Examining where to go: pediatric psychology trainees' perception of their graduate training in culture and diversity.

OBJECTIVE: Culture and diversity-related training is critical to the development of competent pediatric psychologists. Evaluation of training efforts have been conducted at the program level, yet evaluation of trainee experiences in culture and diversity-related training remains unassessed. This trainee-led study was the first formal assessment of pediatric psychology trainee experiences of culture and diversity-related training and the impact of training on their own cultural humility. METHODS: Study overview and a survey link was distributed across 2 listservs associated with the American Psychological Association (Division 53, Division 54) and sent directly to directors of graduate, internship, and fellowship training programs with a request to share with trainees. Surveys assessing integration of cultural training and trainee cultural humility were completed. Trainees also provided qualitative feedback regarding their multicultural training and development. RESULTS: Pediatric psychology trainees (N = 90) reported inconsistent integration of culture and diversity topics into their training. Of the 34 training areas assessed, 10 were perceived as thoroughly integrated into formal training by at least half of the respondents. Trainees often sought independent cultural training outside of their programs, and no relationship was detected between perceived integration of cultural training and trainee cultural competence. DISCUSSION: Results indicate room for improvement regarding integration of cultural training and a need to better understand driving forces behind trainees independently seeking training outside of their formal training programs. Moreover, understanding the aspects of training that are most contributory to trainee development is needed given that no relationship between training and development emerged in the current study.

Implementation of Concussion Management Policies in High Schools: The Critical Role of School Nurses.

Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N = 304), and responses (n = 201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.

Lived Experiences of an Elite Performance Management Team Through Injury Rehabilitation: An Interpretative Phenomenological Analysis.

OBJECTIVES: Injury is a common and challenging experience for many athletes, and return-to-sport outcomes have been persistently poor despite advancements in research and practice. To ameliorate this challenge and to bridge a gap that exists in the sport injury literature between theoretical conceptualization and intervention design, research is needed to explore team-based approaches to professional practice. The current study aimed to begin this work through exploration of a single performance management team (PMT) through 2 injury and rehabilitation cases leading into and across the 2014 Olympic Winter Games. DESIGN: Qualitative, interpretative phenomenological analysis. METHOD: Interviews were conducted with the 5 members of the PMT (coach, physiotherapist, sport psychology consultant, case manager, and athlete) involved in both injury cases. Lower-order and higher order themes were identified and interpreted through the extent literature. RESULTS: Results indicate that 3 higher order themes interacted to impact the lived experiences of the PMT members across the 2 injury cases. Participants described the sociocultural context that surrounded the team, the individual struggles they faced, and the functioning of the team as the primary contributors to their lived experiences as well as observed rehabilitation outcomes. CONCLUSIONS: Findings of this study mirror previous research in team science within the general health care domain, and prompt ongoing exploration of how to improve the experiences for PMT members as well as rehabilitation and return-to-sport outcomes for athletes.

Machine Learning Enhances the Efficiency of Cognitive Screenings for Primary Care.

BACKGROUND: Incorporation of cognitive screening into the busy primary care will require the development of highly efficient screening tools. We report the convergence validity of a very brief, self-administered, computerized assessment protocol against one of the most extensively used, clinician-administered instruments-the Montreal Cognitive Assessment (MoCA). METHOD: Two hundred six participants (mean age = 67.44, standard deviation [SD] = 11.63) completed the MoCA and the computerized test. Three machine learning algorithms (ie, Support Vector Machine, Random Forest, and Gradient Boosting Trees) were trained to classify participants according to the clinical cutoff score of the MoCA (ie, < 26) from participant performance on 25 features of the computerized test. Analysis employed Synthetic Minority Oversampling TEchnic to correct the sample for class imbalance. RESULTS: Gradient Boosting Trees achieved the highest performance (accuracy = 0.81, specificity = 0.88, sensitivity = 0.74, F1 score = 0.79, and area under the curve = 0.81). A subsequent K-means clustering of the prediction features yielded 3 categories that corresponded to the unimpaired (mean = 26.98, SD = 2.35), mildly impaired (mean = 23.58, SD = 3.19), and moderately impaired (mean = 17.24, SD = 4.23) ranges of MoCA score ( F = 222.36, P < .00). In addition, compared to the MoCA, the computerized test correlated more strongly with age in unimpaired participants (ie, MoCA ≥26, n = 165), suggesting greater sensitivity to age-related changes in cognitive functioning. CONCLUSION: Future studies should examine ways to improve the sensitivity of the computerized test by expanding the cognitive domains it measures without compromising its efficiency.

Targeting Pain Science Education in Youth With Chronic Pain: What Are the Sticking Points for Youth and Their Parents?

OBJECTIVES: An important part of providing pain science education is to first assess baseline knowledge and beliefs about pain, thereby identifying misconceptions and establishing individually-tailored learning objectives. The Concept of Pain Inventory (COPI) was developed to support this need. This study aimed to characterize the concept of pain in care-seeking youth and their parents, to examine its clinical and demographic correlates, and to identify conceptual gaps. MATERIALS AND METHODS: Following an initial interdisciplinary evaluation, a cohort of 127 youth aged 8 to 18 years, and their parents, completed a series of questionnaires. RESULTS: Parents had slightly higher COPI scores than youth did, reflecting parents' greater alignment with contemporary pain science. The moderate positive association with older age among youth ( r =.32) suggests that COPI is sensitive to cognitive development and life experiences. Youth and parent COPI responses were weakly associated ( r =0.24), highlighting the importance of targeting the concept of pain in both groups. For both parents and youth, 'Learning about pain can help you feel less pain' was the least endorsed concept. This conceptual 'gap' is a key point of intervention that could potentially lead to greater engagement with multidisciplinary pain treatment. DISCUSSION: The COPI appears useful for identifying conceptual gaps or 'sticking points'; this may be an important step to pre-emptively address misconceptions about pain through pain science education. Future research should determine the utility of COPI in assessing and treating youth seeking care for pain. The COPI may be a useful tool for tailoring pain science education to youth and their parents.

Enhancing Exposure Treatment for Youths With Chronic Pain: Co-design and Qualitative Approach.

BACKGROUND: Increasing the access to and improving the impact of pain treatments is of utmost importance, especially among youths with chronic pain. The engagement of patients as research partners (in contrast to research participants) provides valuable expertise to collaboratively improve treatment delivery. OBJECTIVE: This study looked at a multidisciplinary exposure treatment for youths with chronic pain through the lens of patients and caregivers with the aim to explore and validate treatment change processes, prioritize and develop ideas for improvement, and identify particularly helpful treatment elements. METHODS: Qualitative exit interviews were conducted with patients and caregivers at their discharge from 2 clinical trials (ClinicalTrials.gov NCT01974791 and NCT03699007). Six independent co-design meetings were held with patients and caregivers as research partners to establish a consensus within and between groups. The results were validated in a wrap-up meeting. RESULTS: Patients and caregivers described that exposure treatment helped them better process pain-related emotions, feel empowered, and improve their relationship with each other. The research partners developed and agreed upon 12 ideas for improvement. Major recommendations include that pain exposure treatment should be disseminated more not only among patients and caregivers but also among primary care providers and the general public to facilitate an early referral for treatment. Exposure treatment should allow flexibility in terms of duration, frequency, and delivery mode. The research partners prioritized 13 helpful treatment elements. Most of the research partners agreed that future exposure treatments should continue to empower patients to choose meaningful exposure activities, break long-term goals into smaller steps, and discuss realistic expectations at discharge. CONCLUSIONS: The results of this study have the potential to contribute to the refinement of pain treatments more broadly. At their core, they suggest that pain treatments should be disseminated more, flexible, and transparent.

Application of PainDETECT in pediatric chronic pain: how well does it identify neuropathic pain and its characteristics?

Introduction: Neuropathic pain (NP) arises from nerve damage or disease, and when not defined, it can impair function and quality of life. Early detection allows for interventions that can enhance outcomes. Diagnosis of NP can be difficult if not properly evaluated. PainDETECT is a NP screening tool developed and successfully used in adults. Objectives: We evaluated the validity of painDETECT in a pediatric population. Methods: Adolescents and young adults (10-19 years old) completed painDETECT and quantitative sensory testing (QST), which assessed mechanical allodynia and hyperalgesia, common symptoms of NP. Pain diagnoses, including neuropathic pain (n = 10), were collected through documentation in the medical chart. Descriptive statistics were used to examine age, gender, pain diagnoses, and painDETECT scores. Kruskal-Wallis H tests were conducted to examine differences in QST results across painDETECT categorizations. Results: Youth with chronic pain (N = 110, Mage = 15.08 ± 2.4 years, Nfemale = 88) and peers without pain (N = 55, Mage = 15.84 ± 3.9 years, Nfemale = 39) completed the painDETECT. The painDETECT scores for youth with pain (M = 12.7 ± 6.76) were significantly higher than those for peers without pain (M = 2.05 ± 2.41). PainDETECT demonstrated 80% sensitivity and 33% specificity in a pediatric population. Individuals who screened positively on the PainDETECT had significantly higher mechanical allodynia (M = 0.640 ± 0.994) compared with those who screened negatively (M = 0.186 ± 0.499; P = 0.016). Conclusion: PainDETECT demonstrated the ability to screen for NP, and QST mechanical allodynia results were consistent with a positive NP screen. Results of the study offer preliminary support for the ongoing assessment of the painDETECT as a brief, inexpensive, and simple-to-use screening tool for pediatric patients with primary pain complaints.

Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design.

BACKGROUND: Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain. OBJECTIVE: This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design. METHODS: This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice. RESULTS: The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024. CONCLUSIONS: Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR. TRIAL REGISTRATION: ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40705.

Perceptions of implementation of Massachusetts sports concussion regulations: results of a survey of athletic directors.

BACKGROUND: In 2011 the Massachusetts Department of Public Health issued regulations pursuant to 2010 Massachusetts youth sports concussion legislation that provided policies and procedures for persons engaged in the prevention, training, management, and return-to-activity for students who sustain head injury during interscholastic athletics, including Athletic Directors (ADs). METHODS: A survey instrument was developed with participation from injury prevention experts at the Boston University School of Medicine, the Massachusetts Department of Public Health, and ADs. An electronic survey was sent to all AD members of the Massachusetts Interscholastic Athletic Association to assess their perceptions of implementation of the sports concussion law. RESULTS: Response rate was 75% (260/346). The mean rating on a 0-10 scale (10 being "very important") on importance of the law for student safety was 9.24, and the mean rating of the law's impact on workload was 5.54. Perceived impact on workload varied as a function of whether or not the school also employed an athletic trainer (t = 2.24, p = 0.03). Most respondents (88%) reported that their school had a concussion management team, and 74% reported that they were informed "always" (31%) or "often" (43%) when a student-athlete experienced a head injury in a venue other than extracurricular sports. Most respondents (95%) endorsed that "all" or "most" school nurses were "very knowledgeable" about the law and regulations. Approximately half of all respondents endorsed that "all" or "most" teachers and guidance counselors were "very knowledgeable" about the law and regulations; 76% endorsed that "all" or "most" of students' physicians were "very knowledgeable" about the law and regulations; 59% endorsed that "all" or "most" parents were "very knowledgeable" about the law and regulations. Sixty-six percent endorsed that student-athletes with concussion "often" (10%) or "sometimes" (56%) misrepresent their symptoms to accelerate return-to-play; and, 70% perceived that student-athletes with concussion "often" (15%) or "sometimes" (55%) misrepresent their symptoms to avoid academics. CONCLUSIONS: ADs perceive the sports concussion legislation as very important to student safety and positively assess implementation of the law and associated regulations. More effort is needed to increase understanding of the law among stakeholders including teachers, parents, and physicians.

Subjective Versus Objective Assessment of Cognitive Functioning in Primary Care.

PURPOSE: This study examined the clinical utility of highly efficient subjective and objective screens of cognitive impairment. METHOD: Participants (N = 124, age ≥ 65, mean = 73.59, SD = 6.26) completed a 2-item questionnaire of subjective memory functioning, a brief computerized cognitive test, and the Montreal Cognitive Assessment (MoCA). Next, participants were assigned to 1 of 4 conditions, based on their subjective (low/high) and objective (impaired/unimpaired) levels of cognitive functioning. Further analysis divided the sample into age-based groups (ie, age < 75, age ≥ 75). RESULTS: The proportion of participants in the impaired subsample (ie, MoCA < 26), who reported a high level of subjective concern about their memory, was low (ie, 0.15). Among unimpaired participants, analysis detected significant group differences across subjective memory levels (P < .0003) and age (P < .005) categories on one of the three tasks of the computerized test (ie, cognitive control). In contrast, the MoCA offered no differentiation between these groups. CONCLUSION: Screening protocols in which cognitive testing is administered subsequent to patient complaint are prone to underdiagnosis. In addition, common dementia screens are insensitive to subjective deficits and healthy cognitive aging. Therefore, they may lead to dismissing valid concerns that deserve preventive attention. Primary care needs efficient screening tools that are sensitive to prodromal decline.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools.

PURPOSE: There is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA. METHODS: A cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA. RESULTS: The scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (ß=-0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (ß=0.43, p=0.03); and school size (ß=-0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (ß=-0.01, p=0.03, adj-R2=0.1135). CONCLUSION: Among public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.

Parent Perceptions of Pediatric Primary Care Providers' Mental Health-Related Communication and Practices.

INTRODUCTION: The pediatric primary care office is an ideal setting to address children's socioemotional-behavioral health. However, research is limited regarding parents' experiences and satisfaction in sharing mental-health concerns about their children during well-child visits. METHOD: One thousand seven hundred sixty-three parents and caregivers with children aged 3-17 years completed an online survey that addressed mental-health-related communication. RESULTS: Findings supported the key role that primary care providers play in communicating about mental-health issues; 75% of parents who had such a concern about their child raised it during the visit, although the majority desired more time devoted to discussing mental health. Parents' comfort discussing mental-health concerns was inversely related to providers' dismissing those concerns. DISCUSSION: Despite satisfaction with how providers addressed mental-health issues, results suggested that nonjudgmental, knowledgeable staff and discussion of child and parent strengths could facilitate both parental comfort and communication between parents and pediatricians.

Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression.

In 2016, the U.S. Preventive Services Task Force recommended routine depression screening for individuals aged 13 and above. Questionnaire-based screening will likely increase treatment in patients with milder symptoms. Although professional groups who develop clinical practice guidelines recognize the importance of considering the risks and benefits of interventions, no official mandate exists for a stepped-care approach. Physical activity warrants increased consideration in guidelines, given the optimal risk/benefit profile and the increasing evidence of efficacy for the treatment and prevention of depression. The aim of the current study was to evaluate clinical practice guidelines for the treatment of major depressive disorder, specifically the recommendation of physical activity and adherence to a stepped-care approach. Authors searched three databases to identify treatment guidelines for depression. Guidelines were reviewed on the following domains regarding recommendation of physical activity: (a) front-line intervention, (b) explicit but not front-line recommendation, (c) inexplicit recommendation, (d) no mention, (e) adherence to a stepped-care approach, and (f) presentation of empirical support for their recommendation. Seventeen guidelines met inclusion criteria. Four guidelines recommended physical activity as a front-line intervention, two did not mention physical activity, eleven made some mention of physical activity, seven presented evidence to support their recommendation, and seven employed a stepped-care approach. The majority of guidelines did not use a stepped-care approach and varied greatly in their inclusion of physical activity as a recommended intervention for mild to moderate depression. Implications for practice, research, and policy are discussed.