (self or child) and concussion knowledge and attitudes.

Results:

Knowledge was moderate (mean, 23.3 ± 2.5 of 29), while attitudes prioritized disclosure (mean, 46.3 ± 3.7 of 49). Parents’ experience of the sleep-arousal symptom cluster was positively associated with concussion attitudes (r = 0.22, P = .002; β = –3.301, P = .011). Parents with children who experienced sleep-arousal and vestibular-somatic symptom clusters were weakly associated with parental concussion knowledge (sleep-arousal: r = 0.15, P = .041; vestibular-somatic: r = 0.17, P = .020; β = 0.540, P = .012).

Conclusion:

Our findings suggest that parents’ personal experiences with concussion-related symptoms have little effect on parental knowledge and attitudes as a whole. However, clinicians should consider particular symptom clusters that may provide insight into targets for future concussion education. According to these findings, parents of youth sport participants would benefit from increased concussion education focusing on the types of symptoms as well as the consequences of suffering a concussion.

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

Background

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

Methods

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

Results

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

Conclusions

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