Child and parent reactions to participation in clinical research

From opt-out to opt-in consent for secondary use of medical data and residual biomaterial: An evaluation using the RE-AIM framework

BACKGROUND

Patient records, imaging, and residual biomaterial from clinical procedures are crucial resources for medical research. In the Netherlands, consent for secondary research has historically relied on opt-out consent. For ethical-legal experts who purport passive consent undermines patient autonomy, opt-in consent (wherein affirmative action is required) is seen as the preferred standard. To date, there is little empirical research exploring patient feasibility, organizational consequences, and the potential risks for research based on secondary data. Thus, we applied the RE-AIM framework to evaluate the impact of migrating from an opt-out to an opt-in consent process.

METHODS

This evaluation was carried out in Radboud University Medical Center, a large tertiary hospital located in the southeast of the Netherlands. All non-acute, mentally competent patients ≥16 years of age registered between January 13, 2020 and June 30, 2023 were targeted (N = 101,437). In line with the RE-AIM framework, individual and organizational consequences were evaluated across five domains: reach, efficacy, adoption, implementation, and maintenance.

RESULTS

101,437 eligible patients were approached of whom 66,214 (65.3%) consented, 8,059 (7.9%) refused consent and 27,164 (26.8%) had no response. Of the 74,273 patients with a response, 89.1% consented to secondary use. The migration to an opt-in consent system was modestly successful; yet notably, differential response patterns by key sociodemographic characteristics were observed. Adaptions to the process flow improved its effectiveness and resulted in a reasonable response over time. Implementation was most affected by budgetary restraints, thus impeding the iterative approach which could have further improved domain outcomes.

CONCLUSION

This evaluation provides an overview of logistical and pragmatic issues encountered when migrating from opt-out to opt-in consent. Response bias remains a major concern. Though not always directly transferable, these lessons can be broadly used to inform other health care organizations of the potential advantages and pitfalls of an opt-in consent system.

Parental perspectives on research for Down syndrome

BACKGROUND

Down syndrome is the most common genetic disorder associated with intellectual and developmental disabilities. Research to improve health care outcomes in Down syndrome lags significantly behind other disease categories. Among these reasons are funding, recruitment and availability of research studies being conducted.

METHODS

We surveyed 228 parents of individuals with Down syndrome to understand their perceptions of research, study design, how they seek out information and topics they would like to see researched.

RESULTS

Parents with children 18 years and younger responded to our survey. Parents indicated their willingness to participate in research (72%), yet few have (36%). Parents identified barriers to participation, research they feel would help their child, and interests in seeing new therapies and drug studies.

CONCLUSION

These findings identify recommendations and insights from parents on future research agendas, studies and recruitment strategies that may help researchers improve outcomes for individuals with Down syndrome.

Assessing trauma and related distress in refugee youth and their caregivers: should we be concerned about iatrogenic effects?

Assessment of potentially traumatic events and related psychological symptoms in refugee youth is common in epidemiological and intervention research. The objective of this study is to characterize reactions to assessments of trauma exposure and psychological symptoms, including traumatic stress, in refugee youth and their caregivers. Eighty-eight Somali youth and their caregivers participated in a screening and baseline interview for a psychological intervention in three refugee camps in Ethiopia. Participants were asked about their levels of distress prior to, immediately after, and approximately two weeks after completing the interview. Other quantitative and qualitative questions inquired about specific reactions to interview questions and procedures. Children and caregivers became increasingly relaxed over the course of the interview, on average. Few children (5.3%) or caregivers (6.5%) who reported being relaxed at the beginning of the interview became upset by the end of the interview. Some children and caregivers reported that certain assessment questions were upsetting and that feeling upset interfered with their activities. Despite some participants reporting persistent negative reactions, most reported liking and benefitting from the interview. While the majority of refugee youth and their caregivers reported positive experiences associated with completing trauma-related assessments, some reported negative reactions. Researchers and practitioners must consider the necessity, risks, and benefits of including questions about potentially traumatic events and related symptoms that are particularly upsetting in screening, survey research, and clinical assessment. When included, it is important that researchers and practitioners monitor negative reactions to these assessments and connect participants who become distressed with appropriate services.

Enablers of psychosocial recovery in pediatric burns: perspectives from the children, parents and burn recovery support staff

Background

Pediatric burn injuries are a major cause of death and injury, occurring mainly in resource poor environments. Recovery from burns is widely reported to be constrained by physical, psychological, relationship and reintegration challenges. These challenges have been widely described, but not the enablers of psychosocial recovery. This is especially true in pediatric burn research, with few multi- perspective studies on the recovery process.

Methods

This qualitative study involved 8 focus group discussions (four with 15 children post-burn injury, four with 15 caregivers) and 12 individual interviews with staff working in pediatric burns that explored the psychosocial needs of children after a burn and the enablers of their recovery. Purposive sampling was utilized and recruitment of all three categories of participants was done primarily through the only hospital burns unit in the Western Cape, South Africa. The interviews focused on factors that supported the child’s recovery and were sequentially facilitated from the child and the family’s experiences during hospitalization, to the return home to family and friends, followed by re-entry into school. Thematic analysis was used to analyze verbatim interview transcripts.

Results

The recovery enablers that emerged included: (i) Presence and reassurance; indicating the comfort and practical help provided by family and close friends in the hospital and throughout the recovery process; (ii) Normalizing interactions and acceptance; where children were treated the same as before the injury to promote the acceptance of self and by others especially once the child returned home; and (iii) Sensitization of others and protection; signifying how persons around the child had assisted the children to deal with issues in the reintegration process including the re-entry to school.

Conclusions

This study indicates that the psychosocial recovery process of children hospitalized for burns is enabled by the supportive relationships from family members, close friends and burn staff, present during hospitalization, the return home, and school re-entry. Support included comfort and physical presence of trusted others and emotional support; affirmation of the child’s identity and belonging despite appearance changes; and the advocacy and protection for the re-entry back into the school, and more generally the community.

Carers' Motivations for, and Experiences of, Participating in Suicide Research

(1) Background: First-hand accounts of lived experience of suicide remain rare in the research literature. Increasing interest in the lived experience of suicide is resulting in more opportunities for people to participate in research based on their personal experience. How individuals choose to participate in research, and their experience of doing so, are important considerations in the ethical conduct of research. (2) Methods: To understand the experience of providing care for someone who has previously attempted suicide, a cross-sectional online community survey was conducted. This survey concluded with questions regarding motivation to participate and the experience of doing so. Of the 758 individuals who participated in the survey, 545 provided open-ended text responses to questions regarding motivation and 523 did so for questions regarding the experience of participating. It is these responses that are the focus of this paper. Data were analysed thematically. (3) Results: Motivations to participate were expressed as primarily altruistic in nature, with a future focus on improving the experience of the person who had attempted suicide alongside carers to ease distress. The experience of participating was difficult yet manageable, for all but a few participants. (4) Conclusions: With the increasing interest in first-hand accounts of suicide, how individuals experience participation in research is an important focus that requires further attention.

Best Practices for Obtaining Genomic Consent in Pediatric Traumatic Brain Injury Research

BACKGROUND

Precision health relies on large sample sizes to ensure adequate power, generalizability, and replicability; however, a critical first step to any study is the successful recruitment of participants.

OBJECTIVES

This study seeks to explore how the enrollment strategies used in a parent study contributed to the high consent rates, establish current best practices that can be used in future studies, and identify additional factors that contribute to consent into pediatric traumatic brain injury biobanks.

METHODS

Retrospective secondary analysis of data from a parent study with high consent rates was examined to explore factors affecting consent into biobanking studies.

RESULTS

Of the 76 subjects who were approached, met the eligibility criteria, and reviewed the consent form, only 16 (21.1%) declined to participate. The consented group (n = 60) represents 64.5% of those who met the eligibility criteria upon initial screening (n = 93) and 78.9% of those with confirmed eligibility (n = 76). Analysis of screening data suggested there were no major barriers to consenting individuals into this pediatric traumatic brain injury biobank.

DISCUSSION

There were no demographic or research-related characteristics that significantly explained enrollment. Ethically, to obtain true informed consent, parents need to understand only their child's diagnosis, prognosis, and medical care, as well as the purpose of the proposed research and its risks and benefits. Researchers need to implement best practices, including a comprehensive review of census data to identify eligible participants to approach, a prescreening protocol, and effective consenting process to obtain informed consent so that precision care initiatives can be pursued.

Perceptions of participating in family-centered fertility research among adolescent and young adult males newly diagnosed with cancer: A qualitative study

BACKGROUND

Over half of male childhood cancer survivors experience infertility after treatment, which is known to cause distress and impact future quality of life. Sperm banking rates remain low, and little is known about how adolescent and young adult (AYA) males and their families make fertility preservation (FP) decisions. This study examined AYA and parent perceptions of participating in a research study focused on testing a new FP decision tool at the time of cancer diagnosis.

METHODS

Forty-four participants (19 mothers, 11 fathers, 14 male AYAs 12-25 years old) from 20 families completed brief assessments at diagnosis and approximately one month later, including a qualitative interview exploring the impact of study participation. Verbatim transcripts were coded through thematic content analysis using the constant comparison method.

RESULTS

Two major themes emerged: (1) a positive effect of participating in the study and (2) a neutral effect (no positive/negative effect of participation). Subthemes that emerged for participants who noted a positive effect included (a) participation prompted deeper thinking, (b) participation influenced family conversations, and (c) participation resulted in altruism/helping others. No participant reported a negative effect.

CONCLUSIONS

This study demonstrates that participation in family-centered research focused on FP among AYA males, before treatment begins, is perceived as beneficial or neutral at the time of a new cancer diagnosis. These findings provide support for future family-centered FP interventions for this population.

Conducting reproductive research during a new childhood cancer diagnosis: ethical considerations and impact on participants

PURPOSE

Research among adults shows benefits and low perceived burden of engaging in behavioral research. However, questions remain regarding the ethics of conducting behavioral research in pediatric populations during sensitive situations, including during a new life-threatening diagnosis or at end-of-life. We examined reactions to participating in a behavioral reproductive research study among male adolescents newly diagnosed with cancer and their parents, as a step towards optimizing fertility preservation utilization in a population where future infertility is common.

METHODS

Pediatric literature regarding the ethics of behavioral research was reviewed. In our pilot, forty-four participants (19 mothers, 11 fathers, 14 male adolescents newly diagnosed with cancer) from 20 families completed demographic questionnaires and a fertility preservation decision tool developed by the study team. Qualitative interviews exploring the impact of study participation were subsequently conducted. Verbatim transcripts were coded for thematic content using the constant comparison method.

RESULTS

Literature review showed positive reactions to research participation among youth/caregivers. In our pilot study, 89% (n = 17) of mothers, 64% (n = 7) of fathers, and 71% (n = 10) of adolescents reported at least one benefit of participating. Eleven percent (n = 2) of mothers, 36% (n = 4) of fathers, and 29% (n = 4) of adolescents said they were not affected; none of the participants reported a negative effect.

CONCLUSION

Consistent with prior literature, our study suggests behavioral reproductive research prior to cancer treatment can offer direct benefits to participants and society, without increasing burden. These findings will inform future interventions to improve long-term psychosocial and reproductive outcomes for youth with cancer.

Reported Levels of Upset in Youth After Routine Trauma Screening at Mental Health Clinics

Importance

Clinical guidelines recommend routine screening for trauma at youth mental health clinics. However, many clinicians are concerned that screening may be upsetting both for youths who have been exposed to trauma and for those who have not.

Objectives

To investigate levels of upset following routine trauma screening and whether type of trauma and symptoms of posttraumatic stress were associated with level of upset.

Design, Setting, and Participants

Survey study in which data from routine screening for trauma exposure and trauma-related symptoms were collected from January 1, 2015, to December 31, 2017. Nearly half (n = 40) of all youth mental health clinics in Norway submitted survey data. Participants included youths aged 6 to 18 years referred to treatment.

Main Outcomes and Measures

The trauma screening inventory, Child & Adolescent Trauma Screening Questionnaire, was administered. Self-reported levels of upset after initial screening were scored on a scale ranging from 1 (not upsetting) to 7 (very upsetting).

Results

Among 10 157 youths aged 6 to 18 years (mean [SD] age, 13.0 [3.1] years; 5320 [55.0%] female), surveyed, 8021 (79.1%) reported exposure to at least 1 potentially traumatizing event and a mean (SD) of 2.44 (2.27) different types of events (range, 0-15). Only 453 participants (4.5%) reported high levels of upset, while 2757 participants (27.2%) reported moderate levels of upset and 6942 participants (68.4%) reported no or low levels of upset. Youths who had been exposed to any type of traumatic event reported significantly higher levels of upset compared with those reporting no trauma exposure, and a higher number of reported traumatic events was associated with a higher level of upset (point estimate, 0.23; 95% CI, 0.22-0.24; P < .001). Among participants who reported trauma, exposure to sexual abuse (point estimate, 0.87; 95% CI, 0.77-0.95; P < .001) and higher levels of posttraumatic stress symptoms (point estimate, 0.05; 95% CI, 0.04-0.05; P < .001) were associated with higher levels of upset.

Conclusions and Relevance

A high level of trauma exposure was found among youths referred to youth mental health clinics, but trauma screening was well tolerated, with most participants reporting no or low levels of upset. These findings can be used to support therapists and health care leaders in implementing routine trauma screening to better identify youths who are in need of trauma-focused treatment.

Maltreatment history, trauma symptoms and research reactivity among adolescents in child protection services

OBJECTIVE

There is a well-documented link between child maltreatment and poor health across the lifespan. This provides a strong case for ongoing research with youth involved in the child welfare system to reduce negative outcomes and support resilience while being inclusive of youth voices. However, detailed inquiries about maltreatment history and health consequences may cause re-experiencing of events and psychological distress for study participants. Data that accounts for different contexts, such as severity of maltreatment history and current trauma symptomatology, have been limited in considering the question of potential harms to youth who participate in research-especially longitudinal studies.

METHODS

This study compared self-reported impact of research participation against maltreatment history and current post-traumatic stress symptomatology among a randomly selected group of adolescents (< 18 years old) in the child protection service (CPS) system.

RESULTS

Adolescents who report more serious child maltreatment and current trauma symptom severity reported higher scores on distress questions from pre- to post-assessment participation. Critically, participants who were more negatively impacted by study involvement also reported greater benefit from study involvement.

CONCLUSION

The increase in both negative and positive impact does not shift the risk/reward ratio for participation, as risks alone do not increase for this vulnerable group of CPS involved youth. These results are consistent with previous findings from studies involving non-CPS populations and underlies the importance of empirical data to address the question of change in the risk/reward ratio and what factors might play a role in any change. This information can inform inclusion/exclusion criteria for future research with these vulnerable populations, thereby reducing the risk of distress among study participants.

Perceived Risks and Benefits in IPV and HIV Research: Listening to the Voices of HIV-Positive African American Women

African American women living with HIV were asked to reflect on the perceived risks and benefits of research participation after completing a study examining socially sensitive issues in their lives, including intimate partner violence (IPV) and HIV. Administration of standardized quantitative instruments yielded positive responses to the research experience. However, qualitative assessments of perceived risks and benefits revealed more nuanced responses. For example, confidentiality concerns were more prominent in open-ended responses as was participants' positive attitudes toward monetary compensation. In addition, some women reported that study participation provided them with new insights about their experiences with IPV. Findings suggest that empirical studies on research protections involving potentially distressing and socially sensitive experiences with vulnerable populations require both quantitative and qualitative assessments of perceived risks and benefits. We discuss implications of our findings for ethics practices in trauma-related research among populations with multiple social vulnerabilities.

A proposed model for evaluating the impact of participating in trauma-focused research

This article describes the development of a model for assessing levels of risk in trauma-focused research, with evidence for the empirical validity of the model being provided by findings from a study of 438 undergraduate students who participated in a survey regarding past-year exposure to intimate partner violence. A minor increase in risk over minimal risk was found to constitute the modal risk category, with evidence for the empirical validity of the model being provided by the fact that levels of risk assessed by the model were associated with anticipated decreases in the proportion of positive cost–benefit ratios, with different levels of risk being predicted by a unique constellation of risk factors. These findings are discussed with respect to their implications for further research and in relation to the way in which the impact of trauma-focused research is conceptualised.

Does the Risk Outweigh the Benefits? Adolescent Responses to Completing Health Surveys

The aim of this study is to describe the self-reported experiences of adolescents in population-based samples when completing health-related surveys on topics with varying potential for evoking distress. Survey data were collected in three school-based studies of bullying behaviors (N = 1,771, 12-14 years), alcohol use (N = 823, 12, 15, and 17 years), and electronic image sharing (N = 274, 13 years). Between 5% and 15% of respondents reported being upset at survey completion, but at most 1.4% were entirely negative in their evaluation. Age was not associated with being upset, but younger adolescents were more likely to see benefit in participation. Although concurrent mental health symptoms increased the risk of being upset, this was mostly mitigated by perceived benefits from participation.

The child's perspective on discomfort during medical research procedures: a descriptive study

OBJECTIVE

The evaluation of discomfort in paediatric research is scarcely evidence-based. In this study, we make a start in describing children's self-reported discomfort during common medical research procedures and compare this with discomfort during dental check-ups which can be considered as a reference level of a 'minimal discomfort' medical procedure. We exploratory study whether there are associations between age, anxiety-proneness, gender, medical condition, previous experiences and discomfort. We also describe children's suggestions for reducing discomfort.

DESIGN

Cross-sectional descriptive study.

SETTING

Paediatric research at three academic hospitals.

PATIENTS

357 children with and without illnesses (8-18 years, mean=10.6 years) were enrolled: 307 from paediatric research studies and 50 from dental care.

MAIN OUTCOME MEASURES

We measured various generic forms of discomfort (nervousness, annoyance, pain, fright, boredom, tiredness) due to six common research procedures: buccal swabs, MRI scans, pulmonary function tests, skin prick tests, ultrasound imaging and venepunctures.

RESULTS

Most children reported limited discomfort during the research procedures (means: 1-2.6 on a scale from 1 to 5). Compared with dental check-ups, buccal swab tests, skin prick tests and ultrasound imaging were less discomforting, while MRI scans, venepunctures and pulmonary function tests caused a similar degree of discomfort. 60.3% of the children suggested providing distraction by showing movies to reduce discomfort. The exploratory analyses suggested a positive association between anxiety-proneness and discomfort.

CONCLUSIONS

The findings of this study support the acceptability of participation of children in the studied research procedures, which stimulates evidence-based research practice. Furthermore, the present study can be considered as a first step in providing benchmarks for discomfort of procedures in paediatric research.

Are positive experiences of children in non-therapeutic research justifiable research benefits?

BACKGROUND

Conducting non-therapeutic research is ethically challenging because participation conveys risks and burden and no health benefit. In this paper, we report the positive experiences of a diverse group of healthy and ill children (6-18 years) who participated in non-therapeutic research studies and discuss whether these positive experiences can justifiably be viewed as benefits.

METHODS

We used semistructured interviews from an earlier study about children's experiences in clinical research and did a secondary analysis on the positive experiences of the children in the non-therapeutic studies (N=30). Interviews were analysed using 'thematic' analysis.

RESULTS

The interviewed children most frequently mentioned as positive experiences of non-therapeutic research participation helping others and the gratification that comes with it, possible health benefits in the future, having fun and new/increased knowledge about the human body, hospitals and doing research. Less frequently mentioned were getting a present, not having to go to school and getting extra attention from healthcare staff.

CONCLUSIONS

Our study shows that children participating in non-therapeutic research have various positive experiences while taking part. We argue that some of these justifiably could be taken into the risk-benefit analysis in certain situations or maybe even as a standard part of this analysis. This may help to increase the number of (crucial) non-therapeutic studies with children.

The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review

The experience of childhood trauma (CT) and stressful life events (SLEs) is associated with subsequent development of a variety of mental health conditions, including psychotic illness. Recent research identifying adolescents and young adults at clinical high risk (CHR) for psychosis allows for prospective evaluation of the impact of trauma and adverse life events on psychosis onset and other outcomes, addressing etiological questions that cannot be answered in studies of fully psychotic or non-clinical populations. This article provides a comprehensive review of the current emerging literature on trauma and adverse life events in the CHR population. Up to 80% of CHR youth endorse a lifetime history of childhood traumatic events and victimization (e.g., bullying). Several studies have shown that the experience of CT predicts psychosis onset among CHR individuals, while the literature on the influence of recent SLEs (e.g., death of a loved one) remains inconclusive. Multiple models have been proposed to explain the link between trauma and psychosis, including the stress-vulnerability and stress-sensitivity hypotheses, with emphases on both cognitive processes and neurobiological mechanisms (e.g., the hypothalamic-pituitary-adrenal axis). Despite the preponderance of CHR individuals who endorse either CT or SLEs, no clinical trials have been conducted evaluating interventions for trauma in CHR youth to date. Furthermore, the current process of formal identification and assessment of trauma, SLEs, and their impact on CHR youth is inconsistent in research and clinical practice. Recommendations for improving trauma assessment, treatment, and future research directions in the CHR field are provided.

Children's self reported discomforts as participants in clinical research

INTRODUCTION

There is little empirical evidence on children's subjective experiences of discomfort during clinical research procedures. Therefore, Institutional Review Boards have limited empirical information to guide their decision-making on discomforts for children in clinical research. To get more insight into what children's discomforts are during clinical research procedures, we interviewed a group of children on this topic and also asked for suggestions to reduce possible discomforts.

MATERIALS AND METHODS

Forty-six children (aged 6-18) participating in clinical research studies (including needle-related procedures, food provocation tests, MRI scans, pulmonary function tests, questionnaires) were interviewed about their experiences during the research procedures. Thematic analysis was used to analyze the interviews.

RESULTS

The discomforts of the interviewed children could be divided into two main groups: physical and mental discomforts. The majority experienced physical discomforts during the research procedures: pain, shortness of breath, nausea, itchiness, and feeling hungry, which were often caused by needle procedures, some pulmonary procedures, and food provocation tests. Mental discomforts included anxiousness because of anticipated pain and not knowing what to expect from a research procedure, boredom and tiredness during lengthy research procedures and waiting, and embarrassment during Tanner staging. Children's suggestions to reduce the discomforts of the research procedures were providing distraction (e.g. watching a movie or listening to music), providing age-appropriate information and shortening the duration of lengthy procedures.

DISCUSSION

Our study shows that children can experience various discomforts during research procedures, and it provides information about how these discomforts can be reduced according to them. Further research is needed with larger samples to study the number of children that experience these mentioned discomforts during research procedures in a quantitative way.

Reasons for and reservations about research participation in acutely injured adults

PURPOSE

The purpose of this study was to explore the reasons adult patients seeking emergency department care for minor injuries agree to participate in clinical research and to identify their reservations about participating in a research study.

DESIGN AND METHODS

This is a secondary analysis of data from a longitudinal cohort study of 275 adults who sought emergency department care for physical injury and were followed over 12 months. At the final interview, participants were asked open-ended short-answer questions about their perception of participating in the study. Free text responses were analyzed using conventional content analysis.

FINDINGS

The final sample of 214 participants was composed equally of males and females, predominantly Black (54%) and White (42%), with a mean age of 41 years. Six themes about reasons for participation emerged from free text responses: being asked, altruism, potential for personal benefit, financial gain, curiosity, and valuing or knowledge of research. Most did not report reservations. Those reservations identified included time constraints, confidentiality, and whether patients felt well suited to fulfill the study requirements.

CONCLUSIONS

Although injured patients are identified by the research community as vulnerable, they are willing to participate in research studies for diverse reasons, and their participation is commonly associated with positive experiences.

CLINICAL RELEVANCE

Understanding perceptions of participants' experiences of being in a research study after acute injury can guide researchers to improve future study protocols and recruitment strategies in order to optimize participants' experiences. Recruitment and retention into clinical research studies is essential to build nursing science to enhance the recovery of injured individuals.

Perceptions of trauma research with a sample of at-risk youth

Growing body of research demonstrates that participants generally report favorable perceptions of participating in trauma research. However, questions remain on the long-term impact of asking at-risk youth about trauma in settings where such questions are unexpected. Perceptions of participation were examined in the current longitudinal study comprising a sample of adolescent girls recruited from the child welfare system to participate in a healthy relationship project. Over a year, teens (n = 180) completed four research sessions during which they were interviewed about interpersonal trauma exposure and trauma-related symptoms. Results indicated that adolescents reported stable, favorable benefit-to-cost ratios over time. Perceptions of research participation and symptom severity did not impact retention.

Reactions to research participation in victims of childhood sexual abuse

We examined whether adults with a documented or self-reported history of childhood sexual abuse (CSA) report more emotional reactions and negative responses to research participation and whether psychiatric symptoms play a moderating role in their reactions. Using a prospective cohort design, individuals with documented histories of CSA and non-abused matched controls were followed up and interviewed in adulthood (n = 460). Reactions to research participation were measured with a brief questionnaire. Concurrent symptoms of depression, anxiety, and PTSD were assessed via standardized measures. Results showed that those with a history of CSA, documented or self-reported, experienced similar reactions compared to controls. Psychiatric symptoms predicted stronger emotional reactions and more negative responses, but also greater personal benefit, regardless of CSA history.

Emotional risks to respondents in survey research

Some survey research has documented distress in respondents with pre-existing emotional vulnerabilities, suggesting the possibility of harm. In this study, respondents were interviewed about a personally distressing event; mood, stress, and emotional reactions were assessed. Two days later, respondents participated in interventions to either enhance or alleviate the effects of the initial interview. Results indicated that distressing interviews increased stress and negative mood, although no adverse events occurred. Between the interviews, moods returned to baseline. Respondents who again discussed a distressing event reported moods more negative than those who discussed a neutral or a positive event. This study provides evidence that, among nonvulnerable survey respondents, interviews on distressing topics can result in negative moods and stress, but they do not harm respondents.

Commentary on Canadian child maltreatment data

The issue of how to best collect child maltreatment data is a key concern within the Public Health Agency of Canada (PHAC). We argue that maltreatment data can be collected from children, adolescents, and parents with approaches that are accurate, methodologically robust, legal, and ethical. It has been done in other countries. First, we clarify ongoing child maltreatment data collection by the Canadian government and address PHAC initiatives to include child maltreatment questions in national contemporaneous surveys. Second, we identify examples of population-based studies with child, adolescent, and parent respondents. Third, we highlight some measurement considerations. Fourth, we address ethical considerations in conducting this type of research.

Children's Perception of Research Participation: Examining Trauma Exposure and Distress

USING THE REACTIONS TO RESEARCH Participation Questionnaire for Children (RRPQ-C), this study examined perceptions of research participation among 181 school-aged children with and without trauma histories. As part of two larger studies, children completed non-trauma related tasks to assess emotion understanding and cognitive ability. Parents (and not children) reported on children's interpersonal (e.g., sexual abuse, physical abuse, witnessing domestic violence, witnessing community violence) and non-interpersonal (e.g., motor vehicle accidents, medical traumas, natural disasters) trauma exposure. Children's perceptions of costs and benefits of research participation and understanding of informed consent did not vary as a function of trauma exposure. The number of traumatic events experienced was unrelated to children's perceptions. Furthermore, children across trauma-exposure groups generally reported a positive cost-benefit ratio, and understanding of the consent information. Implications of these data are discussed.

Ethical issues in trauma-related research: a review

ETHICAL DECISION-MAKING ABOUT TRAUMA-RELATED STUDIES requires a flexible approach that counters assumptions and biases about victims, assures a favorable ethical cost-benefit ratio, and promotes advancement of knowledge that can benefit survivors of traumatic stress. This paper reviews several ethical issues in the field of traumatic stress: benefit and risks in trauma-related research, whether trauma-related research poses unique risks and if so what those might be, informed consent and mandatory reporting, and supervision of trauma-related research. For each topic, we review potential ethical issues, summarize the research conducted thus far to inform ethical practice, and recommend future practice, research questions and policies to advance the field so that research on trauma can continue to be a win-win situation for all stakeholders in the research enterprise.

Perceptions of participating in longitudinal trauma research among women exposed to intimate partner abuse

We examine motivations for, and costs/benefits of, participation in three interviews across a one-year period among women recently exposed to intimate partner abuse (IPA). Recruited from publicly accessible police reports, women were not informed that the study focused on IPA in recruiting materials or when they scheduled the first interview. Women's ratings on the Response to Research Participation Questionnaire (RRPQ) indicated a positive benefit-to-cost ratio across all three interviews. Negative responses to participation as well as severity of IPA and PTSD symptoms did not predict retention at the next interview. These data demonstrate that studies asking about IPA experiences, even when survivors do not know in advance that IPA will be the focus of study, can be implemented within a stable benefit-to-cost ratio over time.

Trauma in people with intellectual and developmental disabilities: reactions of parents and caregivers to research participation

Generally, studies have revealed that only a minority of people are bothered by participation in research on traumatic stress. Severity of traumatic events and subsequent responses are typically unrelated to negative reactions. We included 386 family members and caregivers (respondents) of people with intellectual and developmental disabilities (focus people). Focus people (ages 4-82) had a wide range of physical and intellectual disabilities, medical and behavioral problems, and exposure to potentially traumatic events. The measures of impact of research participation (based on J. I. Ruzek & D. F. Zatzick's [2000] Reactions to Research Participation Questionnaire [RRPQ]; S. Folkman and R. S. Lazarus's [1986 , 1988 ] Emotional Responses to Participation Scale) showed good psychometric properties. Response to participation was highly skewed toward good understanding of informed consent, valuing participation, and minimal negative reactions. Number of traumatic events was related, positively, to only one RRPQ subscale: Valuing Participation. Implications for research and clinical work are discussed.

Ethical issues in research on sensitive topics: participants' experiences of distress and benefit

While many studies ask participants to disclose sensitive information or to participate in emotionally arousing tasks, little is known about participants' subjective experiences of discomfort and benefit. Ethics review committees, therefore, have little information about participant experiences to guide their informed decision-making. We asked undergraduate females about their experiences in a study that included an experimental session, interviews, and self-report measures on sensitive topics. We examined results overall, and compared the responses of individuals with and without childhood abuse experiences. Participants who had experienced child abuse were more likely to report distress due to remembering the past, but also more likely to report that participation was helpful. Implications for future research, and recommendations for review boards, are discussed.

Ethical issues in mental health research: the case for community engagement

PURPOSE OF REVIEW

To describe community-engaged research (CEnR) and how it may improve the quality of a research study while addressing ethical concerns that communities may have with mental health and substance abuse research. This article includes a review of the literature as well as recommendations from an expert panel convened with funding from the US National Institute of Mental Health.

RECENT FINDINGS

CEnR represents a broad spectrum of practices, including representation on institutional ethics committees, attitude research with individuals from the study population, engaging community advisory boards, forming research partnerships with community organizations, and including community members as co-investigators.

SUMMARY

CEnR poses some challenges; for example, it requires funding and training for researchers and community members. However, it offers many benefits to researchers and communities, and some form of CEnR is appropriate and feasible in nearly every study involving human participants.

Adolescent distress in traumatic stress research: data from the National Survey of Adolescents-Replication

Small numbers of adults report distress in response to traumatic stress surveys. Less is known about adolescent research participants. We examined distress in response to a survey on traumatic stress using data from the National Survey of Adolescents-Replication, a nationally representative sample of 3,614 youth aged 12-17 years. Although 204 (5.7%) adolescents found some questions distressing, only 8 (0.2%) remained upset at the end of the interview, and 2 (<0.1%) wished to speak to a counselor. Adolescents reporting traumatic experiences or mental health problems were significantly more likely to report distress compared to those not endorsing such problems. Significantly more girls (7.5%) reported distress than boys (3.9%). Findings suggest that survey questions about trauma pose minimal risk to adolescents.

Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma

OBJECTIVE

The objective of the study was to develop and implement a stepped collaborative care intervention targeting posttraumatic stress disorder (PTSD) and related comorbidities to enhance the population impact of early trauma-focused interventions.

METHOD

We describe the design and implementation of the Trauma Survivors Outcomes and Support study. An interdisciplinary treatment development team was composed of trauma surgical, clinical psychiatric and mental health services "change agents" who spanned the boundaries between frontline trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.

RESULTS

Two hundred seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by frontline acute care masters in social work and nurse practioner providers.

CONCLUSIONS

Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other nonspecialty posttraumatic contexts.

Parental attitude to participating in long-term follow-up studies of their children's health after in utero diagnosis of abnormalities

OBJECTIVE

To determine whether parents might be distressed if approached to take part in long-term follow-up of their children's health and development.

METHODS

A short, closed format anonymous questionnaire seeking parental opinion on being asked about their child's health was offered to attendees for obstetric ultrasound and parents of children attending paediatric cardiology clinics.

RESULTS

In total, 70% of the 266 respondents were attending for ultrasound and approximately 30% paediatric cardiology clinics. In total, 66 respondents had children with long-term health problems, 28 with learning difficulties and 61 had previously had an abnormal obstetric ultrasound scan. Greater than 90% of parents were happy to be contacted and asked questions about their children's health and development, regardless of their child's health or their experiences during prenatal ultrasonography.

CONCLUSIONS

Our results provide reassurance to future researchers and ethics committees that studies of children's later health after in utero diagnosis of anomalies are unlikely to prove unacceptable to many parents.

The psychologic impact on children of admission to intensive care

There is growing literature on the psychologic impact on parents and families of having a child on the pediatric intensive care unit (PICU), but less is known about the child's experience. In this article the relevant literature is explored and illustrated with examples from the author's research. Recurring themes are the persistence of distress in a significant minority of children and the association between parental anxiety and child's psychologic symptoms. The evidence on the extent of children's factual and delusional memories relating to PICU is also examined. Finally, the implications of the current state of knowledge for future research and for clinical work are discussed.

Emergency department screening for risk for post-traumatic stress disorder among injured children

OBJECTIVE

To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED).

METHODS

The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained.

RESULTS

The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered.

CONCLUSIONS

Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.