Disease-modifying therapies for sickle cell disease: Decisional needs and supports among adolescents and young adults

BACKGROUND

Shared decision-making is one promising solution to addressing barriers in use of disease-modifying therapies for adolescents and young adults (AYAs) with sickle cell disease (SCD). A thorough understanding of decisional needs can guide the development of decisional supports and promote shared decision-making.

PROCEDURE

Informed by the Ottawa Decision Support Framework (ODSF), we conducted a qualitative analysis to assess decisional needs and supports reported by AYAs with SCD, their caregivers, and healthcare providers. Semi-structured qualitative interviews were conducted with AYAs and their caregivers, and online crowdsourcing was used with SCD providers. Thematic and descriptive content analyses were used to summarize perspectives on decisional needs and supports regarding disease-modifying therapies.

RESULTS

Fourteen AYAs (Mage  = 21 years, 57% male, 93% non-Hispanic Black, 79% HbSS), 11 caregivers (80% female, 100% non-Hispanic Black), and 40 healthcare providers (65% female, 65% non-Hispanic White, Myears in practice  = 14.8 years, 75% physicians) participated. Thematic analysis revealed needs related to: decisional conflict, inadequate knowledge, unclear expectations, and inadequate supports and resources. Six forms of support emerged as important for decision-making: establishing an open and trusting patient/family-provider relationship, providing information, accepting ambivalence and unreadiness, supporting implementation of a decision, addressing inadequate health and social services, and promoting adequate social, emotional, and instrumental help.

CONCLUSIONS

This is the first study to assess decisional needs and supports for AYAs with SCD considering disease-modifying therapies. Additional research is needed to examine which decision supports are the most impactful to promote effective shared decision-making in this population.

Exploring Referral and Service Utilization Patterns Within an Outpatient Interdisciplinary Pediatric Chronic Pain Program

Purpose

We examine referral sources and clinical characteristics for youth presenting to an outpatient interdisciplinary pediatric chronic pain program.

Patients and Methods

Referral data were extracted from the electronic health record. PROMIS Pediatric Anxiety and Pain Interference Scales were administered at an initial evaluation visit.

Results

The program received 1488 referrals between 2016 and 2019, representing 1338 patients, with increasing volume of referrals over time. Referrals were primarily from orthopedics (19.6%), physical medicine and rehabilitation (18.8%), neurology (14.4%), and rheumatology (12.6%). Patients referred were primarily female (75.4%), White (80.1%), English-speaking (98.4%) adolescents (median=15.0 years). Of those referred, 732 (54.7%) attended an interdisciplinary evaluation (ie, with ≥2 disciplines). Adolescent anxiety was within the expected range by self-report (N=327, MT-score=55.67) and parent proxy-report (N=354, MT-score=57.70). Pain interference was moderately elevated by self-report (N=323, MT-score=61.52) and parent proxy-report (N=356, MT-score=64.02). There were no differences between patients referred who attended versus did not attend an interdisciplinary evaluation based on age, sex, ethnicity, or language. A smaller than expected proportion of referred Black patients (44%, P=0.02) and patients referred from orthopedics (40%) or pulmonology (11%) attended an evaluation, whereas a larger than expected proportion of those referred from physical medicine and rehabilitation (78%) were evaluated (P<0.001).

Conclusion

Results highlight the demand for outpatient interdisciplinary pediatric chronic pain treatment. Findings can inform decisions related to staffing and service design for pediatric hospitals that aim to establish or grow outpatient pediatric chronic pain programs.

Feasibility of Electronic Medication Monitoring Among Adolescents and Emerging Adults with Sickle Cell Disease

Purpose

To examine the feasibility of using MEMS® bottles to assess adherence among adolescents and emerging adults with sickle cell disease.

Patients and Methods

Eighteen non-Hispanic Black participants with HbSS (M = 17.8 years; 61% male) were given a MEMS® bottle to store hydroxyurea (n = 14) or deferasirox (n = 4).

Results

One hundred percent initiated MEMS® use and 61% sustained use through the 18-week study; at follow-up, only 11% returned their bottle on time. Barriers to MEMS® use included medication changes and transition to adult care; facilitators included tip sheets and reminders.

Conclusion

While MEMS® is acceptable to this population, ensuring sustained use and timely provision of bottles will require additional supports.

Improved pain acceptance and interference following outpatient interdisciplinary pediatric chronic pain treatment

OBJECTIVES

Intensive interdisciplinary chronic pain treatment programs have demonstrated that pain acceptance predicts positive treatment outcomes, but limited research has focused on less-intensive programs. This study aimed to examine associations between changes in pain acceptance and pain interference among youth participating in an outpatient interdisciplinary chronic pain treatment program.

DESIGN

Youth presenting to an evaluation within an interdisciplinary outpatient pediatric chronic pain program completed questionnaires at initial program evaluation (T1) and three months later (T2).

MAIN OUTCOME MEASURES

Youth (N = 94, Mage = 14.59 years, 74% female) completed the Chronic Pain Acceptance Questionnaire, Adolescent Version (CPAQ-A) and PROMIS Pediatric Pain Interference scale.

RESULTS

Pain acceptance increased significantly from T1 to T2 (p=.001), driven primarily by activity engagement (p=.001). Pain interference decreased from T1 to T2 (p<.001). Improvements in acceptance were strongly associated with reductions in interference (p<.001). An exploratory cross-lagged structural equation model revealed a number of direct and indirect effects between pain acceptance and pain interference at T1 and T2.

CONCLUSION

Pain acceptance and interference improved after three months in an outpatient chronic pain treatment program. Improvements in acceptance were strongly related to reductions in interference. Future research should examine these relationships over longer periods, in larger samples.

Trajectories of Traumatic Stress Symptoms Among Siblings of Children With Cancer: The First Two Years Post-Diagnosis

OBJECTIVE

Identify and describe trajectories of cancer-related posttraumatic stress symptoms (PTSS) among siblings of children with cancer within two years of diagnosis.

METHOD

Siblings (aged 8-18; M = 11.2 years) across the United States, and for each, one caregiver, were recruited for a cohort sequential longitudinal study with three data collection points six months apart beginning at 6- or 12-months after cancer diagnosis. Siblings (N = 229; 42% of eligible/approached; 53% identifying as female; 68% identifying as non-Hispanic White) completed the Child Posttraumatic Stress Disorder Symptom Scale. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ). Latent class growth analysis (LCGA) and growth mixture modeling (GMM) identified PTSS patterns across time.

RESULTS

Fit statistics supported models with three to five PTSS trajectories. The three-class LCGA model included a large mild PTSS group (61%), a moderate PTSS group (35%), and a small (4%) stable severe PTSS group. The four-class LCGA and three- and four-class GMM included groups improving from moderate to mild PTSS (7-21%) and worsening to moderate PTSS across time (12-17%). Across models, siblings with mild PTSS had fewer caregiver-reported emotional and behavioral difficulties on the SDQ.

CONCLUSIONS

A large group of siblings of children with cancer demonstrate resiliency, however, substantial subsets experience patterns of PTSS that include levels in the moderate-to-severe range during the first two years post-diagnosis. Future research should examine these patterns in more diverse/representative samples and identify factors associated with increasing and sustained severe PTSS to inform intervention targets and reduce cancer-related burden on families.

Competencies for Psychology Practice in Pediatric Palliative Care

OBJECTIVE

Pediatric psychologists have unique expertise to contribute to the care of youth with serious illnesses yet are not routinely integrated into pediatric palliative care (PPC) teams. To better define the role and unique skillset of psychologists practicing in PPC, support their systematic inclusion as part of PPC teams, and advance trainee knowledge of PPC principles and skills, the PPC Psychology Working Group sought to develop core competencies for psychologists in this subspecialty.

METHODS

A Working Group of pediatric psychologists with expertise in PPC met monthly to review literature and existing competencies in pediatrics, pediatric and subspecialty psychology, adult palliative care, and PPC subspecialties. Using the modified competency cube framework, the Working Group drafted core competencies for PPC psychologists. Interdisciplinary review was conducted by a diverse group of PPC professionals and parent advocates, and competencies were revised accordingly.

RESULTS

The six competency clusters include Science, Application, Education, Interpersonal, Professionalism, and Systems. Each cluster includes essential competencies (i.e., knowledge, skills, attitudes, roles) and behavioral anchors (i.e., examples of concrete application). Reviewer feedback highlighted clarity and thoroughness of competencies and suggested additional consideration of siblings and caregivers, spirituality, and psychologists' own positionality.

CONCLUSIONS

Newly developed competencies for PPC psychologists highlight unique contributions to PPC patient care and research and provide a framework for highlighting psychology's value in this emerging subspecialty. Competencies help to advocate for inclusion of psychologists as routine members of PPC teams, standardize best practices among the PPC workforce, and provide optimal care for youth with serious illness and their families.

Persistent Disparities in Pediatric Health Care Engagement During the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic has disrupted traditional health care, including pediatric health care. We described the impact of the pandemic on disparities in pediatric health care engagement.

METHODS

Using a population-based cross-sectional time-series design, we compared monthly ambulatory care visit volume and completion rates (completed vs no-show and cancelled visits) among pediatric patients aged 0-21 years in 4 states in the mid-Atlantic United States during the first year of the COVID-19 pandemic (March 2020-February 2021) with the same period before the pandemic (March 2019-February 2020). We used unadjusted odds ratios, stratified by visit type (telehealth or in-person) and sociodemographic characteristics (child race and ethnicity, caregiver primary language, geocoded Child Opportunity Index, and rurality).

RESULTS

We examined 1 556 548 scheduled ambulatory care visits for a diverse pediatric patient population. Visit volume and completion rates (mean, 70.1%) decreased during the first months of the pandemic but returned to prepandemic levels by June 2020. Disparities in in-person visit completion rates among non-Hispanic Black versus non-Hispanic White patients (64.9% vs 74.3%), patients from socioeconomically disadvantaged versus advantaged communities as measured by Child Opportunity Index (65.8% vs 76.4%), and patients in rural versus urban neighborhoods (66.0% vs 70.8%) were the same during the remainder of the first year of the pandemic as compared with the previous year. Concurrent with large increases in telehealth (0.5% prepandemic, 19.0% during the pandemic), telehealth completion rates increased.

CONCLUSIONS

Disparities in pediatric visit completion rates that existed before the pandemic persisted during the pandemic. These findings underscore the need for culturally tailored practices to reduce disparities in pediatric health care engagement.

Psychologists as leaders in equitable science: Applications of antiracism and community participatory strategies in a pediatric behavioral medicine clinical trial

Psychologists have an ethical responsibility to advance health equity and can play a significant role in improving health care experiences for families racialized as Black, including those with sickle cell disease (SCD), a group of genetic blood disorders primarily affecting communities of color. Parents of children with SCD report experiences of stigma and discrimination due to racism in the health care system. The current commentary describes the application of antiracism and participatory strategies to the research design, implementation, and dissemination of a behavioral medicine clinical trial (Engage-HU; NCT03442114) of shared decision-making (SDM) for pediatric patients with SCD, including (a) the development of a research question to promote justice for racialized groups; (b) a focus on "redressing imbalances" through SDM and a multidisciplinary, inclusive research team led by a Black psychologist; (c) community participatory approaches through the integration of stakeholder feedback across the study; and (d) centering context by attending to structural realities in response to the COVID-19 and racism pandemics. With attention to the fact that most primary caregivers of children with SCD are Black women, an intersectionality lens was applied. Implications and considerations for psychologists working to advance health equity in medical settings are also discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Family-centered communication in pediatric sickle cell disease

BACKGROUND

Individuals with sickle cell disease (SCD) experience systemic barriers in accessing high-quality care. Research suggests that patient/family-provider relationships are an important indicator of healthcare quality and can influence disease self-management and outcomes. The Patient Centered Communication (PCC) framework holds that patient/family-centered communication (e.g., eliciting, understanding, and validating patients' perspectives within their unique psychosocial contexts) contributes to improved family-provider relationships, as well as self-efficacy for disease management, adherence, and health outcomes. While the PCC framework has been useful in guiding the evaluation of patient/family-provider communication in other pediatric populations, it has not yet been applied in the context of pediatric SCD. This study aimed to use this framework to examine patient and family perceptions of communication with pediatric SCD healthcare providers.

PROCEDURE

Total 17 caregivers (82% mothers, 94% Black/African American) and eight patients (62% female, aged 13-19 years, M = 16.50) completed semi-structured interviews. The PCC framework informed the development of a preliminary codebook. Thematic content analysis summarized family perspectives regarding communication with providers.

RESULTS

For youth with SCD and their caregivers, specific themes related to family-centered communication included: reducing patient/family distress, supporting disease self-management efforts, facilitating information exchange and decision-making, and fostering positive and trusting relationships with providers.

CONCLUSIONS

This study helps to address gaps in the literature related to patient/family-provider communication within pediatric SCD. Results underscore the importance of patient- and family-centered communication across pediatric SCD care. These findings can inform future research and clinical care initiatives to improve patient/family-provider interactions and health outcomes for this underserved population.

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.

Validation of the COVID-19 Exposure and Family Impact Scales

Objective

The COVID-19 Exposure and Family Impact Scales (CEFIS) were developed in Spring 2020 to assess effects of the COVID-19 pandemic on families and caregivers. Initial psychometric properties were promising. The current study examined the factor structure and evaluated convergent and criterion validity of the CEFIS in a new sample.

Methods

In October and November 2020, caregivers (N = 2,531) of youth (0–21 years) scheduled for an ambulatory care visit at Nemours Children’s Hospital, Delaware completed the CEFIS and measures of convergent (PROMIS Global Mental Health Scale, Family Assessment Device) and criterion validity (PTSD Checklist—Civilian). Confirmatory factor analysis was used to examine the factor structure of the CEFIS. Bivariate correlations and logistic regression were used to examine convergent and criterion validity.

Results

Factor analysis supported the original six- and three-factor structures for the Exposure and Impact scales, respectively. Second-order factor analyses supported the use of Exposure, Impact, and Distress total scores. Higher scores on the CEFIS Exposure, Impact, and Distress scales were associated with increased mental health concerns and poorer family functioning. Higher scores on all CEFIS scales were also associated with greater odds of having clinically significant posttraumatic stress symptoms.

Conclusions

The CEFIS is a psychometrically sound measure of the impact of the COVID-19 pandemic on family and caregiver functioning and may also be useful in identifying families who would benefit from psychological supports.

Who Gets Referred? A Pilot Study of Risk Stratification and Treatment Referral in Pediatric Headache Using the Pediatric Pain Screening Tool

OBJECTIVE

Headaches are common among youth and are associated with significant negative outcomes. Despite advances in interdisciplinary treatments for youth with chronic pain, research suggests disparities in access to these services.

METHODS

A total of 186 youth (M = 14.19 years old, 70.8% female) presenting to a neurology appointment at a children's hospital system were screened using the Pediatric Pain Screening Tool (PPST), a brief, validated measure to identify youth that may benefit from additional pain management services.

RESULTS

Two-thirds of participants (n = 124, 66.7%) screened as medium or high risk on the PPST. Risk categorization did not vary by patient age or sex. A greater proportion of Hispanic/Latino patients were categorized as low-risk relative to non-Hispanic/Latino patients (55.6% vs. 30.1%), and a somewhat lower proportion of patients of color were categorized as medium-risk relative to White patients (14.0% vs. 30.5%). Three-quarters (n = 94, 75.8%) of patients who were screened as medium or high risk were not referred for any additional pain management services. Referrals did not vary by patient age or ethnicity. While not statistically significant, a lower proportion of males received referrals at both medium (8.3% vs. 17.6%) and high levels of risk (15.8% vs. 34.5%), and a greater proportion of youth of color who screened as medium risk received referrals relative to White youth categorized as medium risk (37.5% vs. 10.3%).

CONCLUSION

Future research should continue to explore factors influencing decision-making regarding referral to specialized pain management services for youth with headache.

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.

Survey Research With Families in the Context of Pediatric Chronic Health Conditions: Key Considerations and Future Directions

Self-report family functioning measures play a critical role in advancing our understanding of how families are impacted by, and adapt to, the demands of childhood health conditions. In this article, we present key considerations when conceptualizing, assessing, and analyzing dynamic family processes in research; discuss related implications for selecting instruments; and provide an update on the evidence base of self-report family functioning measures. Researchers need to consider theory, definitions of the family, informants, instruments, and procedural and data analytic issues when designing family research. Examples of questionnaires assessing general family functioning, dyadic relationships, and family functioning within the context of pediatric health conditions are provided. Additional evidence of validity, reliability, clinical utility, and cultural sensitivity of these measures is needed within pediatric chronic illness populations. Future research should include multiple family members and utilize varied assessment methods to obtain a comprehensive understanding of family functioning in the context of pediatric health conditions.

Engaging Caregivers and Providers of Children With Sickle Cell Anemia in Shared Decision Making for Hydroxyurea: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers' preferences and values, to facilitate a shared discussion with caregivers.

OBJECTIVE

The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences).

METHODS

We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes.

RESULTS

The Ethics Committee of the Cincinnati Children's Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants.

CONCLUSIONS

The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27650.

Trial Registration and Outcome Reporting in Child and Pediatric Psychology: A Systematic Review

OBJECTIVE

To examine rate of registration for randomized controlled trials (RCTs) published in the Journal of Pediatric Psychology (JPP) and Journal of Clinical Child & Adolescent Psychology (JCCAP). Secondary aims were to investigate associations between trial characteristics and registration status and compare registered and published primary outcomes.

METHODS

RCTs published in JPP or JCCAP between January 1, 2007 and December 31, 2017 were included. Secondary analyses of previously published RCTs, meta-analytic, systematic, and narrative reviews, and articles reporting primary aims related to intervention acceptability, feasibility, and/or cost-effectiveness were excluded. Trial registration status, primary registered and published outcomes, dates of registration, participant enrollment and publication, sample size, and country where the trial was conducted were extracted from articles and trial registries.

RESULTS

Of 61 RCTs included, 48% were registered. Among registered trials, only 14% were registered before participant enrollment began. Most were registered late (i.e., retrospectively; 86%) in ClinicalTrials.gov (90%). Registration status did not differ based on journal, study sample size, or geographic region where the study was conducted. A greater proportion of trials published in 2013-2017 were registered (61%) relative to those published in 2007-2012 (32%), p = .03. Among registered trials, 57% had discrepancies between registered and published primary outcomes.

CONCLUSIONS

Findings reveal low rates of prospective registration and considerable risk for incomplete or selective outcome reporting among RCTs published in JPP and JCCAP. Coordinated efforts from all stakeholders involved in the conduct and reporting of clinical child and pediatric psychology research are needed to improve transparent reporting of clinical trials.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SE_ab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SE_c' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

A preliminary investigation of the psychometric properties of PROMIS® scales in emerging adults with sickle cell disease

OBJECTIVE

To report preliminary psychometric properties of PROMIS® assessments among emerging adults with sickle cell disease (SCD).

METHOD

Forty-five emerging adults with SCD ages 18-24 (M = 20.81, SD = 1.73) completed PROMIS® Pain Interference and Fatigue short forms and the Pediatric Quality of Life Inventory (PedsQL). Chart review was used to obtain information regarding SCD complications and health care utilization in the 3 years prior to study enrollment. Multivariate path analysis was used to compare PROMIS® scores by disease severity and use of disease-modifying therapies. Cronbach's alpha was used to evaluate internal consistency, and Pearson correlations assessed convergent validity between PROMIS® measures and the PedsQL.

RESULTS

Internal consistency was excellent for PROMIS® Pain Interference (α = .95) and good for PROMIS® Fatigue (α = .85). Associations between PROMIS® measures and PedsQL subscales were in the expected direction and large in magnitude (all ps < .001). There were no differences in PROMIS® scores based on disease severity or use of disease-modifying therapy (ps = .14-.86).

CONCLUSIONS

Findings provide preliminary evidence of validity and reliability of the PROMIS® Pain Interference and Fatigue short forms among emerging adults with SCD. Additional research is needed to replicate these findings in larger samples and assess sensitivity to change over time. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The role of appraisals and coping in predicting posttraumatic stress following pediatric injury

OBJECTIVE

Given the millions of children who experience potentially traumatic injuries each year and the need to maximize emotional and physical health outcomes following pediatric injury, the current study examined the individual and collective contributions of the malleable variables of appraisals and coping in predicting posttraumatic stress symptoms (PTSS) in children following injury.

METHOD

This study combined data from 3 prospective investigations of recovery from pediatric injury (N = 688) in which children ages 8-17 years were recruited shortly after an injury (within 4 weeks). At baseline (T1), children completed measures of their threat appraisals of the injury event and PTSS. Six to twelve weeks later (T2), children completed a measure of coping and PTSS. Finally, PTSS was assessed again 6 months post-injury (T3).

RESULTS

Structural equation modeling analyses provide evidence that appraisals and coping contribute to PTSS. Furthermore, results suggest that escape coping mediates the relationship between threat appraisals and PTSS.

CONCLUSIONS

Early interventions designed to prevent or reduce PTSS after pediatric injury may be more successful if they primarily target modifying escape coping behaviors. To best inform clinical practice, future research should examine factors influencing the development of children's appraisals and coping behaviors in the context of potentially traumatic events. (PsycINFO Database Record

Implementing a Trauma-Informed Approach in Pediatric Health Care Networks

Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.

Posttraumatic stress in school-age children and adolescents: medical providers&rsquo; role from diagnosis to optimal management

Millions of children and adolescents each year are exposed to potentially traumatic events (PTEs), placing them at risk for posttraumatic stress (PTS) disorder symptoms. Medical providers play an important role in the identification and treatment of PTS, as they are typically the initial point of contact for families in the wake of a PTE or during a PTE if it is medically related (eg, injury/illness). This paper offers a review of the literature focused on clinical characteristics of PTS, the assessment and diagnosis of PTS, and current effective treatments for PTS in school-age children and adolescents. The clinical presentation of PTS is often complex as symptoms may closely resemble other internalizing and externalizing disorders. A number of screening and evaluation tools are available for medical providers to assist them in the accurate diagnosis of PTS. Treatment options are available for youth at minimal risk of PTS as well as for those with more intensive needs. Additional training regarding trauma-informed medical care may benefit medical providers. By taking a trauma-informed approach, rooted in a solid understanding of the clinical presentation of PTS in children and adolescents, medical providers can ensure PTS does not go undetected, minimize the traumatic aspects of medical care, and better promote health and well-being.

Systematic, theoretically-grounded development and feasibility testing of an innovative, preventive web-based game for children exposed to acute trauma

BACKGROUND

Millions of children are affected by acute medical events annually, creating need for resources to promote recovery. While web-based interventions promise wide reach and low cost for users, development can be time- and cost-intensive. A systematic approach to intervention development can help to minimize costs and increase likelihood of effectiveness. Using a systematic approach, our team integrated evidence on the etiology of traumatic stress, an explicit program theory, and a user-centered design process to intervention development.

OBJECTIVE

To describe evidence and the program theory model applied to the Coping Coach intervention and present pilot data evaluating intervention feasibility and acceptability.

METHOD

Informed by empirical evidence on traumatic stress prevention, an overarching program theory model was articulated to delineate pathways from a) specific intervention content to b) program targets and proximal outcomes to c) key longer-term health outcomes. Systematic user-testing with children ages 8-12 (N = 42) exposed to an acute medical event and their parents was conducted throughout intervention development.

RESULTS

Functionality challenges in early prototypes necessitated revisions. Child engagement was positive throughout revisions to the Coping Coach intervention. Final pilot-testing demonstrated promising feasibility and high user-engagement and satisfaction.

CONCLUSION

Applying a systematic approach to the development of Coping Coach led to the creation of a functional intervention that is accepted by children and parents. Development of new e-health interventions may benefit from a similar approach. Future research should evaluate the efficacy of Coping Coach in achieving targeted outcomes of reduced trauma symptoms and improved health-related quality of life.

Coping and coping assistance among children with sickle cell disease and their parents

The ways in which a family copes with the physical and psychosocial burdens of sickle cell disease (SCD) can influence the child and family functioning. However, few studies have examined SCD-related stressors beyond pain or how children and parents cope with these stressors. This study aimed to describe child coping and parent attempts to help their children cope (ie, coping assistance) with a range of SCD stressors by using a triangulated mixed methods design. We also explored convergence between findings from qualitative interviews and quantitative coping inventories. Fifteen children (aged 6 to 14 years) with SCD and their parents (N=15) completed semistructured interviews and self-report measures to assess SCD-related stressors, coping, and coping assistance strategies. Findings indicate that children experience numerous stressors related to SCD and its treatment, including, but not limited to, pain. To manage these stressors, families employ a range of approach and avoidance-oriented coping strategies. Quantitative and qualitative assessments provided complementary and unique contributions to understanding coping processes among children with SCD and their parents. Examining a broad range of stressors and integrating multiple assessment methods helps improve our understanding of coping with pediatric SCD, which may inform clinical practice and family-focused intervention development.

The Cellie Coping Kit for Sickle Cell Disease: Initial acceptability and feasibility

Sickle Cell Disease (SCD) and its treatment can place physical and psychosocial strain on children and their families, underlining the need for behavioral and emotional support. Much of SCD is often managed at home, which may prevent children from obtaining supportive services from medical and psychosocial teams. Children with SCD report a restricted number of coping strategies specific to managing SCD and may benefit from education on adaptive coping. To address this unmet need, a coping tool for children with cancer (Cellie Cancer Coping Kit) was adapted for children with SCD. The Cellie Coping Kit for SCD (Cellie Coping Kit) includes a stuffed "Cellie" toy, coping cards for children, and a book for caregivers. This study sought to assess the acceptability and feasibility of an intervention utilizing the Cellie Coping Kit. Fifteen children with SCD (ages 6-14) and their caregivers participated in a baseline assessment including semi-structured interviews to examine SCD-related stressors and coping strategies. Next, families received a brief introduction to the Cellie Coping Kit and were provided with a kit to use independently over the next four weeks before completing a follow-up assessment. Results indicated strong intervention acceptability overall. While families reported using and learning information and skills from the Cellie Coping Kit, several challenges were identified (e.g., child's living situation, busy schedules). The Cellie Coping Kit is a promising tool to support children with SCD and their families. Future research should examine whether use of the Cellie Coping Kit impacts behavioral change and improved health outcomes.

Understanding recovery in children following traffic-related injuries: exploring acute traumatic stress reactions, child coping, and coping assistance

Millions of children incur potentially traumatic physical injuries every year. Most children recover well from their injury but many go on to develop persistent traumatic stress reactions. This study aimed to describe children's coping and coping assistance (i.e., the ways in which parents and peers help children cope) strategies and to explore the association between coping and acute stress reactions following an injury. Children (N = 243) rated their acute traumatic stress reactions within one month of injury and reported on coping and coping assistance six months later. Parents completed a measure of coping assistance at the six-month assessment. Children used an average of five to six coping strategies (out of 10), with wishful thinking, social support, and distraction endorsed most frequently. Child coping was associated with parent and peer coping assistance strategies. Significant acute stress reactions were related to subsequent child use of coping strategies (distraction, social withdrawal, problem-solving, blaming others) and to child report of parent use of distraction (as a coping assistance strategy). Findings suggest that children's acute stress reactions may influence their selection of coping and coping assistance strategies. To best inform interventions, research is needed to examine change in coping behaviors and coping assistance over time, including potential bidirectional relationships between trauma reactions and coping.

A mixed methods assessment of coping with pediatric cancer

The purpose of this study was to describe child coping and parent coping assistance with cancer-related stressors during treatment. Fifteen children (age 6-12) with cancer and their parents (N = 17) completed semistructured interviews and self-report measures to assess coping and coping assistance. Results suggest families utilized a broad array of approach and avoidance strategies to manage cancer and its treatment. Quantitative and qualitative assessments provided complementary and unique contributions to understanding coping among children with cancer and their parents. Using a mixed methods approach to assess coping provides a richer understanding of families' experiences, which can better inform clinical practice.

Preventing posttraumatic stress following pediatric injury: a randomized controlled trial of a web-based psycho-educational intervention for parents

OBJECTIVE

The study objective is to evaluate the feasibility and efficacy of a web-based intervention for parents (AfterTheInjury.org [ATI]) in promoting emotional recovery following pediatric injury.

METHODS

100 children with injuries requiring medical attention and their parents were randomly assigned to the intervention or usual care. Efficacy outcomes included parent knowledge and child and parent posttraumatic stress symptoms (PTSS).

RESULTS

All parents in the intervention group completed the intervention (directed use of ATI) in the hospital. 56% reported using ATI online post-discharge, and 100% of these parents found it helpful. Parent knowledge increased immediately post-intervention, but there was no significant intervention impact on parent knowledge or PTSS at a 6-week follow-up. Relationships between knowledge and PTSS were identified.

CONCLUSIONS

Brief web-based interventions introduced during child hospitalization are a feasible strategy to reach many parents following pediatric injury. Preventing psychological symptoms may require more than parental education alone.

Increased risk for school violence-related behaviors among adolescents with insufficient sleep

BACKGROUND

School violence is associated with significant acute and long-term negative health outcomes. Previous investigations have largely neglected the role of pertinent health behaviors in school violence, including sleep. Insufficient sleep is associated with adverse physical, behavioral, and psychosocial consequences among adolescents, many of which are concurrently implicated in youth violence. This study examined the relationship between insufficient sleep and school violence behaviors in a nationally representative sample of high school students.

METHOD

We used data from the 2009 National Youth Risk Behavior Survey (YRBS). Logistic regression analyses evaluated the association between insufficient sleep and school violence behaviors, controlling for demographic factors. In addition to examining main effects, interaction terms were entered into the models to examine whether potential associations varied by sex or race/ethnicity.

RESULTS

Students with insufficient sleep had higher odds of engaging in the majority of school violence-related behaviors examined compared to students with sufficient sleep. Males with insufficient sleep were at increased risk of weapon carrying at school, a finding not observed for females with insufficient sleep. White students with insufficient sleep had higher odds of missing school because of safety concerns, a pattern that did not emerge among Black and Hispanic/Latino students.

CONCLUSION

Results highlight the potential value of incorporating sleep education interventions into school-based violence prevention programs and underline the need for further examination of the relationship between sleep and school violence among adolescents.

The use of stimulant medication to treat neurocognitive deficits in patients with pediatric cancer, traumatic brain injury, and sickle cell disease: a review

Several chronic health conditions of childhood, including pediatric cancers, traumatic brain injury (TBI), and sickle cell disease (SCD) are associated with significant neurocognitive impairments that can compromise educational attainment and future vocational opportunities. The prominence of attentional deficits as part of the neurocognitive sequelae associated with each of these conditions has led some researchers to draw parallels with another chronic condition that manifests in childhood, specifically the inattentive subtype of attention-deficit/hyperactivity disorder (ADHD). Because ADHD shares similar neurocognitive and symptomatological features with pediatric cancer, TBI, and SCD, stimulant medications may be indicated to treat associated deficits in each condition. However, relatively few studies have investigated the safety and effectiveness of stimulant medications in treating neurocognitive sequelae in children with cancer, TBI, or SCD. Thus, clinicians have received little guidance regarding a potentially useful treatment modality for ameliorating the neurocognitive deficits that can profoundly impact the educational, psychosocial, and vocational development of youth with these chronic health conditions. We provide a review of the literature and synthesize current developments in research regarding treatment with stimulant medication for children with cancer, TBI, and SCD, as well as discuss special considerations for each condition.

Coping with pediatric cancer: strategies employed by children and their parents to manage cancer-related stressors during treatment

Pediatric cancer patients and their families face significant physical, emotional, and psychosocial challenges. Few studies have investigated how children manage these challenges and how parents may help in the process. This qualitative study aimed to explore common cancer-related stressors for children and to examine child coping and parental assistance in coping with these stressors during treatment. Fifteen children undergoing cancer treatment and their parents participated in semistructured interviews. Four themes emerged capturing cancer-related stressors: cancer treatment/side effects, distressing emotions, disruption in daily routines, and social challenges. Six themes emerged regarding child coping strategies that were classified within an approach/avoidance coping framework. Approach coping strategies included the following: cognitive restructuring, relaxation, practical strategies, seeking social support, and emotional expression. Distraction was the only avoidant coping strategy. Parents tended to encourage approach coping strategies (eg, cognitive restructuring, social support). Within families, few coping strategies were reported (child: M = 1.47, SD = 0.99; parent: M = 3.33, SD = 1.18), suggesting that early family-based interventions teaching coping techniques for cancer-related stressors may be beneficial.

After the injury: initial evaluation of a web-based intervention for parents of injured children

The purpose of this study was to survey parent knowledge of child injury reactions (including post-traumatic stress symptoms) and to evaluate parent satisfaction and learning outcomes following a video- or web-based intervention. Fifty parents of children ages 6-17 years who were injured within the past 2 months were recruited from emergency and inpatient settings. A repeated-measures experimental design was employed in which participants were assigned to either a web-based or video intervention. Parent knowledge was assessed pre- and post-intervention. Learning outcomes and satisfaction were evaluated post-intervention. Parents showed high levels (∼70% accuracy) of knowledge about potential psychological injury reactions at baseline and post-intervention. In addition, post-intervention parents were able to generate new positive strategies to help their child recover and became more specific about types of reactions to monitor (e.g. avoidance). Participants reported high levels of satisfaction with both web and video interventions. While parents possess high levels of basic knowledge about child recovery from injury, the Web site and video tools provided concrete guidance that was useful in enhancing parent understanding of specific traumatic stress reactions to monitor in children post-injury.