A comparative effectiveness trial of functional behavioral assessment methods.

Clinicians report primarily using functional behavioral assessment (FBA) methods that do not include functional analyses. However, studies examining the correspondence between functional analyses and other types of FBAs have produced inconsistent results. In addition, although functional analyses are considered the gold standard, their contribution toward successful treatment compared with other FBA methods remains unclear. This comparative effectiveness study, conducted with 57 young children with autism spectrum disorder, evaluated the results of FBAs that did (n = 26) and did not (n = 31) include a functional analysis. Results of FBAs with and without functional analyses showed modest correspondence. All participants who completed functional communication training achieved successful outcomes regardless of the type of FBA conducted.

Commentary: Actionable Steps for Addressing Pediatric Pain in Rural and Underserved Communities: Disrupting Our Approach to Psychological Science and Care.

Although chronic pain is one of the most common health issues affecting children, disparities in access to behavioral healthcare limit its proper identification and management. There is a critical need to move beyond traditional care delivery approaches for chronic pain to reach those in communities that have limited access to care. We argue one means of doing so is to leverage our skills and expertise as psychologists to partner with and train professionals who have established relationships with youth in these communities. Drawing from a community-engaged dissemination and implementation science framework and our research implementing pain management strategies in rural and underserved communities, we review actionable strategies for disrupting traditional psychological methods to expand access to care for children with chronic pain.

"I'd like more options!": Interviews to explore young people and family decision-making needs for pain management in juvenile idiopathic arthritis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a common pediatric rheumatic condition and is associated with symptoms such as joint pain that can negatively impact health-related quality of life. To effectively manage pain in JIA, young people, their families, and health care providers (HCPs) should be supported to discuss pain management options and make a shared decision. However, pain is often under-recognized, and pain management discussions are not optimal. No studies have explored decision-making needs for pain management in JIA using a shared decision making (SDM) model. We sought to explore families' decision-making needs with respect to pain management among young people with JIA, parents/caregivers, and HCPs. METHODS: We conducted semi-structured virtual or face-to-face individual interviews with young people with JIA 8-18 years of age, parents/caregivers and HCPs using a qualitative descriptive study design. We recruited participants online across Canada and the United States, from a hospital and from a quality improvement network. We used interview guides based on the Ottawa Decision Support Framework to assess decision-making needs. We audiotaped, transcribed verbatim and analyzed interviews using thematic analysis. RESULTS: A total of 12 young people (n = 6 children and n = 6 adolescents), 13 parents/caregivers and 11 HCPs participated in interviews. Pediatric HCPs were comprised of rheumatologists (n = 4), physical therapists (n = 3), rheumatology nurses (n = 2) and occupational therapists (n = 2). The following themes were identified: (1) need to assess pain in an accurate manner; (2) need to address pain in pediatric rheumatology consultations; (3) need for information on pain management options, especially nonpharmacological approaches; (4) importance of effectiveness, safety and ease of use of treatments; (5) need to discuss young people/families' values and preferences for pain management options; and the (6) need for decision support. Themes were similar for young people, parents/caregivers and HCPs, although their respective importance varied. CONCLUSIONS: Findings suggest a need for evidence-based information and communication about pain management options, which would be addressed by decision support interventions and HCP training in pain and SDM. Work is underway to develop such interventions and implement them into practice to improve pain management in JIA and in turn lead to better health outcomes.

"My gut feeling is ": An Ethnographic Study Exploring Interprofessional Communication About Children and Adolescents With Chronic Musculoskeletal Pain in Paediatric Rheumatology.

Interprofessional communication about inflammatory and non-inflammatory musculoskeletal conditions is an important component of assessment and management in paediatric rheumatology. Chronic pain is a feature of some of these conditions which likely influences the extent and type of communication about pain. Research investigating interprofessional communication about paediatric pain is limited but has found that communication is inclusive of the biopsychosocial context of children/adolescents as well as their families. The aim of this ethnographic study was to explore interprofessional communication about children and adolescents with chronic musculoskeletal pain in paediatric rheumatology. We observed forty-five healthcare professionals recruited from 3 UK paediatric rheumatology teams during thirty multi-disciplinary team meetings. Contemporaneous field notes created during observations were analysed using grounded theory procedures. Core processes identified in interprofessional communication involved describing, making sense of, and managing children/adolescents with pain and their families. Topic areas discussed within these core processes included healthcare professional perceptions about children's and parents' personality characteristics, as well as healthcare professionals' familiarity with families. Underlying diagnoses and possible attributions of pain aetiology were also discussed. Interprofessional narratives included consideration of the potential anxieties and uncertainties about pain within families. Healthcare professionals communicated about strategies for managing expectations about pain. These findings characterise the nuances in interprofessional communication about pain and can be used to inform future work aimed at understanding and optimising the impact of interprofessional communication on clinical decisions and pain outcomes. PERSPECTIVE: This study characterises the processes (series of actions), the function (purpose) and the content (topic areas) of interprofessional communication about paediatric pain in rheumatology settings. These findings should be used to inform interventions targeting both the appropriateness and effectiveness of this communication.

A Prospective Evaluation of the Effects of the COVID-19 Pandemic on Youth with Primary Headache Disorders.

Alterations in certain academic and social/family routines during the COVID-19 pandemic have been speculated to be either a risk factor or buffer for poor health outcomes for youth with stress-sensitive health conditions such as primary headache disorders. The current study evaluated patterns and moderators of pandemic impacts on youth with primary headache disorders, with an aim of extending our understanding of the relationship between stress, resilience, and outcomes in this population. Children recruited from a headache clinic in the midwestern United States reported on their headaches, schooling, routines, psychological stress, and coping at four timepoints ranging from within a few months of the pandemic onset to a long-term follow-up 2 years later. Changes in headache characteristics over time were analyzed for association with demographics, school status, altered routines, and stress, and coping. At baseline, 41% and 58% of participants reported no change in headache frequency or intensity, respectively, relative to pre-pandemic levels, with the remainder almost equally divided between reporting an improvement or worsening. The results of multilevel growth model analyses indicated that headache intensity remained more elevated over time since the start of the pandemic for respondents whose stress scores were relatively higher (b = 0.18, t = -2.70, p = 0.01), and headache-related disability remained more elevated over time for older respondents (b = 0.01, t = -2.12, p = 0.03). The study results suggest, overall, that the outcomes of primary headache disorders in youth were not systematically altered by the COVID-19 pandemic.

Acceptability and Tolerability of Extended Reality Relaxation Training with and without Wearable Neurofeedback in Pediatric Migraine.

Objective. To determine the acceptability of using extended reality (XR) relaxation training as a preventive treatment for pediatric migraine. Methods. Youths aged 10-17 years old with migraine were recruited from a specialty headache clinic and completed baseline measures evaluating their vestibular symptoms and attitudes about technology. The patients were then instructed in three XR-based relaxation training conditions (fully immersive virtual reality with and without neurofeedback, and augmented reality with neurofeedback), in counterbalanced order, and completed acceptability and side effect questionnaires after each. The patients also took XR equipment home for one week to use for relaxation practice and again completed the measures about their experience. The acceptability and side effect data were compared against predetermined acceptable thresholds and were evaluated for their association with the participant characteristics. Results. The aggregate acceptability questionnaire scores exceeded our minimum threshold of 3.5/5, with the two fully immersive virtual reality conditions preferred over augmented reality for relaxation training (z = -3.02, p = 0.003, and z = -2.31, p = 0.02). The endorsed side effects were rated by all but one participant as mild, with vertigo being the most common. The acceptability ratings were not reliably associated with age, sex, typical hours per day of technology use, or technology attitudes, but were inversely related to the side effect scores. Conclusions. The preliminary data on acceptability and tolerability of immersive XR technology for relaxation training among youths with migraine supports further intervention development work.

Rates of Positive Suicide Screens in the Emergency Department and Outpatient Clinics at a Tertiary Care Children's Hospital.

PURPOSE: To provide guidance to hospitals that are developing suicide screening programs, we identified rates of positive screens across outpatient visits within a tertiary care children's hospital. METHODS: Suicide screening results from healthcare encounters occurring between February 2019 and January 2020 were estimated for ambulatory clinics (OP), urgent care (UC) clinics, and the emergency department (ED). RESULTS: Positive screens (95% confidence interval [CI]) occurred in 10.8% (10.6, 11.0)%) of visits overall. Rates of positive screens were 14.5 (14.1, 14.9)%, 9.9 (9.7, 10.1)%, and 9.3 (8.9, 9.7)% in the ED, OP, and UC, respectively. Rates of positive screens in outpatient clinics were highest in child abuse (33.4 (28.0, 39.2) %) and adolescent specialty (19.2 (17.3, 21.1) %). DISCUSSION: Some outpatient clinics had rates of positive suicide screens that surpass those seen in the ED. These findings could inform targeted suicide screening in hospital systems with limited resources to do universal screening.

Clinical Characterization of Juvenile Fibromyalgia in a Multicenter Cohort of Adolescents Enrolled in a Randomized Clinical Trial.

OBJECTIVE: Juvenile fibromyalgia (JFM) is a complex chronic pain condition that remains poorly understood. The study aimed to expand the clinical characterization of JFM in a large representative sample of adolescents with JFM and identify psychological factors that predict pain interference. METHODS: Participants were 203 adolescents (ages 12-17 years) who completed baseline assessments for the multisite Fibromyalgia Integrative Training for Teens (FIT Teens) randomized control trial. Participants completed the Pain and Symptom Assessment Tool, which includes a Widespread Pain Index (WPI; 0-18 pain locations) and Symptom Severity checklist of associated somatic symptoms (SS; 0-12) based on the 2010 American College of Rheumatology criteria for fibromyalgia. Participants also completed self-report measures of pain intensity, functional impairment, and psychological functioning. RESULTS: Participants endorsed a median of 11 painful body sites (WPI score) and had a median SS score of 9. Fatigue and nonrestorative sleep were prominent features and rated as moderate to severe by 85% of participants. Additionally, neurologic, autonomic, gastroenterologic, and psychological symptoms were frequently endorsed. The WPI score was significantly correlated with pain intensity and catastrophizing, while SS scores were associated with pain intensity and all domains of physical and psychological functioning. Depressive symptoms, fatigue, and pain catastrophizing predicted severity of pain impairment. CONCLUSION: JFM is characterized by chronic widespread pain with fatigue, nonrestorative sleep, and other somatic symptoms. However, how diffusely pain is distributed appears less important to clinical outcomes and impairment than other somatic and psychological factors, highlighting the need for a broader approach to the assessment and treatment of JFM.

'That's what makes me better': Investigating children and adolescents' experiences of pain communication with healthcare professionals in paediatric rheumatology.

BACKGROUND: Pain communication should be an integral part of clinical consultations, particularly in paediatric rheumatology where children and adolescents frequently present with chronic musculoskeletal pain. To date, literature exploring the nature of and extent to which pain communication occurs has focused on healthcare professionals as respondents, yielding inconsistent and incomplete findings. The aim of this study was to explore children and adolescents' experiences of pain communication in the context of paediatric rheumatology consultations. METHODS: Data were collected using semi-structured telephone interviews with children and adolescents recruited from three tertiary paediatric rheumatology centres in the United Kingdom. A framework analysis approach was used to explore the similarities and divergences in participant accounts. RESULTS: Twenty-six children and adolescents (aged 6-18 years, median = 14, 58% female) participated. Diagnoses included: juvenile idiopathic arthritis, Chronic Idiopathic Pain Syndromes, Ehlers Danlos Syndrome/Hypermobility. Four themes were identified: (1) Co-ordination of pain communication; (2) Barriers to pain communication; (3) Facilitators of pain communication; (4) Dissatisfaction with pain communication. These themes particularly encompassed the process of communication, disclosure of effective and ineffective approaches and the impact of communication. Participants expected questions about pain, felt cared about and found talking about pain natural. Challenges included augmenting the feeling of being different to peers and concerns about management plans changing as a result of pain conversations. CONCLUSIONS: Children and adolescents recalled a range of effective and ineffective pain communication approaches. Our study informs recommendations which highlight how healthcare professionals can improve their communication about pain with children and adolescents in the future. SIGNIFICANCE: Our findings demonstrate that children and adolescents attending paediatric rheumatology expect to be and value being asked about their pain during consultations with healthcare professionals. Children and adolescents remember many of the processes involved, experiences of and the outcomes of pain communication. The current study reveals insights which can improve healthcare professional pain communication with children and adolescents. Our study introduces key recommendations for healthcare professionals to have more effective pain conversations in future.

FIT Teens RCT for juvenile fibromyalgia: Protocol adaptations in response to the COVID 19 pandemic.

Objective: To describe protocol adaptations to the Fibromyalgia Integrative Training for Teens (FIT Teens) randomized controlled trial in response to the COVID-19 pandemic. The overarching aims of the FIT Teens multi-site 3-arm comparative effectiveness trial are to assess whether a specialized neuromuscular exercise training intervention combined with cognitive-behavioral therapy (CBT) is superior to CBT alone or graded aerobic exercise alone. Design/methods: The trial was originally designed as an in-person, group-based treatment with assessments at baseline, mid- and post-treatment, and four follow-up time points. The original study design and methodology was maintained with specific modifications to screening, consenting, assessments, and group-based treatments to be delivered in remote (telehealth) format in response to COVID-19 restrictions. Results: Study enrollment was paused in March 2020 for five months to revise operations manuals, pilot remote treatment sessions for accuracy and fidelity, complete programming of REDCap assent/consent and assessment materials, train study staff for new procedures and obtain regulatory approvals. The trial was relaunched and has been successfully implemented in remote format since July 2020. Trial metrics thus far demonstrate a consistent rate of enrollment, strong attendance at remote treatment sessions, high retention rates and high treatment fidelity after protocol adaptations were implemented. Conclusions: Preliminary findings indicate that FIT Teens protocol adaptations from in-person to remote are feasible and allowed for sustained enrollment, retention, and treatment fidelity comparable to the in-person format. Methodologic and statistical considerations resulting from the adaptations are discussed as well as implications for interpretation of results upon completion of the trial.

Microtemporal Relationships in the Fear Avoidance Model: An Ecological Momentary Assessment Study.

OBJECTIVES: Current literature in pediatric pain evaluates the Fear Avoidance model (FAM) pathways at the trait (or macrotemporal) level, but it is unknown if these pathways also occur at the state (or microtemporal) level. Identifying microtemporal processes can improve our understanding of how the relationships within the Fear Avoidance constructs vary when specific Fear Avoidance variables wax and wane. We hypothesized that changes in FAM constructs would be associated with changes in the next variable in the sequence on a microtemporal level, including: (1) higher pain when there is more pain-related fear, (2) higher pain-related fear when there is more avoidance, and (3) higher avoidance when there is more reported disability. METHODS: 71 pediatric patients with chronic abdominal pain ( M =13.34 y, SD=2.67 y) reported pain severity, pain-related fear, and avoidance via ecological momentary assessments over 14 days. RESULTS: Our results indicated significant microtemporal relationships between Fear Avoidance constructs for pain predicting pain-related fear, pain-related fear predicting avoidance, and avoidance predicting disability. DISCUSSION: The current study suggests that the ways in which the FAM is related to various aspects of pain functioning differs on a state-level, which adds new clinical and research opportunities.

Motivating Behavior Change in Parents for Suicide Prevention in the Midwest, USA.

Safe storage of lethal means is an evidence-based approach to suicide prevention that is underutilized. This naturalistic study investigated whether a presentation on parenting teenagers that includes education about safe storage of firearms and medications, paired with tools to enact change, can impact storage practices. Ten community presentations for parents were given between November 2018 and September 2019 in the Midwest region of the United States. Multiple topics pertinent to parenting adolescents were included with an emphasis on safe storage of firearms and medications to reduce suicide risk. Toolkits including medication storage boxes and cable gun locks were offered to help parents enact recommended changes. Surveys were completed prior to the presentation (T1), immediately following the presentation (T2), and 2 weeks after the presentation (T3). Five-hundred eighty-one parents comprised the initial study sample, of whom 410 (70.6%) completed the primary study endpoint. Generalized linear mixed models with and without worst-case imputation were used to evaluate changes in safe storage practices. Results suggested the odds of storing firearms in the safest manner possible increased 5.9 times (95% CI 2.6-13.5, p < 0.001) without imputation and increased 2.0 times (95% CI 1.1-3.4, p = 0.02) with the worst-case imputation. Among participants with unlocked medications at baseline, 56.5% reported they had disposed of old medications and 53.0% reported locking up bottles of medication by the primary study endpoint. This study provides preliminary evidence that safe storage education paired with tools for behavior change motivates parents to enact safe storage measures.

Combining Guided Intervention of Education and Relaxation (GIER) with Remote Electrical Neuromodulation (REN) in the Acute Treatment of Migraine.

BACKGROUND: Evidence indicates that combining behavioral treatments with pharmacological treatments for migraine prevention improves efficacy, but little is known about the outcomes of combining neuromodulation and behavioral interventions for acute treatment of migraine. Remote electrical neuromodulation (REN) is a U.S. Food and Drug Administration (FDA)-cleared nonpharmacological migraine treatment. The present study evaluated the clinical benefits of augmenting REN treatment with a specially tailored behavioral therapy consisting of Guided Intervention of Education and Relaxation (GIER) for the acute treatment of migraine. METHODS: In this two-arm observational study, real-world data were collected from patients across the United States who were using the REN device. Eighty-five migraine patients ≥18 years of age who treated their attacks with REN in parallel with the GIER intervention were individually matched on age and sex with 85 patients who used REN alone. The groups were compared on the proportion of migraine attacks in which they achieved pain relief, pain freedom, improvement of function, and return to normal function, all at 2 hours after treatment. RESULTS: Data from 170 users were analyzed (85 per group). Compared with the REN-only group, the REN+GIER group displayed a statistically significant higher proportion of patients achieving consistent pain relief (P = 0.008), consistent improvement in function (P = 0.014), and consistent return to normal function (P = 0.005), all at 2 hours after treatment. CONCLUSIONS: The results suggest that combining the GIER behavioral intervention with REN treatment can improve the therapeutic efficacy beyond that of REN alone, in terms of both pain level and improvement of disability.

Suicide Risk in Adolescents During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic created high levels of psychological distress and may have increased suicide risk. METHODS: We used the 4-item Ask Suicide-Screening Questions (ASQ) to assess suicide risk among all patients 12 to 24 years of age at a children's hospital. We compared demographics, encounter type (telehealth or face-to-face [F2F]), and screening results from April to June 2020 (T2) to those from April to June 2019 (T1). RESULTS: Fewer patients were seen at T2 than T1 (17 986 vs 24 863). A greater proportion of visits at T2 were by telehealth (0% vs 43%). The rate of positive suicide screens was higher in T2 than in T1 (12.2% vs 11.1%, adjusted odds ration [aOR], 1.24; 95% confidence interval [CI], 1.15-1.35). The odds of a positive screen were greater for older patients (aOR of 1.12 for age in years; 95% CI, 1.10-1.14), female patients (aOR, 2.23; 95% CI, 2.00-2.48), patients with public versus private insurance (aOR, 1.88; 95% CI, 1.72-2.07), and lower for Black versus White patients (aOR, 0.85; 95% CI, 0.77-0.95). Rates of positive screens were highest among inpatients (20.0%), intermediate for emergency department patients (14.4%), and lowest in outpatient clinics (9.9%) (P < .05). CONCLUSIONS: Rates of positive suicide risk screens among adolescents rose in the pandemic's early months with differences related to sociodemographics and visit type. Changes in health care delivery highlight the complexities of assessing and responding to mental health needs of adolescents. Additional research might determine the effects of screening methods and patient populations on screening results.

Development and Assessment of an Abbreviated Acupuncture Curriculum for Pediatricians.

OBJECTIVE: Acupuncture has been shown to improve pain and other health outcomes in children and is well tolerated. However, use of acupuncture by pediatric medical providers is rare, in part due to the cost and time associated with formal training. We aimed to develop an abbreviated acupuncture curriculum and assess its impact and acceptability with academic pediatricians. METHODS: In this pilot study, pediatricians received instruction in 2 acupuncture protocols for treating acute and chronic pain (Battlefield Acupuncture and Four Gates) during a 10-hour course developed by board-certified medical acupuncturists. Learning methods included an online module with videos and articles, 2 live workshops, and additional home practice. Participants completed a skills-based exam and pre- and post-tests measuring knowledge and attitudes about acupuncture treatment. RESULTS: Forty-five physicians (divided among 3 cohorts) began the acupuncture training course, and 38 (84.4%) completed all components. The course significantly increased participants' perceived efficacy of acupuncture for acute and chronic pain. Participants showed significant improvement in acupuncture knowledge. All participants agreed that the course would influence their current medical practice, and all participants felt confident utilizing basic acupuncture. Additionally, all participants indicated that they would recommend the abbreviated acupuncture curriculum to a colleague. CONCLUSIONS: Pediatricians became proficient in 2 acupuncture protocols with a 10-hour curriculum and found the format and content highly acceptable. Future plans include studying acupuncture implementation and expanding the course to other departments and institutions.

Technology to Assess and Treat Pain in Pediatric Rheumatology.

Advancements in eHealth offer unique opportunities for assisting in and augmenting aspects of evidence-based pain evaluation and management with children and adolescents. In this article, we present an overview of some of the opportunities and challenges in pain eHealth for pediatric rheumatologists to consider while caring for children and adolescents seen in their practice.

PD-L1 expression on circulating tumor cells and platelets in patients with metastatic breast cancer.

BACKGROUND: Immune checkpoint inhibition is effective in several cancers. Expression of programmed death-ligand 1 (PD-L1) on circulating tumor or immune effector cells could provide insights into selection of patients for immune checkpoint inhibition. METHODS: Whole blood was collected at serial timepoints from metastatic breast cancer patients and healthy donors for circulating tumor cell (CTC) and platelet PD-L1 analysis with a phycoerythrin-labeled anti-human PD-L1 monoclonal antibody (Biolegend clone 29E.2A3) using the CellSearch® assay. CTC PD-L1 was considered positive if detected on at least 1% of the cells; platelet PD-L1 was considered positive if ≥100 platelets per CellSearch frame expressed PD-L1. RESULTS: A total of 207 specimens from 124 metastatic breast cancer patients were collected. 52/124 (42%) samples at timepoint-1 (at or close to time of progressive disease) had ≥5 CTC/7.5ml whole blood. Of those, 21 (40%) had positive CTC PD-L1. In addition, platelet PD-L1 expression was observed in 35/124 (28%) at timepoint-1. Platelet PD-L1 was not detected in more than 70 specimens from 12 healthy donors. Platelet PD-L1 was associated with ≥5 CTC/7.5ml whole blood (p = 0.0002), less likely in patients with higher red blood cell counts (OR = 0.72, p<0.001) and a history of smoking tobacco (OR = 0.76, p<0.001). Platelet PD-L1 staining was not associated with tumor marker status, recent procedures or treatments, platelet-affecting drugs, or CTC PD-L1 expression. CONCLUSION: PD-L1 expression was found in metastatic breast cancer patients on both CTC and platelets in an independent fashion. Inter-patient platelet PD-L1 expression was highly heterogeneous suggesting that it is a biological event associated with cancer in some but not all patients. Taken together, our data suggest that CTC and platelet PD-L1 expression could play a role in predicting which patients should receive immune checkpoint inhibition and as a pharmacodynamics biomarker during treatment.

Identifying the content and context of pain within paediatric rheumatology healthcare professional curricula in the UK: a summative content analysis.

BACKGROUND: The curriculum for professionals working in paediatric rheumatology should include pain but it is unclear to what extent this currently occurs. The aim of this study was to identify pain-related curriculum content and the context in which pain is presented in educational and training documentation for healthcare professionals in this clinical speciality. METHODS: Core curricula documents from UK based professional organisations were identified in partnership with healthcare professionals. Documents were analysed using a summative content analysis approach. Key pain terms were quantified and weighted frequencies were used to explore narrative pain themes. Latent content was interpreted qualitatively to explore the context within which pain terms were positioned. RESULTS: Nine curriculum documents were identified and analysed from doctors, nurses, physiotherapists and occupational therapists specialising in paediatric rheumatology. Pain themes represented a mean percentage of 1.51% of text across all documents. Pain was rarely presented in the context of both inflammatory and non-inflammatory condition types despite being a common feature of each. Musculoskeletal pain was portrayed simply as a 'somatic' symptom, rather than as a complex phenomenon involving biological and psychosocial processes. Content around the assessment and management of pain was vague and inexplicit. CONCLUSION: Current educational and training documentation in paediatric rheumatology do not include core pain topics. Curricula for these healthcare professionals would benefit from updates in contemporary pain theories and examples of in-context, evidence-based pain practices. This should be a priority starting point for optimising patient pain care in paediatric musculoskeletal healthcare.

Implementing Universal Suicide Risk Screening in a Pediatric Hospital.

BACKGROUND: Health care providers are in a prime position to identify teens at risk for suicide, yet many do not. The research team developed and implemented a hospitalwide program to identify teens at elevated risk for suicide and connect them with services. METHODS: Screening was implemented at both locations of a pediatric hospital, including two emergency departments, three urgent care clinics, and ambulatory clinics. Patients aged 12 years and older presenting for care were screened for suicide risk using the Ask Suicide-Screening Questions (ASQ) in most settings, while the Columbia-Suicide Severity Rating Scale (C-SSRS) was used in mental health areas. A social worker responded to positive screens to complete a more thorough assessment and determine next steps. Social workers also completed outreach to patients in the weeks following a positive screen. Implementation began with pilot locations and expanded after refinements were made. Stakeholders provided screening recommendations, and education was provided prior to implementation. The cost of implementation was calculated based on the time screening required from nursing and social work. RESULTS: Review of the program focused on implementation fidelity, quality improvement, and trends among screening results. During the first year of screening, 138,598 screens were completed, and 6.8% of screens were positive for elevated risk. The annualized cost of the program was estimated to be $887,708.65 for personnel directly involved in screening and following up on positive screens. CONCLUSION: Early involvement of stakeholders and hospital leaders and a robust response plan were essential to successful implementation of this suicide-screening program.

Randomized clinical trial of Fibromyalgia Integrative Training (FIT teens) for adolescents with juvenile fibromyalgia - Study design and protocol.

OBJECTIVE: Juvenile-onset fibromyalgia (JFM) is a chronic debilitating pain condition that negatively impacts physical, social and academic functioning. Cognitive-behavioral therapy (CBT) is beneficial in reducing functional disability among adolescents with JFM but has only a modest impact on pain reduction and does not improve physical exercise participation. This randomized controlled trial (RCT) aims to test whether a novel intervention that combines CBT with specialized neuromuscular exercise training (the Fibromyalgia Integrative Training program for Teens "FIT Teens") is superior to CBT alone or a graded aerobic exercise (GAE) program. DESIGN/METHODS: This 3-arm multi-site RCT will examine the efficacy of the FIT Teens intervention in reducing functional disability (primary outcome) and pain intensity (secondary outcome), relative to CBT or GAE. All interventions are 8-weeks (16 sessions) in duration and are delivered in small groups of 4-6 adolescents with JFM. A total of 420 participants are anticipated to be enrolled across seven sites with approximately equal allocation to each treatment arm. Functional disability and average pain intensity in the past week will be assessed at baseline, post-treatment and at 3-, 6-, 9- and 12-month follow-up. The 3-month follow-up is the primary endpoint to evaluate treatment efficacy; longitudinal assessments will determine maintenance of treatment gains. Changes in coping, fear of movement, biomechanical changes and physical fitness will also be evaluated. CONCLUSIONS: This multi-site RCT is designed to evaluate whether the combined FIT Teens intervention will have significantly greater effects on disability and pain reduction than CBT or GAE alone for youth with JFM. Clinical trials.gov registration: NCT03268421.