Emerging challenges and opportunities in innovating food science technology and engineering education

Progress in science, technology, innovation, and digital capabilities call for reassessing food science, technology, and engineering (FST&E) education and research programs. This survey targeted global professionals and students across food disciplines and nutrition. Its main objectives included assessing the status of FST&E higher education, identifying challenges and opportunities, and furnishing recommendations. Seven topics affecting the future of the FST&E curricula were evaluated by the panel as 'High' to 'Very high', namely: 'Critical thinking', followed by 'Problem-solving projects', 'Teamwork/collaboration', 'Innovation/Open innovation' and 'Multidisciplinary'. The importance of academic partnership/collaboration with the Food Industry and Nutrition Sciences was demonstrated. Significant positive roles of the food industry in collaboration and partnerships were found. Other essential food industry attributes were related to internships, education, strategy, and vision. Collaboration between FST&E and nutrition sciences indicated the high standing of this direction. The need to integrate or converge nutrition sciences and FST&E is emphasized, especially with the growing consumer awareness of health and wellness. The study provides insights into new education and learning opportunities and new topics for future curricula.

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

POS1365 THE FMF&AID SURVEY - A PATIENT ORGANIZATION DRIVEN SURVEY FOR AUTOINFLAMMATORY DISEASES

Background

Autoinflammatory diseases (also referred to as hereditary periodic fever syndromes) are caused by defects in the innate immune system. Many autoinflammatory syndromes arise from inherited genetic mutations which begin in childhood and persist throughout adult life. These diseases are often present in several members and generations within a family. Newer research also reflects that, cases can often present at any age through-out childhood, teenage years, and even into older adulthood. These cases appear to be acquired, perhaps due to the interplay of genetic, immune, and environmental factors (somaticism). It is not uncommon that a patient is diagnosed with rheumatoid arthritis, multiple sclerosis or another autoimmune issue, as many physicians are not aware of monogenic inborn errors, nor how to conduct a thorough work up due to a lack of medical knowledge.

Objectives

Unfortunately, the knowledge base that many doctors have with regards to autoinflammatory genetic diseases is minimal to non-existent, when compared to the well-established expertise of autoimmune disease management. Concerns about the increasing patient accounts detailing lack of medical diagnosis, treatment, and pain management, lead to the important decision to collect further data from the autoinflammatory patient community. The aim of the survey responses collected, and post data aggregation will help identity patient trends and use this information to educate and increase awareness amongst the medical community as to the unmet diagnostic and treatment requirements for the autoinflammatory population.

Methods

A questionnaire comprised of thirty questions was developed by members of the patient organization FMF & AID Global Association (Executive Director, Malena Vetterli with Research Director, H. Ellen Cohen) under the guidance of Dr. med. Juergen Rech focused on collecting basic information (e.g. age, country, onset and duration of symptoms, pain and fatigue). The survey was published at the end of 2020 on social media (Facebook) and on the FMF&AID website (www.fmfandaid.org). Participation was voluntary and the patients agreed that the anonymised response information of the survey may be evaluated and published. This international survey was approved by the ETHICS Committee FAU in Erlangen-Nuremberg, Germany.

Results

Worldwide, over a thousand patients or parents/caregivers of patients (younger than 18 years) in fifty-two countries took part in this survey and answered the questionnaire. Eighty percent (80%) of the participants had already been diagnosed with an autoinflammatory disease. However, despite classic periodic symptom presentation, twenty percent (20%) of the participants were still without a concise diagnosis. FMF - forty-three percent (43%) was cited as the most common diagnosis and M. Behçet thirty percent (30%) as the second, with a variety of others (e.g. PFAPA, CAPS, HIDS, TRAPS, DADA, Yao syndrome, and uSAID). The minimum age at diagnosis ranged from 1 to 70+ years old with an average age of 33 years when properly diagnosed. Three-hundred and nine (309) patients reported that their pain had not been taken seriously and adequately treated in the past. Pain and fatigue, as measured by the standard visual analogue scale (VAS 0-10), was high in the past 30 and 7 days, respectively. VAS pain 30 days was 4.8 (SD +/-2.7) or 7 days with 4.2 (SD +/- 3), as well as fatigue VAS 30 days 5.7 (SD +/- 2.8) or fatigue VAS 7 days with 5.5 (SD +/- 3).

Conclusion

One-fifth of patients with classic symptoms of autoinflammatory diseases remain undiagnosed and therefore not specifically treated. Although, the rest of the participants eighty percent (80%) have a diagnosis of an autoinflammatory disease, therapy does not appear to be sufficient to manage their wide-ranging and debilitating symptoms, in particular pain and fatigue. Patients continue to carry the burden of receiving mental diagnosis vs actual medical diagnosis and are still forced to seek additional medical support, often incurring travel or relocation costs to obtain proper care.

Disclosure of Interests

Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Biogen, BMS, Chugai, GSK, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Novartis, Sobi, Koray Tascilar: None declared, Abdurrahman Tufan: None declared, Marco Gattorno: None declared, J. B. Kuemmerle-Deschner: None declared, Seza Ozen: None declared, Tobias Krickau: None declared, Ellen Cohen: None declared, Leonardo Oliveira Mendonca: None declared, Apostolos Kontzias: None declared, Malena Vetterli: None declared

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

Covid-19 vaccination and possible link to Herpes zoster

PURPOSE

To report 3 otherwise healthy patients with Herpes zoster reactivation shortly after administration of a mRNA vaccine against the novel COVID-19 virus.

OBSERVATIONS

Patient 1 is a 54 year old who presented with Herpes zoster meningitis complicated by enhancing nodular leptomeningeal lesions of the spinal cord. The subsequent two patients had Herpes zoster ophthalmicus of the cornea (Case 2) and eyelid (Case 3). All three presented within 2 weeks of receiving the Pfizer/BioNTech COVID-19 vaccine.

CONCLUSIONS

Herpes zoster may be a side effect of m RNA vaccination against the Sars-CoV2 vaccine and requires further investigation.

Complex chronic conditions among children born to women with schizophrenia

PURPOSE

Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known.

METHODS

In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity.

RESULTS

CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46).

CONCLUSIONS

The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

Deep Exclusive Electroproduction of π^{0} at High Q^{2} in the Quark Valence Regime

We report measurements of the exclusive neutral pion electroproduction cross section off protons at large values of x_{B} (0.36, 0.48, and 0.60) and Q^{2} (3.1 to 8.4  GeV^{2}) obtained from Jefferson Lab Hall A experiment E12-06-014. The corresponding structure functions dσ_{T}/dt+εdσ_{L}/dt, dσ_{TT}/dt, dσ_{LT}/dt, and dσ_{LT^{'}}/dt are extracted as a function of the proton momentum transfer t-t_{min}. The results suggest the amplitude for transversely polarized virtual photons continues to dominate the cross section throughout this kinematic range. The data are well described by calculations based on transversity generalized parton distributions coupled to a helicity flip distribution amplitude of the pion, thus providing a unique way to probe the structure of the nucleon.

Creating "a Safe Haven": Emotion-Regulation Strategies Employed by Mothers and Young Children Exposed to Recurrent Political Violence

Growing evidence underscores the need to counteract the mental health risks for children growing up in traumatic situations of political violence. This study examined the concurrent emotional regulation (ER) strategies employed by mothers and their children in meeting this challenge. Following several incidents of rocket attacks, in southern Israel, we conducted semi-structured interviews with 30 mothers and their children (ages 5-7). Additionally, mothers completed the Emotion Regulation Questionnaire (Gross and John 2003). The main theme emerging from the qualitative analyses of the interviews with the children was adherence to the perception of the shelter room in the home as a "safe haven", supported by constructed knowledge and acquired skills related to physical safety, as well as the sense of emotional availability of their caregivers. The children used imagination, play and physiological regulation modeled by the mothers. The interviews with the mothers revealed their effort to convey a sense of calm and routine, even when these were interrupted. They used self-talk concerning the children's needs and tried to regulate their own physiological and psychological arousal. Mothers who expressed in the interviews satisfaction with the management of their ER reported significantly higher use of cognitive reappraisal strategies than those expressing dissatisfaction. Mothers help children construct meanings related to stressful events and teach and model evidence-based tactics for ER. Interventions for coping with a toxic reality should involve both psycho-education about children's needs and address mothers' own ER strategies, especially the use of cognitive reappraisal.

Increased maternal new-onset psychiatric disorders after delivering a child with a major anomaly: a cohort study

BACKGROUND

The birth of a child with a major congenital anomaly may create chronic caregiving stress for mothers, yet little is known about their psychiatric outcomes.

AIMS

To evaluate the association of the birth of a child with a major congenital anomaly with subsequent maternal psychiatric risk.

METHODS

This Danish nationwide cohort study included mothers who gave birth to an infant with a major congenital anomaly (n = 19 220) between 1997 and 2015. Comparators were randomly selected mothers, matched on maternal age, year of delivery and parity (n = 195 399). The primary outcome was any new-onset psychiatric diagnosis. Secondary outcomes included specific psychiatric diagnoses, psychiatric in-patient admissions and redeemed psychoactive medicines. Cox models were used to estimate hazard ratios (HRs), adjusted for socioeconomic and medical variables.

RESULTS

Mothers of affected infants had an elevated risk for a new-onset psychiatric disorder vs. the comparison group (adjusted HR, 1.16, 95% CI 1.11-1.22). The adjusted HR was particularly elevated during the first postpartum year (1.65, 95% CI 1.42-1.90), but remained high for years, especially among mothers of children with multiorgan anomalies (1.37, 95% CI 1.18-1.57). The risk was also elevated for most specific psychiatric diagnoses, admissions and medicines.

CONCLUSIONS

Mothers who give birth to a child with a major congenital anomaly are at increased risk of new-onset psychiatric disorders, especially shortly after birth and for mothers of children with more severe anomalies. Our study highlights the need to screen for mental illness in this high-risk population, as well as to integrate adult mental health services and paediatric care.

Becoming "Teletherapeutic": Harnessing Accelerated Experiential Dynamic Psychotherapy (AEDP) for Challenges of the Covid-19 Era

The covid-19 pandemic raises substantial challenges for the practice of psychotherapy. The rapid changes in the personal experiences of both clients and therapists, and the required adaptations in the therapeutic setting, affect the therapeutic relationship and its process. We examine common challenges observed through supervision of therapists and peer group discussions, viewing them in light of reports of previous collective traumatic events. Consequently, we introduce major premises and techniques borrowed from Accelerated Experiential Dynamic Psychotherapy as they may apply to teletherapy. These interventions aim to maintain and strengthen the intimacy and safety of the therapeutic attachment relationship, essential for processing actual experiences of emotions and creating affective changes. We explicate the rationale and the clinical application of these relational and experiential interventions, and organize them through a comprehensive model. The model visually illustrates the matching of therapeutic interventions to the handling of the psychological upheavals triggered by the changes imposed by the pandemic, particularly the move to teletherapy. In addition to theoretical and practical suggestions, which could be adapted to various models of therapy, we present a brief clinical case demonstrating the application of the suggested therapeutic thinking and interventions.

Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM.

METHODS

PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint.

DISCUSSION

PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery.

TRIAL REGISTRATION

The trial was registered in clinicaltrials.gov ( NCT02963025 ) on 15 November 2016.

Urban young women's preferences for intervention strategies to promote physical and mental health preconception: A Healthy Life Trajectories Initiative (HeLTI)

This study aimed to qualitatively investigate young women's preferences for preconception intervention strategies to promote physical and mental health in a rapidly transitioning, urban setting. Four semi-structured focus group discussions were conducted with young women (n = 29, 18–24 years old) from Soweto, South Africa. Qualitative data were thematically analysed. Two main themes were identified: 1) challenges and needs of intervention beneficiaries; and 2) preferences for intervention strategies (content and delivery). The challenges participants mentioned could be classified as those relating to social pressure, identity, and socioeconomic circumstances. Mental health support appeared to be a greater need than physical health, and this featured in their preferences for intervention content, although a number of physical health topics were also mentioned (healthy eating and contraception). Participants had mixed preferences for intervention materials, ranging from printed to electronic and mobile resources. Their preferences for intervention activities ranged from educational sessions, to fun and interactive practical activities, and activities they could take home. Community health workers (CHWs) were the preferred agent of delivery for interventions, though participants emphasised the importance of CHWs having appropriate interpersonal skills and own life experience. Some women preferred one-on-one sessions with a CHW, while others preferred group sessions. While recognising the value of family sessions, young women were less enthusiastic about this approach. These findings provide valuable formative data for developing effective interventions to optimise young women's preconception health in urban Africa. These contextual realities should be acknowledged when addressing key physical and mental health issues facing young women.

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Social pressure is a major challenge for young women in urban South Africa.

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Mental health should be a key feature of preconception interventions.

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Community health workers are the preferred agent of delivery in this context.

Mothers and Toddlers Exposed to Political Violence: Severity of Exposure, Emotional Availability, Parenting Stress, and Toddlers' Behavior Problems

This study examined the potential risks of maternal and child exposure to traumatic events resulting from political violence, specifically those related to emotional availability, parenting stress and children's behavioral problems. It also evaluated the feasibility of mitigating these effects through a play-based group intervention for conjoint dyads of mothers and toddlers. Results from 54 dyads show that the higher maternal and especially child exposure to political violence and other trauma, the lower their emotional availability in dyadic interactions (r = .40, p < .01). Emotional availability was associated with the mother's parenting stress, and both parenting stress and emotional availability were associated with the mother's perceptions of her child's behavior problems. Comparisons of observed emotional availability, child behavior problems as perceived by the mother, and reported stress in 28 dyads before and after participating in the intervention suggest that it may be possible to bolster emotional availability and to reduce child's behavior problems.

Abstract P6-14-03: Metastatic breast cancer alliance's patient education and access to trials: Perceptions and actions

Background

Those living with metastatic breast cancer (MBC) have distinct and shifting concerns in regard to education and decision making in considering clinical trials as a treatment option. Clinical trials designs, are becoming increasingly complex, and many patients have concerns for biomarker requirements Aims/Research Questions

· What is the status of MBCA advocacy members' and partners' digital information, education and access to metastatic breast cancer trials?

· What plans do MBCA members/partners have for the next 6-18 months to educate and inform their constituents for the 2018 rollout of BreastCancerTrials.org's (BCT)Metastatic Trial Search (MTS) and Metastatic Trial Talk (MTT) and other trial matching systems?

· What are the top 5 barriers regarding trial enrollment?

· What are best practices for MBC trial education?

Research Methodology and Design

A comprehensive analysis was conducted comprising both secondary and primary research to inform these specific aims. Secondary research was conducted using previous capture of MBCA online digital resources and strengthened to include additional research on MBCA members and partners online resources including pages specifically devoted to clinical trials and metastatic clinical trials.

Mixed methods approaches include:

1) An assessment of MBCA members' and partners' digital media presence regarding MBC trials using a standardized form and rating system, and an analysis of MBCA members 2017 use of MTS using BCT secondary data;

2) Structured, recorded interviews with selected MBCA members/ partners, sharing the results of the assessments and querying them regarding their future plans and perceived barriers; and

3) Mixed methods analyses of the interview recordings using DeDoose to assess and articulate key trends and perceptions.

Statistical Methods

Simple frequency percentages and means were used in the assessment rankings of the MBCA members. DeDoose was used to provide mixed method analyses of the MBCA member and partner interviews. Results

Analysis of the MBCA members and partners websites and digital media showed that, increasingly, both groups use the full variety of digital media to educate their constituents regarding MBC clinical trials. The 13 MBCA advocacy members providing online access to BreastCancerTrials' MTS in 2017 provided 97% of the traffic to the MTS trial matching service. System types accessing the MTS widget were 57.3% desktops, 28.6% mobile devices and 14% tablets. Table 1 shows assessment totals of 5 categories of the 13 MBCA advocacy group members' websites using MTS as compared to the 19 MBCA members not using the widget. Table 2 shows the 2017 usage of BCT's MTS with 97% of the page views coming from MBCA members.

Table 1.Assessment Ratings of MBCA Advocacy Partners on Metastatic Trial Education/AccessAwareness of Trials (e.g. explains trial Phases)Knowledge SharingInterest in Metastatic Breast CancerAction Potential for clinical trial access or enrollmentTotal (0-100)13 MBCA Advocate Members with MTS widget22.1523.0024.3124.1593.6219 MBCA Members without MTS widget13.2113.9513.5311.9552.16

Table 2.2017 Use Of Metastatic Trial SearchBCT's Metastatic Trial Search (MTS) Results2017Annual Page views33,360Unique Sessions14,295Show Trials8,100Show Trials by month675Average Time on Site (minutes)3:34Total Engagement Events5,006

Citation Format: Vollmer Dahlke DJ, Smith ML, Han G, Ory MG, Cohen E. Metastatic breast cancer alliance's patient education and access to trials: Perceptions and actions [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-14-03.

Gender differences in homocysteine concentrations, a population-based cross-sectional study

BACKGROUND AND AIMS

High concentrations of homocysteine are considered a risk factor for atherosclerosis and coronary artery disease. The aim of this study was to assess whether or not there are gender differences in the plasma concentrations of homocysteine.

METHODS AND RESULTS

Data were collected from medical records of individuals examined at a screening center in Israel between the years 2000-2014. Cross sectional analysis was carried out on 9237 men and 4353 women. Mean (SD) age of the study sample was 48.4 (9.7) and 47.7 (9.7) years for men and women respectively. Average homocysteine concentrations were 12.6 (5.9) and 9.6 (3.2) μmol/L in men and women respectively (p < 0.001). Prevalence of homocysteine concentrations above 15 μmol/L was found to be significantly higher in men than in women; 15.5% vs 3.9% respectively (p < 0.001). Low concentrations of vitamin (B12 < 200 pmol/L) and low concentrations of folate (<12 nmol/L) were found to be significantly higher in men than in women 20.4% vs. 16.0% and 18.5% vs. 10.8% respectively. Compared to women, men had a significantly higher odds ratio (95% CI) of having homocysteine concentrations above 15 μmol/L: non adjusted model, 4.47 (3.80-5.26); adjusted model for age, smoking status, body mass index, diabetes mellitus, kidney function and low serum concentrations of vitamin B12 and folate, 3.44 (2.89-4.09).

CONCLUSION

Plasma homocysteine concentrations are higher in men than in women. This may be a contributing factor to gender differences for developing atherosclerosis and coronary artery disease.

Comparison of Thrombelastography with Common Coagulation Tests

Thrombelastography, although proven as a useful research tool has not been evaluated for its clinical utility against common coagulation laboratory tests. In this study we compare the thrombelastographic measurements with six common tests (the hematocrit, platelet count, fibrinogen, prothrombin time, activated thromboplastin time and fibrin split products). For such comparisons, two samples of subjects were selected, 141 normal volunteers and 121 patients with cancer. The data was subjected to various statistical techniques such as correlation, ANOVA, canonical and discriminant analysis to measure the extent of the correlations between the two sets of variables and their relative strength to detect blood clotting abnormalities. The results indicate that, although there is a strong relationship between the thrombelastographic variables and these common laboratory tests, the thrombelastographic variables contain additional information on the hemostatic process.

The Function of Play for Coping and Therapy with Children Exposed to Disasters and Political Violence

PURPOSE OF REVIEW

The objectives were to identify specific characteristics and patterns of children's play following events of political violence or disasters, examine their associations with risk and resilience, and explore their implications for preventive and therapeutic intervention.

RECENT FINDINGS

Patterns of individual, dyadic, and social play are associated with measures of children's adaptation following collective traumatic events. Modifying the traditional child-centered play therapy, by integrating CBT principles or including parents, may increase efficacy. Preventive interventions in the aftermath of collective traumatic events must address children's need to play in safe spaces, with the support of significant adults. Recognizing that posttraumatic play is a multifaceted phenomenon implies the need for more individualized play therapy models, varying in level of therapist's activity and techniques employed. Research is needed to clarify the validity of play measures for assessing adaptation and to study the effectiveness of integrative play-based models.