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Yoo PY, Kumari S, Stephens S, Yeh EA. Social network characteristics and their relationships with physical activity in children with multiple sclerosis. Mult Scler Relat Disord 2024; 91:105865. [PMID: 39243504 DOI: 10.1016/j.msard.2024.105865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 08/13/2024] [Accepted: 09/01/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Physical activity has been found to associate with improved health outcomes in children with multiple sclerosis (MS). Social networks may facilitate physical activity in children with MS. OBJECTIVES To estimate associations between social network characteristics and physical activity in children with MS compared to children with monophasic acquired demyelinating syndrome (mono-ADS). METHODS Children with MS and mono-ADS recruited from the Hospital for Sick Children completed questionnaires on social network and physical activity. Descriptive and inferential analyses estimated differences between cohorts and correlations. RESULTS Children with MS (n = 16) and mono-ADS (n = 22) did not differ in outcomes. Higher physical activity associated with larger social networks (rs= 0.681, p < 0.01), more Emotional Support (rs= 0.604, p < 0.05), Camaraderie (rs= 0.585, p < 0.05), more social network members with post-secondary education (rs= 0.680, p < 0.05), and members who exercise 3 to 4 times a week (rs= 0.744, p < 0.01). These associations were not found in children with mono-ADS. CONCLUSION Larger social network size, more emotional support and camaraderie, and more individuals with post-secondary education and who regularly exercise in the social network associated with higher physical activity in children with MS. Social network characteristics may help understand health behaviors in children with MS.
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Affiliation(s)
- Paul Yejong Yoo
- Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, Hospital for Sick Children, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.
| | - Sonika Kumari
- Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, Hospital for Sick Children, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
| | - Samantha Stephens
- Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, Hospital for Sick Children, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, Hospital for Sick Children, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Neal WN, Richardson EV, Motl RW. Informing the development of a mobile application for the physical activity guidelines in multiple sclerosis: a qualitative, pluralistic approach. Disabil Rehabil Assist Technol 2024; 19:1161-1169. [PMID: 36490227 DOI: 10.1080/17483107.2022.2153937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/24/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The uptake of Physical Activity Guidelines (PAGs) for adults with multiple sclerosis (MS) may be facilitated through mHealth solutions such as a mobile app. To date, there is limited information regarding preferred features of an app for people with MS. We explored desired features for an app that supports physical activity behaviour among persons with MS. MATERIALS AND METHODS Using a pluralistic analytical approach, we conducted a secondary qualitative analysis on a portion of data collected from an earlier study to explore (i) what persons with MS wanted in an app based on the PAGs and (ii) how the PAG-based app should facilitate behaviour change. The data were subjected to deductive, content analysis to identify populous mentions of desired PAG-based app elements. We then used inductive, semantic reflexive thematic analysis to further explore the opinions and evaluations of participants. RESULTS Participants (n = 16) perceived features such as activity tracking, incentives for completing milestones, and customization as both triggers for doing PA and supporting engagement with the app. Participants desired a personalized PA prescription based on mobility and fitness level, expert feedback based on data entered in the app, and an exercise library with a range of evidence-based content. Participants insisted the app be backed by a solid scientific foundation and that accessibility of personal data be controlled by the user. CONCLUSIONS This study identifies several design considerations for an app based on the PAGs. The results suggest a simple, trustworthy, and evidence-based app that focuses on helping persons with MS reach the PAGs.
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Affiliation(s)
- Whitney N Neal
- Department of Health Behavior, University of Alabama, Birmingham, AL, USA
| | - Emma V Richardson
- School of Sport and Exercise, University of Worchester, Worchester, UK
| | - Robert W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
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Yoo PY, Kumari S, Stephens S, Yeh EA. Social network size and mental health outcomes in youth with neuroinflammatory disorders. Mult Scler Relat Disord 2023; 79:105046. [PMID: 37813072 DOI: 10.1016/j.msard.2023.105046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND 75 % of youth with MS report symptoms of fatigue, depression, and anxiety. Social network size (number of people in an individual's network) is known to have positive impacts on health and health behavior in pediatric populations and in individuals with multiple sclerosis. OBJECTIVES To estimate associations between social network size (SNS) and depression, anxiety, symptoms of post-traumatic stress disorder (PTSD), and quality of life among youth with recurrent neuroinflammatory disorders (RNI) in comparison to that of youth with monophasic acquired demyelinating syndrome (mono-ADS). METHODS Youth with RNI and mono-ADS were recruited from the Pediatric Neuroinflammatory Disorders Clinic at the Hospital for Sick Children between September 2020 and August 2022. After consent, participants completed the questionnaires on social network composition, depression, anxiety, PTSD, and quality of life. Descriptive and inferential analyses were conducted for differences between cohorts and correlations. RESULTS Youth with RNI (n = 37, Female= 22, Median age= 15, IQR= 3) and mono-ADS (n = 23, Female= 12, Median age= 14, IQR= 4.5) did not differ in: SNS, depression, anxiety, PTSD, and quality of life. Larger SNS was associated with lower anxiety (rs= -0.350, p<0.05) in youth with RNI and youth with RNI who presented anxiety disorder had significantly lower number of social contacts than those who did not (t = 2.23, p = 0.033, ES= 0.90) but not in mono-ADS. When analyzing the two cohorts grouped together, all youth who screened for anxiety had significantly smaller network size than those who did not (t = 2.06, p = 0.045, ES= 0.66). This was similar with those who screened for depression (t = 2.05, p = 0.046, ES= 0.58). CONCLUSIONS In youth with RNI, SNS was associated with anxiety. SNS is one important aspect of social networks that have the potential to shape mental health in youth with neuroinflammatory disorders. Future studies should focus on social network composition, strength of ties, and types of support in shaping health outcomes.
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Affiliation(s)
- Paul Yejong Yoo
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Division of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Sonika Kumari
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Division of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Stephens
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Division of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Division of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Jadotte Y, Buchholz B, Carroll W, Frum-Vassallo D, MacPherson J, Cole S. Brief Action Planning in Health and Health Care: A Scoping Review. Med Clin North Am 2023; 107:1047-1096. [PMID: 37806724 DOI: 10.1016/j.mcna.2023.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Achieving maximal health outcomes via health promotion and disease prevention requires the adoption of healthy behaviors. Brief action planning (BAP) is a method for patient self-management, health behavior change, and health coaching with potentially broad implications for and clinical applications in health and health care contexts. This scoping review presents 5 major findings about the literature on BAP: the principal geographic locations and the clinical contexts of its application, the types of research evaluations that it has undergone to date, the theoretic frameworks in which it is grounded, and the fidelity of its use in clinical practice.
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Affiliation(s)
- Yuri Jadotte
- Department of Family, Population, and Preventive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA; Northeast Institute for Evidence Synthesis and Translation, Division of Nursing Science, School of Nursing, Rutgers University, Newark NJ, USA.
| | - Benjamin Buchholz
- Sickle Cell Center of Excellence, College of Medicine, Howard University, Washington, DC, USA
| | - William Carroll
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles CA, USA
| | - Deirdra Frum-Vassallo
- Health Promotion Disease Prevention, Northport VA Medical Center, Northport, NY, USA
| | | | - Steven Cole
- BAP Professional Network, US; Department of Psychiatry, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA; Department of Scientific Education, Zucker SOM at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry, Zucker SOM at Hofstra/Northwell, Hempstead, NY, USA
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Capasso N, Virgilio E, Covelli A, Giovannini B, Foschi M, Montini F, Nasello M, Nilo A, Prestipino E, Schirò G, Sperandei S, Clerico M, Lanzillo R. Aging in multiple sclerosis: from childhood to old age, etiopathogenesis, and unmet needs: a narrative review. Front Neurol 2023; 14:1207617. [PMID: 37332984 PMCID: PMC10272733 DOI: 10.3389/fneur.2023.1207617] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Multiple sclerosis (MS) primarily affects adult females. However, in the last decades, rising incidence and prevalence have been observed for demographic extremes, such as pediatric-onset MS (POMS; occurring before 18 years of age) and late-onset MS (corresponding to an onset above 50 years). These categories show peculiar clinical-pathogenetic characteristics, aging processes and disease courses, therapeutic options, and unmet needs. Nonetheless, several open questions are still pending. POMS patients display an important contribution of multiple genetic and environmental factors such as EBV, while in LOMS, hormonal changes and pollution may represent disease triggers. In both categories, immunosenescence emerges as a pathogenic driver of the disease, particularly for LOMS. In both populations, patient and caregiver engagement are essential from the diagnosis communication to early treatment of disease-modifying therapy (DMTs), which in the elderly population appears more complex and less proven in terms of efficacy and safety. Digital technologies (e.g., exergames and e-training) have recently emerged with promising results, particularly in treating and following motor and cognitive deficits. However, this offer seems more feasible for POMS, being LOMS less familiar with digital technology. In this narrative review, we discuss how the aging process influences the pathogenesis, disease course, and therapeutic options of both POMS and LOMS. Finally, we evaluate the impact of new digital communication tools, which greatly interest the current and future management of POMS and LOMS patients.
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Affiliation(s)
- Nicola Capasso
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Eleonora Virgilio
- Neurology Unit, Department of Translational Medicine, AOU Maggiore della Carità Novara, University of Eastern Piedmont, Novara, Italy
| | - Antonio Covelli
- Department of Neurology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Beatrice Giovannini
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Foschi
- Department of Neuroscience, MS Center, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Federico Montini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Nasello
- Neurology Unit, Department of Neurosciences, Mental Health and Sensory organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Elio Prestipino
- UOSC Neuro-Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Giuseppe Schirò
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
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Brenton JN, Florenzo B, Koshiya H, Min S, Woolbright E, Coleman R, Chen S, Goldman M. Six-Minute Walk as a Measure of Walking Capacity and Endurance in Patients With Pediatric-Onset Multiple Sclerosis. Neurology 2022; 99:e2161-e2170. [PMID: 35985830 PMCID: PMC9651457 DOI: 10.1212/wnl.0000000000201098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite low levels of disability, youth with pediatric-onset multiple sclerosis (POMS) engage in less physical activity compared with peers. The contribution of walking capacity, endurance, behavior, and MS comorbidities remains relatively undefined and may provide valuable insights into the limitations toward physical activity in youth with MS. The primary objective of this study was to investigate differences in walking capacity, endurance, and real-world behaviors of daily activity between youth with POMS and controls. METHODS Youth diagnosed with MS prior to 18 years and aged 21 years or younger were recruited in addition to healthy controls. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels and the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels. Participants also completed the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance and were sent home with a waist-worn accelerometer to assess real-world walking behavior. RESULTS Forty-five patients with POMS and 85 control participants were enrolled. The POMS cohort had a mean age of 16.9 ± 2.7 years, with a mean disease duration of 2.8 ± 2.6 years. A greater proportion of the POMS cohort was overweight/obese compared with controls (75% vs 33%). Participants with MS walked a significantly shorter distance in 6 minutes compared with controls (1,848 feet vs 2,134 feet, p < 0.0001) and, unlike controls, were unable to accelerate to their peak speed at the end of the 6MW. Body mass index category and MS disease significantly affected 6MW performance. Using continuous accelerometry, participants with MS spent less time in moderate-to-vigorous physical activity compared with controls (20.4 vs 35.4 min/d, p = 0.0003). The POMS cohort reported significantly higher levels of depression and fatigue but self-reported similar levels of daily physical activity as controls. DISCUSSION Youth with POMS exhibit slower 6MW performance and less daily engagement in moderate-to-vigorous physical activity, suggesting limitations in functional walking capacity, endurance, and daily activity behavior. Limitations in walking endurance and capacity are most prominent in those youth who are overweight/obese and living with MS. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that, compared with healthy controls, patients with POMS walk shorter distances on the 6MW test, are less able to accelerate to peak speed at the end of the test, and are less physically active.
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Affiliation(s)
- J Nicholas Brenton
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond.
| | - Brian Florenzo
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Hitoshi Koshiya
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Seulgi Min
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Emma Woolbright
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Rachael Coleman
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Shanshan Chen
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Myla Goldman
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
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Logan LM, Stephens S, Ciftci-Kavaklioglu B, Berenbaum T, Ly M, Longoni G, Yeh EA. Pandemic-associated mental health changes in youth with neuroinflammatory disorders. Mult Scler Relat Disord 2021; 58:103468. [PMID: 34954653 DOI: 10.1016/j.msard.2021.103468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/27/2021] [Accepted: 12/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Children with neuroinflammatory disorders have high rates of anxiety and depression, alongside low rates of physical activity. Given general concerns for mental and physical health in children during the COVID-19 pandemic lockdown, here we sought to understand how sleep, anxiety, depression, and physical activity changed with the lockdown in children with neuroinflammatory disorders. We hypothesized that outcomes would worsen during the lockdown, and that they would differ by underlying disorder category and age. METHODS Patients attending a specialized neuroinflammatory clinic (n = 314) completed questionnaires (n = 821 responses; Jan 2017-Aug 2020) assessing sleep, anxiety, depression, and physical activity. Respondents had either: childhood-onset chronic or recurrent neuroinflammatory disorders (CRNI), a history of Autoimmune Encephalitis (AE) or Monophasic Acquired Demyelinating Syndromes (monoADS). We performed linear mixed models to examine the association between our outcome measures (sleep, anxiety, depression, and physical activity) and categories of disorder type, sex, age, physical activity, relapses, and time (pre- vs. post- COVID-19 lockdown). Participant ID acted as a random effect, to account for repeated measures. RESULTS Sleep significantly increased in the first 6 months of the COVID-19 lockdown (F(1, 544)=56.85, P<0.001,). Across the whole group, anxiety and depression did not change with the pandemic, but we found differing trends by age category. Anxiety decreased in teenagers (≥13y) (Z = 3.96, P<0.001), but not for pre-teens. Depression remained higher in teenagers than preteens across both timepoints (F(1, 597)=6.30, p = 0.012). Physical activity levels did not change with the pandemic in comparison to pre-pandemic (F(1, 629)=1.92, P = 0.166). Anxiety was higher in inactive individuals regardless of timing (F(2, 547)=3.74, p = 0.024). CONCLUSION For youth with neuroinflammatory disorders, the COVID-19 pandemic lockdown resulted in increased hours of nighttime sleep but did not result in significant overall changes in self-reported anxiety or depression. Pre-lockdown, teenagers had higher depression and anxiety scores than preteens. Post-lockdown, anxiety and depression scores decreased in teenagers compared to pre-teens. Physical activity was low both pre- and post-lockdown, and rates of anxiety were higher for inactive participants at both timepoints. Differences based on age suggest that younger children (<13 years) were more negatively affected by the pandemic than older children (≥ 13 years).
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Affiliation(s)
- Lindsey M Logan
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada; University of Toronto, Canada
| | - Samantha Stephens
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada; University of Toronto, Canada
| | - Beyza Ciftci-Kavaklioglu
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada; University of Toronto, Canada; University of Manitoba, Canada
| | - Tara Berenbaum
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada
| | - Mina Ly
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada
| | - Giulia Longoni
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada; University of Toronto, Canada
| | - E Ann Yeh
- Hospital for Sick Children, Division of Neurology, Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, Canada; University of Toronto, Canada.
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