Topical Review: Enhancing Understanding of the Clinical Meaningfulness of Outcomes to Assess Treatment Benefit from Psychological Therapies for Children with Chronic Pain

OBJECTIVE

Despite the availability of measures for assessing physical, psychological, and health impact in children with chronic pain, there are not established guidelines for interpretation of children's pain outcomes following psychological treatment. The purpose of this topical review is to discuss clinical significance as a neglected area of consideration in pediatric chronic pain assessment and to make recommendations on how the field can move toward benchmarking on core outcome domains.

METHOD

We review definitions of clinical significance and examples of several methodologies that have been used in other populations or are emerging in pediatric chronic pain including anchor-based methods, distribution-based methods, or multimethod approaches.

RESULTS

Few measures across pediatric chronic pain outcome domains have established clinical significance of scores to interpret meaningful change following treatment limiting the interpretability of findings from clinical trials. In the context of clinical practice, several efforts to examine clinical significance to improve the translation of evidence-based measurement into standard clinical decision-making exist.

CONCLUSIONS

Recommendations are provided to encourage additional validation efforts of outcome measures in pediatric chronic pain and to encourage authors to report clinical significance in clinical trials of psychological interventions for pediatric chronic pain.

Parents' Perspectives on the Theoretical Domains Framework Elements Needed in a Pediatric Health Behavior App: A Crowdsourced Social Validity Study

Background

Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health (mHealth) interventions are not meaningfully disseminated after the trial period ends. Consequently, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not based in theory or evidence and may not take stakeholder preferences into account.

Objective

The aim was to assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements.

Methods

This study was a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into three components: (1) capability, (2) motivation, and (3) opportunity. Parents of children were recruited through Amazon Mechanical Turk.

Results

The majority of participants were Caucasian and mean age was 36.9 (SD 8.0) years. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F_2,545=5.18, P=.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F_2,546=4.04, P=.02). When asked about the value of features to help children develop skills, parents preferred those features for dietary behavior over sleep (F_2,546=3.57, P=.03). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F_2,545=5.30, P=.005). Incentive features within the app were seen as most useful for physical activity over sleep (F_2,546=4.34, P=.01).

Conclusions

This study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mHealth intervention. Our approach is innovative in that it took a scientific framework (ie, TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF.

A Meta-Analysis of Single-Subject Research on Behavioral Momentum to Enhance Success in Students with Autism

We conducted a meta-analysis of single-subject research studies investigating the effectiveness of antecedent strategies grounded in behavioral momentum for improving compliance and on-task performance for students with autism. First, we assessed the research rigor of those studies meeting our inclusionary criteria. Next, in order to apply a universal metric to help determine the effectiveness of this category of antecedent strategies investigated via single-subject research methods, we calculated effect sizes via omnibus improvement rate differences (IRDs). Outcomes provide additional support for behavioral momentum, especially interventions incorporating the high-probability command sequence. Implications for research and practice are discussed, including the consideration of how single-subject research is systematically reviewed to assess the rigor of studies and assist in determining overall intervention effectiveness .

Psychosocial Late Effects in Pediatric Cancer Survivors: A Report From the Children's Oncology Group

BACKGROUND

This review was conducted to update the Children's Oncology Group (COG) Long-Term Follow-Up Guidelines (COG-LTFU Guidelines, version 4.0) regarding screening for psychosocial late effects of pediatric cancer.

PROCEDURE

Articles published between August 2009 and January 2011 that addressed psychosocial late effects of long-term survivors of pediatric cancer (n = 35) were reviewed by a multidisciplinary team of COG late effect experts.

RESULTS

The majority of studies in this time period indicate that survivors experience few psychosocial problems in long-term survivorship. A critical subset, however, is at increased risk for psychosocial late effects secondary to the treatment. Highlighted findings from this review include increased rates of suicidal ideation (SI), and health beliefs as robust predictors of SI, anxiety, and global distress. Survivors' health beliefs were associated with their perceptions of physical limitations, overall late effects, and cancer-related pain. While many survivorship studies continue to specify risk factors for anxiety and posttraumatic stress symptoms/posttraumatic stress disorder, others outcomes (e.g., developmental, interpersonal, and familial factors) appear to be emerging in importance.

CONCLUSIONS

Although the majority of childhood cancer survivors do not experience psychosocial problems, a subset will. The recent research findings have been included in the new COG-LTFU Guidelines that will assist in the targeted assessment and the treatment of survivors' psychosocial health.

Single-case experimental designs to evaluate novel technology-based health interventions

Technology-based interventions to promote health are expanding rapidly. Assessing the preliminary efficacy of these interventions can be achieved by employing single-case experiments (sometimes referred to as n-of-1 studies). Although single-case experiments are often misunderstood, they offer excellent solutions to address the challenges associated with testing new technology-based interventions. This paper provides an introduction to single-case techniques and highlights advances in developing and evaluating single-case experiments, which help ensure that treatment outcomes are reliable, replicable, and generalizable. These advances include quality control standards, heuristics to guide visual analysis of time-series data, effect size calculations, and statistical analyses. They also include experimental designs to isolate the active elements in a treatment package and to assess the mechanisms of behavior change. The paper concludes with a discussion of issues related to the generality of findings derived from single-case research and how generality can be established through replication and through analysis of behavioral mechanisms.

Case study: videogame distraction reduces behavioral distress in a preschool-aged child undergoing repeated burn dressing changes: a single-subject design

OBJECTIVE

This single-subject design study evaluated the feasibility and efficacy of passive and interactive videogame distraction on behavioral distress for a preschool-aged child receiving repeated burn dressing changes.

METHOD

A 4-year-old girl underwent 3 baseline and 10 videogame distraction sessions (5 passive and 5 interactive) using a restricted alternating treatments design. Observed behavioral distress was coded, and parents and nurses rated the child's distress and cooperative behavior.

RESULTS

Relative to baseline, behavioral distress decreased and cooperative behavior increased immediately after the onset of videogame distraction. Single Case Randomization Tests revealed significantly lower behavioral distress and greater cooperation during interactive videogame distraction relative to passive videogame distraction.

CONCLUSIONS

Interactive videogame distraction appears to be a feasible and effective pain management strategy for a preschool-aged child undergoing repeated painful medical procedures.