Child life specialist services, practice, and utilization across health care: a scoping review.

OBJECTIVE: The objective of this review was to map the available evidence regarding the scope of child life specialist services, practice, and utilization. INTRODUCTION: The concept of child life services began in 1922 and emerged as the child life specialist services specialty in the United States in the 1970s and 1980s. Child life specialists are members of multidisciplinary health care system teams who prioritize the developmental needs of pediatric patients to support and improve patient and family health care experiences. Evidence of the effectiveness of child life specialist services and the utilization of those services is often incorporated in multidisciplinary research reports and thus overlooked. INCLUSION CRITERIA: All quantitative, qualitative, and mixed methods research study reports and systematic reviews investigating child life specialist services, practice, and utilization in health care systems were included. METHODS: This review was guided by the JBI methodology for scoping reviews and a published a priori protocol. CINAHL (EBSCOhost), MEDLINE (PubMed), Scopus, and PsycINFO (APA) were searched for evidence published from January 1980 to August 2022. RESULTS: Research publications about child life specialist services, practice, and utilization have increased dramatically over the past decade, with more than 50% of studies published in the past 5 years. Although the first authors of the majority of the research publications were physicians, these multidisciplinary author teams depicted child life specialist services in a variety of roles, including co-investigators, interventionists, and research subjects. The 105 full-text publications reviewed were from 9 countries, plus 1 publication that surveyed people across Europe. The contexts spanned a wide scope of clinical settings and medical subspecialties, but primarily in hospitals and health centers, and to a lesser extent, in ambulatory clinics and communities. A wide variety of child life specialist services were described across these settings. CONCLUSION: Mapping the research can help delineate the barriers and facilitators to child life specialist services in health care systems. This scoping review provides evidence of the global diffusion of child life specialist services across health care system settings, with recent increases in research publications involving child life specialist services.

Centering minority-serving institutions to counter dominant narratives about leadership identity development.

This article focuses on Historically Black Colleges and Universities (HBCUs), Hispanic-Serving Institutions (HSIs), Tribal Colleges and Universities (TCUs), and Asian American and Native American Pacific Islander-Serving Institutions (AANAPISIs). These institution types are united by their commitments to racially and ethnically minoritized communities, expanding educational access, facilitating culturally affirming education, and developing collective and socially responsible leaders. As a counternarrative, the authors situate leadership identity development (LID) at Minority-Serving Institutions (MSIs) to decenter whiteness in leadership scholarship and enactment and to elevate MSIs and their impact on students' leader and leadership identity development (LID).

Child life specialist practice and utilization across health care: a scoping review protocol.

OBJECTIVE: The objective of this review is to map the available evidence regarding the scope of child life specialist practice and utilization. INTRODUCTION: Child life specialists provide developmentally appropriate and emotion-focused supportive interventions that aim to build coping skills, enhance resilience, and mitigate traumatic experiences during health care encounters. Evidence of the care provided by a child life specialist is spread throughout health care literature. It is an emerging field that is aligned with a heightened focus on mental health and emotional safety. Evidence for the efficacy of child life specialists continues to grow. INCLUSION CRITERIA: Mapping the current evidence will capture the breadth of services provided by child life specialists. This scoping review will consider all evidence that reports on services provided by child life specialists, including across all quantitative and qualitative study designs, systematic reviews, and scoping reviews. The review will also include child life specialist workforce studies, such as child life specialist utilization, geographic availability, multidisciplinary team integration, and clinician-focused research. Case studies or narrative experiences outside of a qualitative research methodology, descriptions of program implementation, educational surveys, and quality improvement projects will be excluded from the scoping review. METHODS: JBI methodology for scoping reviews will guide the review process. Literature published from 1980 to the present will be included. Databases to be searched include PubMed, Scopus, PsycINFO, and CINAHL. The search for unpublished evidence will include Google Scholar and OpenGrey. Extracted data will be presented in tabular format with accompanying narrative summary.

Is there a relation between visual motor integration and academic achievement in school-aged children with and without ADHD?

Visual-motor integration, motor coordination, and visual perception are associated with academic achievement in early school-aged children; however, our understanding of these associations in older school-aged children and children with neurodevelopmental disorders is limited. A well-characterized, clinically evaluated sample of 39 children with and without ADHD ages 8-13 (M = 10.07, SD = 1.56; 14 girls; 67.5% White/non-Hispanic) were administered standardized academic and visual-motor integration tests. Results: Backward entry regression analyses that initially included age, sex, socioeconomic status, ADHD symptoms, comorbidities, and IQ revealed that better visual perception uniquely predicted better-developed reading (ß = .38) and math skills (ß = .21; both p < .03), whereas better motor coordination was associated with better reading (ß = .25), writing (ß = .50), and math skills (ß = .21 all p < .05). The integration of visual perception and motor coordination processes was uniquely associated only with math skills (ß = .28; p = .007). Children with ADHD exhibited significantly lower visual-motor integration (d = 1.16) and potentially motor coordination (d = 0.51), but did not differ from Non-ADHD children in terms of visual perception (d = 0.03). These findings extend prior evidence from younger, neurotypical samples, and indicate that underdeveloped visual-motor integration and/or its subcomponents (visual perception and motor coordination) reflect unique risk factors for academic underachievement in school-aged children's math, reading, and written language skills.

Executive functions and writing skills in children with and without ADHD.

OBJECTIVE: Pediatric attention-deficit/hyperactivity disorder (ADHD) has been associated with impairments in executive functioning and academic writing skills. However, our understanding of the extent to which these children's writing difficulties are related to their underdeveloped executive functions-and whether this relation is attributable to specific executive functions-is limited. METHOD: A clinically-evaluated and carefully-phenotyped sample of 91 children ages 8-13 (M = 10.60, SD = 1.25; 37 girls) were administered multiple, counterbalanced tests of the three core executive functions (working memory, inhibitory control, set shifting), assessed for ADHD symptoms via multiple-informant reports, and completed standardized, norm-referenced testing of three core writing skills (written expression, spelling, writing fluency). RESULTS: Bias-corrected, bootstrapped conditional effects modeling indicated that underdeveloped working memory exerted significant direct effects on all three writing skills, as well as indirect effects on written expression and spelling via the ADHD symptoms pathway (all 95% CIs exclude 0.0). In contrast, inhibitory control uniquely predicted spelling difficulties only, set shifting was not associated directly or indirectly with any assessed writing skill, and ADHD symptoms failed to uniquely predict writing skills after controlling for working memory. This pattern of results replicated across informants (parent vs. teacher ADHD symptom ratings), and was robust to control for age, sex, socioeconomic status (SES), majority/minority race/ethnicity status, intellectual functioning (IQ), decoding skills, language skills, and learning disability status. CONCLUSION: These findings suggest multiple pathways to writing skill difficulties in children with ADHD, while suggesting that their overt behavioral symptoms may be less involved in their writing difficulties than their underlying neurocognitive vulnerabilities. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Cost-Effectiveness of Tocilizumab (Actemra) Therapy in Giant Cell Arteritis.

BACKGROUND: Tocilizumab (Actemra) is a humanized anti-interleukin-6 receptor antibody that has been used as a steroid-sparing agent in giant cell arteritis (GCA). Although the clinical effects are well described in GCA, the cost-effectiveness of the use of tocilizumab in GCA is ill defined. The purpose of this study was to determine the cost-effectiveness of tocilizumab in GCA compared with prednisone alone. METHODS: A retrospective study of 32 patients with biopsy-proven GCA comparing prednisone alone (16 patients) and prednisone with tocilizumab (16 patients) was performed. The cost for tocilizumab therapy for 26 weeks with mild and severe side effects (Groups 1 and 2, respectively) and for 52 weeks with mild and severe side effects (Group 3 and 4, respectively) was compared with estimated costs of mild and severe steroid-induced side effects (Groups 5 and 6, respectively). Statistical analysis between groups was conducted using independent sample t tests. RESULTS: Three out of the 4 group combinations of tocilizumab with prednisone demonstrated a statistically significant (P < 0.05) difference in cost compared with prednisone alone for GCA. Group 2 (26-week tocilizumab therapy with severe steroid-induced side effects), with no statically significant difference in price when compared with steroid therapy alone and far fewer side effects, demonstrated the potential use of tocilizumab in GCA therapy. As expected, longer treatment duration with tocilizumab was associated with greater cost. With respect to side effect severity, the number of side effects of steroid therapy was inversely associated with difference in cost between tocilizumab therapy and steroid side effect treatment. CONCLUSION: This study demonstrates that combination therapy of tocilizumab and prednisone is significantly more expensive than steroids alone with or without accounting for the cost of steroid-induced side effects in treated GCA. The difference in cost between the 2 therapy types is directly related to tocilizumab therapy duration and inversely related to the number or severity of steroid side effects. Patients with GCA who require a shorter duration of steroid therapy and are at risk for a high number of side effects from steroid use may be potential candidates for tocilizumab therapy, from an economic perspective.

Activities of daily living and working memory in pediatric attention-deficit/hyperactivity disorder (ADHD).

Most children with ADHD have impaired working memory abilities. These working memory deficits predict impairments in activities of daily living (ADLs) for adults with ADHD. However, our understanding of the relation between pediatric ADHD and ADLs is limited. Thus, this study aimed to examine (1) the extent to which pediatric ADHD is associated with ADL difficulties; and if so (2) the extent to which these difficulties are related to their well-documented working memory difficulties and/or core ADHD inattentive and hyperactive/impulsive symptom domains. A well-characterized, clinically evaluated sample of 141 children ages 8-13 years (M = 10.36, SD = 1.46; 51 girls; 70% White/non-Hispanic) were administered a battery of well-validated working memory tests and assessed for ADHD symptoms (teacher-ratings) and ADL difficulties (parent-ratings); cross-informant reports were used to control for mono-informant bias. Children with ADHD exhibited medium magnitude difficulties with ADLs (d = 0.61, p < .005, 38% impaired). Results of the bias-corrected, bootstrapped conditional effects model indicated that lower working memory predicted reduced performance of age-expected ADLs (ß =0.28) and greater ADHD inattentive (ß = -0.40) and hyperactive/impulsive symptoms (ß = -0.16). Greater inattentive, but not hyperactive/impulsive, symptoms predicted greater ADL difficulties (ß = -0.36) even after controlling for working memory. Interestingly, working memory exerted a significant indirect effect on ADLs via inattentive (indirect effect: ß = 0.15, effect ratio = .54) but not hyperactive/impulsive symptoms. These findings implicate ADHD inattentive symptoms as a potential mechanism underlying ADL difficulties for children with ADHD, both independently and via working memory's role in regulating attention.

A randomized controlled trial of central executive training (CET) versus inhibitory control training (ICT) for ADHD.

OBJECTIVE: Executive function deficits are well-established in ADHD. Unfortunately, replicated evidence indicates that executive function training for ADHD has been largely unsuccessful. We hypothesized that this may reflect insufficient targeting, such that extant protocols do not sufficiently and specifically target the neurocognitive systems associated with phenotypic ADHD behaviors/impairments. METHOD: Children with ADHD ages 8-12 (M = 10.41, SD = 1.46; 12 girls; 74% Caucasian/Non-Hispanic) were randomized with allocation concealment to either central executive training (CET; n = 25) or newly developed inhibitory control training (ICT; n = 29). Detailed data analytic plans were preregistered. RESULTS: Both treatments were feasible/acceptable based on training duration, child-reported ease of use, and parent-reported high satisfaction. CET was superior to ICT for improving its primary intervention targets: phonological and visuospatial working memory (d = 0.70-0.84). CET was also superior to ICT for improving go/no-go (d = 0.84) but not stop-signal inhibition. Mechanisms of change analyses indicated that CET-related working memory improvements produced significant reductions in the primary clinical endpoints (objectively assessed hyperactivity) during working memory and inhibition testing (indirect effects: ß ≥ -.11; 95% CIs exclude 0.0). CET was also superior to ICT on 3 of 4 secondary clinical endpoints (blinded teacher-rated ADHD symptoms; d = 0.46-0.70 vs. 0.16-0.42) and 2 of 4 feasibility/acceptability clinical endpoints (parent-reported ADHD symptoms; d = 0.96-1.42 vs. 0.45-0.65). CET-related gains were maintained at 2-4 month follow-up; ICT-related gains were maintained for attention problems but not hyperactivity/impulsivity per parent report. CONCLUSIONS: Results support the use of CET for treating executive function deficits and targeting ADHD behavioral symptoms in children with ADHD. Findings for ICT were mixed at best and indicate the need for continued development/study. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Executive functioning rating scales: Ecologically valid or construct invalid?

OBJECTIVE: Executive functions are commonly measured using rating scales and performance tests. However, replicated evidence indicates weak/nonsignificant cross-method associations that suggest divergent rather than convergent validity. The current study is the first to investigate the relative concurrent and predictive validities of executive function tests and ratings using (a) multiple gold-standard performance tests, (b) multiple standardized rating scales completed by multiple informants, and (c) both performance-based and ratings-based assessment of academic achievement-a key functional outcome with strong theoretical links to executive function. METHOD: A well-characterized sample of 136 children oversampled for ADHD and other forms of child psychopathology associated with executive dysfunction (ages 8-13; 68% Caucasian/non-Hispanic) completed a counterbalanced series of executive function and academic tests. Parents/teachers completed executive function ratings; teachers also rated children's academic performance. RESULTS: The executive function tests/ratings association was modest (r = .30) and significantly lower than the academic tests/ratings association (r = .63). Relative to ratings, executive function tests showed significantly higher cross-method predictive validity and significantly better within-method prediction; executive function ratings failed to demonstrate improved within-method prediction. Both methods uniquely predicted academic tests and ratings. CONCLUSION: These findings replicate prior evidence that executive function tests and ratings cannot be used interchangeably as executive function measures in research and clinical applications, while suggesting that executive function tests may have superior validity for predicting academic behavior/achievement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Rethinking hyperactivity in pediatric ADHD: Preliminary evidence for a reconceptualization of hyperactivity/impulsivity from the perspective of informant perceptual processes.

Hyperactivity is a core ADHD symptom that has been both positively and negatively associated with cognition and functional outcomes. The reason for these conflicting findings is unclear but may relate to subjective assessments that conflate excess physical movement (hyperactivity) with verbally intrusive/impulsive behaviors. The current study adopted a model-driven, rational-empirical approach to distinguish excess physical movement symptoms from other, auditorily perceived behaviors assessed under the "hyperactivity/impulsivity" umbrella. We then tested this alternative conceptualization's fit, reliability, replicability, convergent/divergent validity via actigraphy, and generalizability across informants (parents, teachers) in a well-characterized, clinically evaluated sample of 132 children ages 8-13 years (M = 10.34, SD = 1.51; 47 girls; 67% White/non-Hispanic). The current DSM hyperactivity/impulsivity item pool can be reliably reclassified by knowledgeable judges into items reflecting excess physical movement (visual hyperactivity) and auditory interruptions (verbal intrusion). This bifactor structure showed evidence for multidimensionality and superior model fit relative to traditional hyperactivity/impulsivity models. The resultant visual hyperactivity factor was reliable, replicable, and showed strong convergent validity evidence via associations with objectively assessed hyperactivity. The verbal intrusion factor also showed evidence for reliability and explained a substantive portion of reliable variance, but demonstrated lower estimated replicability. These findings provide preliminary support for conceptualizing ADHD symptoms from the perspective of their cognitive-perceptual impact on others, as well as differentiating excess physical movement (hyperactivity) from other behaviors assessed under the hyperactivity/impulsivity umbrella. "Verbal intrusion" appears to provide a better explanation than "impulsivity" for the reliable, non-hyperactivity variance assessed by these items, but the current item set appears insufficient for replicable measurement of this construct. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Is There a Functional Relation Between Set Shifting and Hyperactivity in Children with Attention-Deficit/Hyperactivity Disorder (ADHD)?

OBJECTIVE: Replicated evidence indicates that children with attention-deficit/hyperactivity disorder (ADHD) show disproportionate increases in hyperactivity/physical movement when their underdeveloped executive functions are taxed. However, our understanding of hyperactivity's relation with set shifting is limited, which is surprising given set shifting's importance as the third core executive function alongside working memory and inhibition. The aim of this study was to experimentally examine the effect of imposing set shifting and inhibition demands on objectively measured activity level in children with and without ADHD. METHOD: The current study used a validated experimental manipulation to differentially evoke set shifting, inhibition, and general cognitive demands in a carefully phenotyped sample of children aged 8-13 years with ADHD (n = 43) and without ADHD (n = 34). Activity level was sampled during each task using multiple, high-precision actigraphs; total hyperactivity scores (THS) were calculated. RESULTS: Results of the 2 × 5 Bayesian ANOVA for hyperactivity revealed strong support for a main effect of task (BF10 = 1.79 × 1018, p < .001, ω2 = .20), such that children upregulated their physical movement in response to general cognitive demands and set shifting demands specifically, but not in response to increased inhibition demands. Importantly, however, this manipulation did not disproportionally increase hyperactivity in ADHD as demonstrated by significant evidence against the task × group interaction (BF01 = 18.21, p = .48, ω2 = .002). CONCLUSIONS: Inhibition demands do not cause children to upregulate their physical activity. Set shifting produces reliable increases in children's physical movement/hyperactivity over and above the effects of general cognitive demands but cannot specifically explain hyperactivity in children with ADHD.

Working memory and information processing in ADHD: Evidence for directionality of effects.

OBJECTIVE: Children with ADHD demonstrate impaired performance on a wide range of neuropsychological tests. It is unclear, however, whether ADHD is associated with many neurocognitive deficits or whether a small number of impairment(s) broadly influence test performance. The current study tests competing model predictions regarding two candidate causal mechanisms in ADHD: information processing speed and working memory. METHOD: A well-characterized sample of 86 children (Mage = 10.52, SDage = 1.54; 34 girls; 64% Caucasian/Non-Hispanic) with ADHD (n = 45) and without ADHD (n = 41) completed eight fully crossed experimental tasks that systematically manipulated working memory (BF10 = 1.80 × 109³) and information processing speed (drift rate; BF10 = 7.61 × 106). RESULTS: Bayesian mixed-model ANOVAs indicated that increasing working memory demands produced significant reductions in information processing speed (drift rate; BF10 = 5.82 × 1096). In contrast, experimentally reducing children's information processing speed did not significantly change their working memory performance (BF10 = 1.31). ADHD status interacted with the working memory manipulation, such that the ADHD and non-ADHD groups showed equivalently high accuracy under the encoding-only conditions (BF01 = 3.45) but differed significantly under high working memory conditions (encoding + recall; BF10 = 19.58). Importantly, however, ADHD status failed to interact with (a) the working memory manipulation to differentially affect information processing speed and (b) the information processing speed manipulation to differentially affect working memory performance (all BF01 > 4.25). CONCLUSIONS: These findings indicate that top-down executive control exerts significant effects on children's ability to quickly process information, but that working memory deficits and slowed information processing speed appear to be relatively independent impairments in ADHD. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Annulation of Oxime-Ether Tethered Donor-Acceptor Cyclopropanes.

Novel oxime-ether tethered cyclopropanes, when exposed to Yb(OTf)3 and heat, annulate to generate hydropyrrolo-oxazines products that can be taken to their respective pyrrolidines via hydrogenative N-O bond cleavage. The hydropyrrolo-oxazines are generated in a diastereoselective manner isolating the cis or trans product based on the temperature of the reaction. 20 examples of selective cis and trans hydropyrrolo-oxazines were generated in high yields by temperature control.

What cognitive processes are "sluggish" in sluggish cognitive tempo?

OBJECTIVE: Sluggish cognitive tempo refers to a constellation of symptoms that include slowed behavior/thinking, reduced alertness, and getting lost in one's thoughts. Despite the moniker "sluggish cognitive tempo," the evidence is mixed regarding the extent to which it is associated globally with slowed (sluggish) mental (cognitive) information processing speed (tempo). METHOD: A well-characterized clinical sample of 132 children ages 8-13 years (M = 10.34, SD = 1.51; 47 girls; 67% White/non-Hispanic) were administered multiple, counterbalanced neurocognitive tests and assessed for sluggish cognitive tempo symptoms via multiple-informant reports. RESULTS: Bayesian linear regressions revealed significant evidence against associations between sluggish cognitive tempo and computationally modeled processing speed (BF01 > 3.70), and significant evidence for associations with slower working memory manipulation speed. These findings were consistent across parent and teacher models, with and without control for attention-deficit/hyperactivity disorder inattentive symptoms and IQ. There was also significant evidence linking faster inhibition speed with higher parent-reported sluggish cognitive tempo symptoms. CONCLUSIONS: These findings provide strong evidence against characterizing children with sluggish cognitive tempo symptoms as possessing a globally sluggish cognitive tempo. Instead, these symptoms appear to be related, to a significant extent, to executive dysfunction characterized by working memory systems that are too slow and inhibition systems that are too fast. Behaviorally, these findings suggest that requiring extra time to rearrange the active contents of working memory delays responding, whereas an overactive inhibition system likely terminates thoughts too quickly and therefore prevents intended behaviors from starting or completing, thereby giving the appearance that children are absent-minded or failing to act when expected. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Do children with attention-deficit/hyperactivity disorder (ADHD) have set shifting deficits?

OBJECTIVE: Set shifting, or cognitive flexibility, is a core executive function involving the ability to quickly and efficiently shift back and forth between mental sets. Meta-analysis suggests medium-magnitude shifting impairments in attention-deficit/hyperactivity disorder (ADHD). However, this conclusion may be premature because the evidence-base relies exclusively on tasks that have been criticized for poor construct validity and may better reflect general neuropsychological functioning rather than shifting specifically. METHOD: A well-characterized sample of 77 children ages 8-13 (M = 10.46, SD = 1.54; 32 girls; 66% Caucasian/non-Hispanic) with ADHD (n = 43) and without ADHD (n = 34) completed the criterion global-local set shifting task and 2 counterbalanced control tasks that were identical in all aspects except the key processes. RESULTS: The experimental manipulation was successful at evoking set shifting demands during the global-local versus both nonshift control tasks (p < .001; ω2 = .12-.14). Mixed-model analyses of variance (ANOVAs) revealed that the ADHD group did not demonstrate disproportional decrements in speed shift costs on the shifting versus nonshift control tasks (p = .30; ω2 = .002), suggesting no evidence of impaired set shifting abilities in ADHD. In contrast, the ADHD group made disproportionately more shifting errors than the non-ADHD group (p = .03; ω2 = 0.03) that were more parsimoniously attributable to prerequisite (nonshifting) processes necessary for successful performance on the global-local task. CONCLUSIONS: Children with ADHD's impaired performance on shifting tasks may be attributable to difficulties maintaining competing rule sets and/or inhibiting currently active rule sets prior to shifting. However, when these higher-order processes are executed successfully, there is no significant evidence to suggest a unique set shifting deficit in ADHD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).