Considerations and Future Directions for Conducting Clinical Research With Pediatric Populations During the COVID-19 Pandemic

ScreenPlus: A comprehensive, multi-disorder newborn screening program

The increasing availability of novel therapies highlights the importance of screening newborns for rare genetic disorders so that they may benefit from early therapy, when it is most likely to be effective. Pilot newborn screening (NBS) studies are a way to gather objective evidence about the feasibility and utility of screening, the accuracy of screening assays, and the incidence of disease. They are also an optimal way to evaluate the complex ethical, legal and social implications (ELSI) that accompany NBS expansion for disorders. ScreenPlus is a consented pilot NBS program that aims to enroll over 100,000 infants across New York City. The initial ScreenPlus panel includes 14 disorders and uses an analyte-based, multi-tiered screening platform in an effort to enhance screening accuracy. Infants who receive an abnormal result are referred to a ScreenPlus provider for confirmatory testing, management, and therapy as needed, along with longitudinal capture of outcome data. Participation in ScreenPlus requires parental consent, which is obtained in active and passive manners. Patient-facing documents are translated into the ten most common languages spoken at our nine pilot hospitals, all of which serve diverse communities. At the time of consent, parents are invited to receive a series of online surveys to capture their opinions about specific ELSI-related topics, such as NBS policy, residual dried blood spot retention, and the types of disorders that should be on NBS panels. ScreenPlus has developed a stakeholder-based, collective funding model that includes federal support in addition to funding from 14 advocacy and industry sponsors, all of which have a particular interest in NBS for at least one of the ScreenPlus disorders. Taken together, ScreenPlus is a model, multi-sponsored pilot NBS program that will provide critical data about NBS for a broad panel of disorders, while gathering key stakeholder opinions to help guide ethically sensitive decision-making about NBS expansion.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background

Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects.

Methods

The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic.

Results

Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) negative deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) negative deviations in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020.

Conclusions

The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

Growth mindset in young people awaiting treatment in a paediatric mental health service: A mixed methods pilot of a digital single-session intervention

BACKGROUND

Wait times are significant in child mental health services but may offer opportunity to promote growth mindsets in young people with physical and mental health needs. A digital growth mindset single-session intervention is effective in young people, but its use in paediatric settings has not been examined. This mixed methods pilot aimed to assess the intervention's feasibility, acceptability, and impact in this population.

METHOD

Patients aged 8-18 on waiting lists in a paediatric hospital's specialist mental health service were offered the intervention remotely. Treatment completion and retention rates, symptoms of depression and anxiety, perceived control, and personality mindset were assessed at baseline, post-treatment, and follow-ups. Semi-structured interviews to explore the intervention's acceptability were conducted post-treatment.

RESULTS

Twenty-five patients completed the intervention and 17 patients and three carers/parents were interviewed. Outcomes showed small to large improvements across time-points. Most patients reported finding the intervention enjoyable, accessible, and instilled a hope for change. They valued elements of the intervention but made suggestions for improvement.

CONCLUSIONS

The digital growth mindset single-session intervention is feasible, acceptable, and potentially beneficial for young people with physical and mental health needs on waiting lists. Further research is warranted to examine its effectiveness and mechanism of change.

Acceptability and Feasibility of eSCCIP: Results From a Pilot Study of the Electronic Surviving Cancer Competently Intervention Program

BACKGROUND

Providing high-quality psychosocial care to parents and other primary caregivers of children with cancer (henceforth referred to as caregivers) is important, given the numerous challenges associated with a pediatric cancer diagnosis and the increased risk for negative psychosocial sequelae among caregivers. The Electronic Surviving Cancer Competently Intervention Program (eSCCIP) is a psychosocial eHealth intervention for caregivers, developed using an iterative, user-centered process.

METHOD

eSCCIP was tested in a single-arm pilot trial at Nemours Children's Hospital, Delaware (NCT05333601). The primary outcomes were intervention acceptability and feasibility, assessed via enrollment and retention targets, and item-level acceptability ratings. Enrollment and retention targets of 45% were set based on previous work, and an item-level acceptability threshold of 80% was set. A secondary exploratory analysis was conducted examining acute distress, anxiety, symptoms of post-traumatic stress, and family functioning.

RESULTS

44 caregivers enrolled in the study and 31 completed. The intervention was rated favorably by completers, with over 80% of the sample selecting "mostly true" or "very true" for all items of the eSCCIP Evaluation Questionnaire, which was used to assess acceptability and feasibility. Enrollment and retention rates were 54% and 70%, respectively. Exploratory psychosocial outcomes showed statistically significant decreases from pre-intervention to post-intervention for overall symptoms of post-traumatic stress disorder (PTSD), cluster D symptoms of PTSD (negative mood and cognitions), and anxiety. Small-moderate effect sizes were observed for all psychosocial outcomes of interest.

CONCLUSIONS

eSCCIP is an acceptable and feasible intervention for caregivers. Results are promising regarding reductions in symptoms of post-traumatic stress and anxiety.

Conducting clinical genomics research during the COVID-19 pandemic: Lessons learned from the CSER consortium experience

Clinical research studies have navigated many changes throughout the COVID-19 pandemic. We sought to describe the pandemic's impact on research operations in the context of a clinical genomics research consortium that aimed to enroll a majority of participants from underrepresented populations. We interviewed (July to November 2020) and surveyed (May to August 2021) representatives of six projects in the Clinical Sequencing Evidence-Generating Research (CSER) consortium, which studies the implementation of genome sequencing in the clinical care of patients from populations that are underrepresented in genomics research or are medically underserved. Questions focused on COVID's impact on participant recruitment, enrollment, and engagement, and the transition to teleresearch. Responses were combined and thematically analyzed. Projects described factors at the project, institutional, and community levels that affected their experiences. Project factors included the project's progress at the pandemic's onset, the urgency of in-person clinical care for the disease being studied, and the degree to which teleresearch procedures were already incorporated. Institutional and community factors included institutional guidance for research and clinical care and the burden of COVID on the local community. Overall, being responsive to community experiences and values was essential to how CSER navigated evolving challenges during the COVID-19 pandemic.

Ethical considerations for developing pediatric mhealth interventions for teens with socially complex needs

TOPIC

Mobile Health (mHealth) stands as a potential means to better reach, assess, and intervene with teens with socially complex needs. These youth often face overlapping adversities including medical illness and a history of experiencing adverse childhood experiences (ACEs). Clinicians are faced with navigating ethical decisions when developing mHealth tools for teens who have socially complex needs. Many tools have been developed for adults from the general population. However, despite the development of thousands of mHealth interventions, developers tend to focus on designing for usability, engagement, and efficacy, with less attention on the ethical considerations of making such tools.

PURPOSE

To safely move mHealth interventions from research into clinical practice, ethical standards must be met during the design phase. In this paper we adapt the Four Box Model (i.e., medical indications, preferences of patients, quality of life, and contextual features) to guide mHealth developers through ethical considerations when designing mHealth interventions for teens who present with a medical diagnosis and a history of ACEs.

SOURCES

A review of language, inclusive features, data sharing, and usability is presented using both the Four Box Model and potential scenarios to guide each consideration.

CONCLUSIONS

To better support designers of mHealth tools we present a framework for evaluating applications to determine overlap with ethical design and are well suited for use in clinical practice with underserved pediatric patients.

Dietary supplements for aggressive behaviour in people with intellectual disabilities: A randomised controlled crossover trial

BACKGROUND

Aggressive incidents are common in people with intellectual disabilities. Therefore, we aimed to assess whether supplementation of multivitamins, minerals, and omega-3 fatty acids (FA) reduces aggressive incidents.

METHODS

We conducted a randomised, triple blind, placebo controlled, single crossover intervention trial. People with intellectual disabilities or borderline intellectual functioning, between 12 and 40 years of age, and showing aggressive behaviour were included. Participants received either a daily dose of dietary supplements, or placebo. Primary outcome was the number of aggressive incidents, measured using the Modified Overt Aggression Scale (MOAS).

RESULTS

there were 113 participants (placebo, n = 56), of whom 24 (placebo, n = 10) participated in the crossover phase of the trial. All 137 trajectories were included in the analyses. There was no significant difference in mean number of aggressive incidents per day between those assigned to supplements and those who received placebo (rate ratio = 0.93: 95% Confidence Interval [CI] = 0.59-1.45).

CONCLUSION

In this pragmatic trial, we did not find significant differences in the outcomes between the supplement and placebo arms. The COVID-19 pandemic started midway through our trial, this may have affected the results.

An initial investigation of using smartphone-enabled micro-temporal data collection to increase acceptability, feasibility, and validity of research on cancer caregiving

PURPOSE

Smartphone-enabled micro-temporal data collection has potential to increase reliability, validity, and feasibility of participant-reported data and is a promising strategy for pediatric oncology supportive care and quality-of-life research. Given the demands of pediatric cancer caregiving, we sought to understand the feasibility and acceptability of smartphone data collection that included short surveys administered daily for 14 days via text message link.

METHODS

We recruited pediatric cancer caregivers, whose children (ages 0-18 years) were on active treatment, to complete a 14-day daily survey study via smartphone. We implemented our study procedures and examined feasibility through study enrollment rates, reasons for refusal, retention rates, number of reminders and number of completed surveys. We examined acceptability using caregiver ratings of survey length, burden, and ease of completion on a smartphone.

RESULTS

We recruited (N = 75) caregivers to the study and had an 84% enrollment rate. Reasons for declining participation included passive refusal (n = 13) and too busy (n = 1). The participant retention rate was 100% and compliance with daily survey completion was 99%. Most surveys were completed following two prompts and took participants 5 minutes or less to complete. Caregivers rated the surveys as easy to complete, low burden, and just right in length.

CONCLUSION

A daily self-report, using a brief (≤5 minutes) survey administered on a smartphone via text message prompt, is a feasible and acceptable method. Future research should extend these findings to understand the generalizability across pediatric cancer caregiving contexts.

Bringing the laboratory into the home: A protocol for remote biobehavioral data collection in pregnant women with emotion dysregulation and their infants

Pregnant women struggling with emotion dysregulation may be more likely to engage in a wide range of health risk behaviors. This protocol describes a study on intergenerational transmission of emotion dysregulation from the third trimester of pregnancy to 18 months postpartum. Biobehavioral markers of emotion dysregulation are typically measured in laboratory settings which was prohibited by many universities during the COVID-19 pandemic. We describe how markers of emotion dysregulation (e.g. maternal, fetal, and infant heart rate variability) are collected remotely. We detail how data collection can be augmented to reach diverse populations who may not otherwise participate in laboratory-based research.

Preparing the Next Generation of Academic Researchers During the Pandemic: Lessons from a National Mental Health Research Postdoctoral Fellowship

OBJECTIVE

The COVID-19 pandemic has severely disrupted all aspects of academic medicine, including post-doctoral research fellowship training. The current survey examined ways in which research fellows across 28 U.S. nationally diverse sites have been impacted.

METHODS

Survey participants included 62 M.D. and Ph.D. post-doctoral fellows and 27 local fellowship center directors within the Veterans Affairs (VA) Advanced Fellowship in Mental Illness Research and Treatment (MIRT), a national fellowship program tasked to develop academic clinician researchers within the field of mental health. Survey questions focused on productivity and challenges experienced by fellows during the pandemic.

RESULTS

Half of fellows reported working entirely off-site during the COVID-19 pandemic. All fellows reported some level of disruption in productivity during the pandemic; 73% reported a disruption in data collection, 69% reported decreased scholarly output, 41% reported disruption in grant writing, and 73% reported disruption in ability to provide clinical care. Yet, the majority of fellows (66%) reported not having to change their research goals, pivoting to telehealth-based data collection, and employing extant data for research projects and peer-reviewed publications.

CONCLUSIONS

The results of the fellow and director surveys highlight the associated disruption of the COVID-19 pandemic on fellowship-related activities and parallel ingenuity of programs to continue conducting research and clinical services in a modified fashion. While many research goals continued unabated, the findings suggest alterations in data collection methodology and a focus on using extant data, which may have a residual influence on future early career research grant applications.

Preliminary Findings from a Telephone-Based Cognitive Screening of an Adult HIV Research Cohort during the COVID-19 Pandemic

Objectives

Few publications have documented the utility of in-home telephone-based cognitive screeners during COVID-19. This manuscript describes the adaptation of select face-to-face (FTF) neuropsychological tests to telephonic administration in a longitudinal cohort of people with HIV (PWH). Using the cohort’s pre-pandemic neuropsychological data, we explore the utility of telephonic administration in this population.

Methods

Of a longitudinal cohort of 170 adult PWH, 59 completed telephonic medical and cognitive screenings with comparable pre-pandemic FTF data. Telephone screeners and FTF evaluations were compared using repeated measures ANCOVAs to examine whether test performance differed between administration types and levels of pre-pandemic cognitive performance. Individuals with pre-pandemic test scores more than a standard deviation below the demographically-corrected mean were categorized as “below average” cognitive performance (n = 23), and the remainder as “average” (n = 36).

Results

Over 90% of participants gave positive feedback about the telephone encounter. The average cognitive performance group scored higher than the below average group on all measures across both administration types. Telephone and FTF test scores did not differ significantly for measures of category fluency, letter fluency, and verbal learning. However, the below average group scored higher on a verbal memory measure administered via telephone compared with FTF.

Conclusions

Support for telephonic adaptation of select FTF measures in longitudinal research is mixed, with verbal fluency tasks showing the strongest equivalency. When employed carefully with a clear understanding of their limitations, telephone adaptations can provide an opportunity to continue study objectives, promote equity, and monitor participant well-being during times of duress.

Rapid Transition to Virtual Assessment and Treatment in an Interdisciplinary Randomized Clinical Trial for Youth With Chronic Pain: Adaptations and Implications for Future Trials

OBJECTIVES

COVID-19 abruptly halted in-person clinical care and research requiring a shift to virtual assessment and treatment. This unexpected transition of a 2-arm randomized controlled trial (RCT) examining interdisciplinary graded exposure treatment (GET Living) compared with multidisciplinary pain management for youth with chronic pain provided an opportunity to implement the first remotely delivered exposure treatment and remotely delivered biomechanical assessment for pediatric chronic pain. Here we describe these new approaches and provide lessons learned to inform future efforts in digital health care.

METHODS

A total of 68 youth (M=14.2 y; 80.9% female) were enrolled in the RCT (n=31 in-person, n=5 hybrid, n=32 virtual, n=9 withdrew). Of those withdrawn, n=3 withdrew due to COVID-19 related reasons. Some RCT elements required slight modification (eg, e-consent, actigraphy deployment, recruitment, and screening), while others were significantly altered (eg, session format and lab-based biomechanical assessment). Data from exit interviews were also examined to assess perspectives on the virtual format transition.

RESULTS

Results showed an increased enrollment rate when virtual care was an option (70.7%) compared with in-person (44.3%). Equivalent rates of completion for daily assessment (in-person, 72.8%; virtual, 73.3) were also observed, and participants described enhanced experience when able to complete exercises and exposures in their home environment during session (vs. a rehabilitation gym) allowing for genuine in vivo exposures (eg, household chores, riding bicycles).

DISCUSSION

Overall, our data demonstrate acceptability, feasibility, and equivalent patient engagement to virtual treatment. Novel methods implemented in this RCT can inform trial design and measures of clinical endpoints for future digital health interventions.

Digital Screening and Automated Resource Identification System to Address COVID-19-Related Behavioral Health Disparities: Feasibility Study

BACKGROUND

Digital mental health (DMH) tools use technology (eg, websites and mobile apps) to conveniently deliver mental health resources to users in real time, reducing access barriers. Underserved communities facing health care provider shortages and limited mental health resources may benefit from DMH tools, as these tools can help improve access to resources.

OBJECTIVE

This study described the development and feasibility evaluation of the Emotional Needs Evaluation and Resource Guide for You (ENERGY) System, a DMH tool to meet the mental health and resource needs of youth and their families developed in the context of the COVID-19 pandemic. The ENERGY System offers a brief assessment of resource needs; problem-solving capabilities; and symptoms of depression, anxiety, trauma, and alcohol and substance use followed by automated, personalized feedback based on the participant's responses.

METHODS

Individuals aged ≥15 years were recruited through community partners, community events, targeted electronic health record messages, and social media. Participants completed screening questions to establish eligibility, entered demographic information, and completed the ENERGY System assessment. Based on the participant's responses, the ENERGY System immediately delivered digital resources tailored to their identified areas of need (eg, relaxation). A subset of participants also voluntarily completed the following: COVID-19 Exposure and Family Impact Survey (CEFIS) or COVID-19 Exposure and Family Impact Survey Adolescent and Young Adult Version (CEFIS-AYA); resource needs assessment; and feedback on their experience using the ENERGY System. If resource needs (eg, housing and food insecurity) were endorsed, lists of local resources were provided.

RESULTS

A total of 212 individuals accessed the ENERGY System link, of which 96 (45.3%) completed the screening tool and 86 (40.6%) received resources. Participant responses on the mental health screening questions triggered on average 2.04 (SD 1.94) intervention domains. Behavioral Activation/Increasing Activities was the most frequently launched intervention domain (56%, 54/96), and domains related to alcohol or substance use were the least frequent (4%, 4/96). The most frequently requested support areas were finances (33%, 32/96), transportation (26%, 25/96), and food (24%, 23/96). The CEFIS and CEFIS-AYA indicated higher than average impacts from the pandemic (ie, average scores >2.5). Participants were satisfied with the ENERGY System overall (65%, 39/60) as well as the length of time it took to answer the questions (90%, 54/60), which they found easy to answer (87%, 52/60).

CONCLUSIONS

This study provided initial support for the feasibility of the ENERGY System, a DMH tool capable of screening for resource and mental health needs and providing automated, personalized, and free resources and techniques to meet the identified needs. Future studies should seek direct feedback from community members to further improve the ENERGY System and its dissemination to encourage use.

COVID-19 Exposure and Family Impact Scales for Adolescents and Young Adults

OBJECTIVE

To understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on adolescents and young adults (AYAs), we adapted the COVID-19 Exposure and Family Impact Scales (CEFIS; Kazak et al., 2021) for AYAs. Here, we report on the development, structure, and psychometric properties of the CEFIS-AYA.

METHODS

The CEFIS-AYA was developed by a multidisciplinary, multi-institutional team using a rapid iterative process. Data from 3,912 AYAs from 21 programs at 16 institutions across the United States were collected from May 2020 to April 2021. We examined the underlying structure of the CEFIS-AYA using principal component analysis (PCA), calculated internal consistencies, and explored differences in scores by gender and age.

RESULTS

Participants reported exposure to a range of COVID-19-related events (M = 9.08 events, of 28). On the bidirectional 4-point Impact scale, mean item scores were mostly above the midpoint, indicating a slightly negative impact. Kuder-Richardson 20/Cronbach's Alpha was good for Exposure (α = .76) and excellent for Impact (α = .93). PCA identified seven factors for Exposure (Severe COVID-19, Loss of Income, Limited Access to Essentials, COVID-19 Exposure, Disruptions to Activities, Disruptions to Living Conditions, and Designation as an Essential Worker) and five for Impact (Self and Family Relationships, Physical Well-Being, Emotional Well-Being, Social Well-Being, and Distress). Gender and age differences in CEFIS-AYA scores were identified.

DISCUSSION

Initial reliability data are strong and support use of the CEFIS-AYA for measuring the effect of the COVID-19 pandemic on AYAs in research and clinical care.

The Impact of COVID-19 on Patient, Family Member, and Stakeholder Research Engagement: Insights from the PREPARE NOW Study

BACKGROUND

Little is known about the impact of COVID-19 on patient, family member, and stakeholder patient-centered outcomes research engagement.

OBJECTIVE

To answer the research questions: (1) What is the impact of COVID-19 on the lives of patients with kidney disease and their families? (2) What is the impact of COVID-19 on research engagement for patient and family member research team members who are themselves at very high risk for poor COVID-19 outcomes? and (3) How can we help patients, family members, and stakeholder team members engage in research during COVID-19?

DESIGN

We conducted virtual semi-structured interviews with patient and family member co-investigators and kidney disease stakeholders from the PREPARE NOW study during November 2020. The interview guide included questions about participants' experiences with the impact of COVID-19 on research engagement.

PARTICIPANTS

Seven patient and family member co-investigators and eight kidney disease stakeholders involved in a kidney disease patient-centered outcomes research project participated in the interviews, data analysis, and writing this manuscript.

APPROACH

We used a content analysis approach and identified the main themes using an inductive process.

KEY RESULTS

Respondents reported three main ways that COVID-19 has impacted their lives: emotional impact, changing behaviors, and changes in health care delivery. The majority of respondents reported no negative impact of COVID-19 on their ability to engage in this research project. Suggestions for patient-centered outcomes research during COVID-19 and other emergencies include virtual research activities; active engagement; and promoting trust, honesty, transparency, and authenticity.

CONCLUSIONS

COVID-19 has had a significant negative impact on patient, family member, and stakeholder research team members; however, this has not resulted in less research engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02722382.

Use of Communication Technology to Improve Clinical Trial Participation in Adolescents and Young Adults With Cancer: Consensus Statement From the Children's Oncology Group Adolescent and Young Adult Responsible Investigator Network

Adolescents and young adults (AYAs; age 15-39 years) with cancer are under-represented in cancer clinical trials because of patient, provider, and institutional barriers. Health care technology is increasingly available to and highly used among AYAs and has the potential to improve cancer care delivery. The COVID-19 pandemic forced institutions to rapidly adopt novel approaches for enrollment and monitoring of patients on cancer clinical trials, many of which have the potential for improving AYA trial participation overall. This consensus statement from the Children's Oncology Group AYA Oncology Discipline Committee reviews opportunities to use technology to optimize AYA trial enrollment and study conduct, as well as considerations for widespread implementation of these practices. The use of remote patient eligibility screening, electronic informed consent, virtual tumor boards, remote study visits, and remote patient monitoring are recommended to increase AYA access to trials and decrease the burden of participation. Widespread adoption of these strategies will require new policies focusing on reimbursement for telehealth, license portability, facile communication between electronic health record systems and advanced safeguards to maintain patient privacy and security. Studies are needed to determine optimal approaches to further incorporate technology at every stage of the clinical trial process, from enrollment through study completion.

Early Impact of Severe Acute Respiratory Syndrome Coronavirus 2 on Pediatric Clinical Research: A Pan-European and Canadian Snapshot in Time

OBJECTIVE

To capture the early effects of the coronavirus disease 2019 (COVID-19) pandemic on pediatric clinical research.

STUDY DESIGN

Pediatric clinical research networks from 20 countries and 50 of their affiliated research sites completed two surveys over one month from early May to early June 2020. Networks liaised with their affiliated sites and contributed to the interpretation of results through pan-European group discussions. Based on first detection dates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), countries formed 1 early detecting and 1 late detecting cluster. We tested the hypothesis that this clustering influenced clinical research.

RESULTS

Research sites were first impacted by the pandemic in mid-March 2020 (March 16 ± 10 days, the same date as lockdown initiation; P = .99). From first impact up until early June, site initiation and feasibility analysis processes were affected for >50% of the sites. Staff were redirected to COVID-19 research for 44% of the sites, and 75.5% of sites were involved in pediatric COVID-19 research (only 6.3% reported COVID-19 cases in their other pediatric trials). Mitigation strategies were used differently between the early and late detecting country clusters and between countries with and without a pediatric COVID-19 research taskforce. Positive effects include the development of teleworking capacities.

CONCLUSIONS

Through this collaborative effort from pediatric research networks, we found that pediatric trials were affected and conducted with a range of unequally applied mitigations across countries during the pandemic. The global impact might be greater than captured. In a context where clinical research is increasingly multinational, this report reveals the importance of collaboration between national networks.

Adaptations to the RVA Breathes clinical trial due to the COVID-19 pandemic

RVA Breathes, a community program to improve asthma management and care coordination among children living in a low-income, urban area, is being evaluated in a randomized clinical trial. In March 2020, RVA Breathes was converted to a remote program due to the COVID-19 pandemic; this report provides an update on the modifications made to the RVA Breathes trial. Additionally, given that families in the program have been disproportionally impacted by both COVID-19 and significant social unrest at both the local and national level, strategies used to enroll and engage families in the trial who bore disproportionately high burdens during this time period are outlined. Remote sessions (telephone or video) for families enrolled in the program prior to the onset of COVID-19 began in April 2020; enrollment of new families began remotely in July 2020 using adapted consent procedures. Baseline, intervention, and follow-up sessions were delivered either via the telephone or video depending upon family preference. Strategies were implemented to engage caregivers and children in completing measures over the telephone or video versus in person. Tangible intervention materials and participant payments were dropped off at family homes using contactless procedures. Our team was able to adapt and safely continue a large, community-based clinical trial, despite the increased health risks and social isolation mandates from the pandemic, by transitioning to a remote format. Challenges remain in determining whether RVA Breathes as a remote program has had the same impact on child asthma as the face-to-face interventions that comprised its original format.

Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study

Background

Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making.

Objective

This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI.

Methods

We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network.

Results

The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience.

Conclusions

Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

Targeting Coping to Improve Surgical Outcomes in Pediatric Patients With Median Arcuate Ligament Syndrome: Feasibility Study

Background: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome leading to postprandial epigastric pain, nausea, and weight loss; it can be treated surgically. While most patients report improved quality of life following surgical intervention, 30% continue to experience chronic abdominal pain. Pre-surgical diagnoses of depression and/or anxiety have been found to significantly predict post-surgical: quality of life, highest experience of pain, anxiety, and parent- and self-reported coping strategies. As such, increasing the coping strategies of pediatric patients with MALS may impact their post-surgical outcomes. The purpose of the current study was to: (1) implement a pre-operative cognitive behavioral therapy protocol with a focus on psychoeducation and coping strategies; and (2) determine feasibility of a pre-surgical intervention for this population. Method: Children (<18 years of age) with a diagnosis of MALS who were eligible for surgical intervention were invited to participate in a 7-week in-person or video-based pre-surgical cognitive behavioral therapy intervention. Psychiatric comorbidities were assessed at baseline and post-surgery; patient-reported distress, pain interference and intensity, health-related quality of life, and health status were assessed at four time points (baseline, week 4, week 7, and post-surgery). Descriptive analyses were used to characterize the sample, assess feasibility outcomes (i.e., attrition rates), and explore symptom-based outcomes across time. Results: Twelve pediatric patients (M age = 15.2 ± 1.7; 91.7% female) and their parents (91.7% mothers) participated. Feasibility metrics based on protocol completion were exceeded for engagement at the stages of consent (68.4% vs. goal of ≥50%), treatment initiation (92.3% vs. 85%), and treatment completion (84.6% vs. 75%). Out of the 12 participants, nine (75%) met criteria for at least one comorbid psychiatric diagnosis at baseline and nine (75%) elected to undergo MALS surgery after completing the intervention. Conclusion: The intervention implementation was feasible, despite chronic pain symptoms experienced by the sample, a high prevalence of psychiatric diagnoses, and an international pandemic, suggesting that it would be beneficial to further evaluate the efficacy of the intervention. Future research should include stakeholder input in the design, deployment, and evaluation of a pilot efficacy trial of pre-surgical cognitive behavioral therapy for pediatric patients with MALS.

COVID-19 Exposure and Family Impact Scales: Factor Structure and Initial Psychometrics

Objective

In response to the rapidly unfolding coronavirus disease 2019 (COVID-19) pandemic in spring 2020, we developed a caregiver-report measure to understand the extent to which children and families were exposed to events related to COVID-19 and their perceptions of its impact. This article reports on the factor structure and psychometric properties of this measure.

Methods

The COVID-19 Exposure and Family Impact Scales (CEFIS) were developed by a multidisciplinary, multi-institutional team using a rapid iterative process. Data from 1805 caregivers recruited from 28 programs at 15 institutions across the United States were collected from May—September 2020. We examined the underlying structure of the CEFIS using exploratory factor analyses and its internal consistency (Cronbach’s alpha).

Results

Participants reported a range of COVID-19-related events (M = 8.71 events of 25). On the bidirectional 4-point impact scale, mean scores were mostly above the midpoint, indicating a slightly negative impact. Cronbach’s alpha was excellent for Exposure (α = .80) and Impact (α = .92). Factor analysis identified six factors for Exposure (COVID-19 experiences, Access to essentials, Disruptions to living conditions, Loss of income, Family caregiving and activities, and Designation as an essential worker). There were three factors for Impact (Personal well-being, Family interactions, and Distress).

Discussion

The CEFIS has strong factors assessing Exposure to events related to COVID-19, and the Impact of these events on families of children in pediatric healthcare. These initial validation data support use of the CEFIS for measuring the effect of the pandemic.

The Enigmatic COVID-19 Vulnerabilities and the Invaluable Artificial Intelligence (AI)

The objective of the study is to conduct an exploratory review of the Covid-19 pandemic by focusing on the theme of Covid-19 pandemic morbidity and mortality, considering the dynamics of artificial intelligence and quality of life (QOL). The methods used in this research paper include a review of literature, anecdotal evidence, and reports on the morbidity of COVID-19, including the scope of its devastating effects in different countries such as the US, Africa, UK, China, and Brazil, among others. The findings of this study suggested that the devastating effects of the coronavirus are felt across different vulnerable populations. These include the elderly, front-line workers, marginalized communities, visible minorities, and more. The challenge in Africa is especially daunting because of inadequate infrastructure, and financial and human resources, among others. Besides, AI technology is being successfully used by scientists to enhance the development process of vaccines and drugs. However, its usage in other stages of the pandemic has not been adequately explored. Ultimately, it has been concluded that the effects of the Covid-19 are producing unprecedented and catastrophic outcomes in many countries. With a few exceptions, the common and current intervention approach is driven by many factors, including the compilation of relevant reliable and compelling data sets. On a positive note, the compelling trailblazing and catalytic contributions of AI towards the rapid discovery of COVID-19 vaccines are a good indication of future technological innovations and their effectiveness.

Impact of COVID-19 on Families of Pediatric Solid Organ Transplant Recipients

OBJECTIVE

The COVID-19 pandemic and lockdown measures have had a clear psychological impact on families, and specifically those with children with chronic illnesses have reported greater overloads and exhaustion. The objective of this study was to evaluate the exposure, impact and experience of the pandemic on families of pediatric solid organ transplant (SOT) recipients compared to families of healthy children and adolescents.

METHODS

We recruited 96 families, 48 with a pediatric SOT recipient and 48 healthy controls, matched by child age and gender. A primary caregiver from each family responded to an online sociodemographic questionnaire and the COVID-19 Exposure and Family Impact Survey (CEFIS), which explores the exposure, impact and experience of the pandemic and lockdown on families.

RESULTS

Exposure to the pandemic was greater in families of healthy children and adolescents. The impact was mostly negative in both groups: caregivers reported increased anxiety (76%) and mood disturbances (71.9%) and hindered quality of sleep (64.6%) and health habits (58.3%). On the positive side, family relationships improved. Qualitatively, the SOT group positively perceived isolation and established hygienic measures as protective and destigmatizing, although they reported fear of virus transmission to their child.

CONCLUSIONS

The psychological impact of the pandemic has been similar in both groups, although families of transplant recipients have protected themselves more, probably because they are used to prevention measures and they see contagion as a graver risk. Additionally, SOT recipients' families presented some idiosyncratic elements, especially a decrease in their perception of stigma associated with the medical condition.

"We Are Anxious Every Day": COVID-19 Impacts on Youth with Spina Bifida

Objective

This study examined the impact of the COVID-19 pandemic on a national sample of adolescents and young adults (AYA) with spina bifida (SB) and parents of youth with SB.

Methods

AYA with SB (15–25; n = 298) and parents of children with SB (n = 200) were recruited to complete an anonymous, online survey in English or Spanish. Participants provided information about demographic and condition characteristics, as well as their technology access and use for behavioral health care. They also completed the COVID-19 Exposure and Family Impact Survey (CEFIS), which includes Exposure, Impact, and Distress subscales. Exploratory correlations and t-tests were used to examine potential associations between CEFIS scores and demographic, medical, and access characteristics. Qualitative data from the CEFIS were analyzed using thematic analysis.

Results

Scores on the Exposure, Impact, and Distress subscales demonstrated significant variability. Demographic associations with Exposure differed for those with higher Impact and Distress (e.g., White, non-Hispanic/Latino AYA reported higher rates of exposure [p = .001]; AYA who identified with a minoritized racial/ethnic identity reported greater impact [p ≤ .03]). Impacts to mental and behavioral health (n = 44), interference with medical care (n = 28), and interpersonal challenges (n = 27) were the most commonly occurring qualitative themes.

Conclusions

The current findings implicate differential impacts to individuals with SB and their families based on demographic, medical, and systemic factors (e.g., minoritized status). Recommendations to support families with SB and other pediatric conditions are made.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background: Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects. Methods: The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic. Results: Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) deviation in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020. Conclusions: The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

Maintaining Momentum in Infant Mental Health Research During COVID-19: Adapting Observational Assessments

Understanding the potential effects of the COVID-19 pandemic on the developing parent-infant relationship is a priority, especially for medically-fragile infants and their caregivers who face distinct challenges and stressors. Observational assessments can provide important insights into parent-child behaviors and relational risk; however, stay-at-home directives and physical distancing measures associated with COVID-19 have significantly limited opportunities for in-person observational parent-infant assessment. To maintain momentum in our research program during the pandemic, we rapidly pivoted to remote, technology-assisted parent-infant observational assessments. In this commentary, we offer a series of strategies and recommendations to assist researchers in adapting observational parent-infant paradigms. We also discuss the benefits, challenges, and limitations of distance-delivered assessments, and offer considerations for clinical service provision and future research during and post the COVID-19 pandemic. .

Commentary: "How's It Going?" Training Experiences of Pediatric Postdoctoral Fellows During COVID-19

The COVID-19 pandemic has impacted the lives and workplaces of individuals across the world substantially, in ways that are yet largely unknown. This commentary aims to provide an early snapshot of the experiences of pediatric postdoctoral fellows in academic medical settings; specifically, we will explore the impact of the pandemic on developing mastery within several competencies (e.g., research, professional development, clinical, interdisciplinary). These competencies are critical elements to fellowship to prepare for independent practice. Several models of training competencies for professional psychology and pediatric psychology exist, which focus on trainee skill development. Measures taken to minimize the spread of COVID-19 have directly impacted hospital systems and training, requiring programs to adapt competencies in various domains, such as increased familiarity with telehealth and virtual supervision. Additionally, fellows experienced an impact of the pandemic on securing employment following fellowship, conducting research and program development activities, and on cognitive flexibility and self-care. Governing bodies, such as the APA and Council of Chairs of Training Councils, have released statements and guidelines on addressing training of postdoctoral fellows including increasing flexibility of training methods, limiting in-person contact, and adjusting educational and licensing requirements. This paper offers informed commentary and diverse perspectives from current postdoctoral fellows engaged in a variety of clinical and research responsibilities regarding how the COVID-19 pandemic has impacted their training. We hope this paper will provide important insight into the unique experiences of postdoctoral fellows during the capstone year(s) of training prior to independent work and inform recommendations for postdoctoral training programs.

Physical Distancing Behavior: The Role of Emotions, Personality, Motivations, and Moral Decision-Making

OBJECTIVE

Physical distancing behavior (PDB) is a key disease prevention strategy for limiting the spread of COVID-19. In order to effectively encourage it among adolescents, it is necessary to understand the associated mental mechanisms. Health behavior theories suggest that emotions, personality, motivation, and moral disengagement could all play a role. On the basis of a longitudinal study, we investigated the importance of these factors in predicting PDB.

METHODS

The participants were 347 adolescents residing in Italy. Data were collected in four waves starting from 1 year before the pandemic. A structural equation model based on health behavior theory was tested.

RESULTS

After the COVID-19 national lockdown, adolescents experienced fewer positive emotions and more negative emotions compared with 1 year earlier. Nevertheless, these emotional changes, and adolescents' personality (except for openness to experiences), were not related to the adoption of PDB. Instead, the autonomous motivation of adolescents significantly predicted a higher likelihood to adopt PDB by increasing the intention to engage in this behavior and, more indirectly, by substantially decreasing moral disengagement, which was negatively related to PDB. In contrast, controlled motivation corresponded to significantly higher levels of moral disengagement and predicted less likelihood of adopting PDB.

CONCLUSIONS

Messages and interventions targeted at adolescents should be oriented towards supporting autonomy, emphasizing the personal and social value of PDB. Communications should avoid the use of coercive strategies based on eliciting emotions such as shame and guilt in adolescents who do not adopt PDB, which appear to trigger off mechanisms of moral disengagement.

Implementing Hypertension Management Interventions in Immigrant Communities in the U.S.: a Narrative Review of Recent Developments and Suggestions for Programmatic Efforts

PURPOSE OF REVIEW

To outline intervention efforts focused on reducing hypertension disparities in immigrant communities in the U.S. and to identify areas in the design, implementation, and evaluation of these interventions that warrant further exploration guided by an implementation science framework.

RECENT FINDINGS

Studies examined (n = 11) included immigrant populations of African, Hispanic, and Asian origin. Men were underrepresented in most studies. Culturally tailored group-based educational sessions in religious or community spaces were common. Intervention agents included research assistants, registered nurses, community health workers, and faith-based organization volunteers. Community stakeholders were engaged in most studies, although most commonly for recruitment efforts. Surveys/interviews were used for intervention evaluation, and documentation of intervention activities and trainings was used to assess fidelity. Identified pathways for further intervention innovation included gender or migration-status-based targeting, diversifying intervention agents, enhancing mixed-method process evaluations, and tailoring to emerging needs during the COVID-19 pandemic.

The Needle in the Haystack: Identifying Credible Mobile Health Apps for Pediatric Populations during a Pandemic and beyond

Background

The COVID-19 pandemic has ignited wider clinical adoption of digital health tools, including mobile health apps (mHealth apps), to address mental and behavioral health concerns at a distance. While mHealth apps offer many compelling benefits, identifying effective apps in the crowded and largely unregulated marketplace is laborious. Consumer demand and industry productivity are increasing, although research is slower, making it challenging for providers to determine the most credible and safe apps for patients in need.

Objectives/Methods

This commentary offers a practical, empirically guided framework and associated resources for selecting appropriate mHealth apps for pediatric populations during the pandemic and beyond.

Results

In the first stage, Narrow the target problem, end user, and contender apps. Beginning the search with continuously updated websites that contain expert app ratings can help expedite this process (e.g., Psyberguide). Second, Explore each contender app’s: (a) scientific and theoretical support (e.g., are app components consistent with health behavior change theories?), (b) privacy policies, and (c) user experience (e.g., through crowdsourcing feedback about app usability and appeal via social media). Third, use clinical expertise and stakeholder feedback to Contextualize whether the selected app is a good fit for a particular patient and/or caregiver (e.g., by considering age, race/ethnicity, ability, gender, sexual orientation, technology access), including conducting a brief self-pilot of the app.

Conclusion

Youth are increasingly turning to technology for support, especially during the pandemic, and pediatric psychologists must be primed to recommend the most credible tools. We offer additional recommendations for rapidly disseminating evidence-based apps to the public.

The Impact of COVID-19 on Pediatric Adherence and Self-Management

The COVID-19 pandemic has presented unique circumstances that have the potential to both positively and negatively affect pediatric adherence and self-management in youth with chronic medical conditions. The following paper discusses how these circumstances (e.g., stay-at-home orders, school closures, changes in pediatric healthcare delivery) impact disease management at the individual, family, community, and healthcare system levels. We also discuss how barriers to pediatric adherence and self-management exacerbated by the pandemic may disproportionately affect underserved and vulnerable populations, potentially resulting in greater health disparities. Given the potential for widespread challenges to pediatric disease management during the pandemic, ongoing monitoring and promotion of adherence and self-management is critical. Technology offers several opportunities for this via telemedicine, electronic monitoring, and mobile apps. Moreover, pediatric psychologists are uniquely equipped to develop and implement adherence-promotion efforts to support youth and their families in achieving and sustaining optimal disease management as the current public health situation continues to evolve. Research efforts addressing the short- and long-term impact of the pandemic on pediatric adherence and self-management are needed to identify both risk and resilience factors affecting disease management and subsequent health outcomes during this unprecedented time.

Implementing Group Parent Training in Telepsychology: Lessons Learned During the COVID-19 Pandemic

OBJECTIVE

We recently transitioned from in-person delivery of a brief behavioral parent intervention to telepsychology delivery to meet families' needs during the COVID-19 pandemic. In this topical review, we describe how we used treatment fidelity as a guiding principle to orient adaptations for telepsychology, as well as preliminary findings and early lessons learned in this implementation. Methods: Using rapid-cycle quality improvement methods, we adapted a brief parent training group (Bootcamp for Attention-Deficit/Hyperactivity Disorder; BC-ADHD) to three groups of caregivers (i.e., 5-7 families) of school-aged children with ADHD (n = 20; 85% males). Families were from the following ethnic backgrounds: 75% White non-Hispanic, 15% White Hispanic, and 10% Black. Clinicians completed measures on their implementation experience. Observers completed measures on content/process fidelity and attendance. Caregivers completed measures on demographics, treatment satisfaction, and telepsychology experience.

RESULTS

Telepsychology BC-ADHD can be implemented with comparably high levels of content and process fidelity and treatment satisfaction to in-person groups; and it appears to be feasible and acceptable to caregivers. Caregiver and clinician qualitative feedback revealed themes of appreciating the convenience of telepsychology, while experiencing some challenges in relating to others and sharing over video.

CONCLUSIONS

When treatment fidelity is used as a guiding tool, telepsychology parent training groups can be delivered with high fidelity and appear to be acceptable and feasible to caregivers and clinicians. Future research using larger and more diverse samples, multimethod and multi-informant measurement approaches, and controlled designs is needed to further assess the generalizability and efficacy of telepsychology parent training groups.