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Halley MC, Young JL, Tang C, Mintz KT, Lucas-Griffin S, Maghiro A, Ashley EA, Tabor HK. Genomics Research with Undiagnosed Children: Ethical Challenges at the Boundaries of Research and Clinical Care. J Pediatr 2023; 261:113537. [PMID: 37271495 PMCID: PMC10527480 DOI: 10.1016/j.jpeds.2023.113537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To explore the perspectives of parents of undiagnosed children enrolled in genomic diagnosis research regarding their motivations for enrolling their children, their understanding of the potential burdens and benefits, and the extent to which their experiences ultimately aligned with or diverged from their original expectations. STUDY DESIGN In-depth interviews were conducted with parents, audio-recorded and transcribed. A structured codebook was applied to each transcript, after which iterative memoing was used to identify themes. RESULTS Fifty-four parents participated, including 17 (31.5%) whose child received a diagnosis through research. Themes describing parents' expectations and experiences of genomic diagnosis research included (1) the extent to which parents' motivations for participation focused on their hope that it would directly benefit their child, (2) the ways in which parents' frustrations regarding the research process confused the dual clinical and research goals of their participation, and (3) the limited clinical benefits parents ultimately experienced for their children. CONCLUSIONS Our results suggest that parents of undiagnosed children seeking enrollment in genomic diagnosis research are at risk of a form of therapeutic misconception-in this case, diagnostic misconception. These findings indicate the need to examine the processes and procedures associated with this research to communicate appropriately and balance the potential burdens and benefits of study participation.
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Affiliation(s)
- Meghan C Halley
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA.
| | - Jennifer L Young
- Center for Genetic Medicine, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Charis Tang
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA
| | - Kevin T Mintz
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA
| | - Sawyer Lucas-Griffin
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA
| | | | - Euan A Ashley
- Department of Genetics, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Holly K Tabor
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine; Stanford, CA
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Lauretta ML, Jarmolowicz A, Amor DJ, Best S, Morgan AT. An Investigation of Barriers and Enablers for Genetics in Speech-Language Pathology Explored Through a Case Study of Childhood Apraxia of Speech. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023:1-15. [PMID: 37713535 DOI: 10.1044/2023_jslhr-22-00714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
PURPOSE Advancements in genetic testing and analysis have allowed improved identification of the genetic basis of childhood apraxia of speech, a rare speech presentation. This study aimed to understand speech-language pathologists' (SLPs') consideration of incorporation of genetics in clinical practice using a theory-informed qualitative approach. METHOD Semistructured interviews were conducted with 12 pediatric SLPs using a behavior change theory (Theoretical Domains Framework [TDF]) within a case study describing a child with complex co-occurring features, including childhood apraxia of speech. Interviews focused on three stages of the patient journey (prereferral, referral, and postreferral). Interviews were analyzed to identify barriers and enablers to considering incorporation of genetics in current clinical practice. Barriers and enablers were grouped and mapped onto a contextually relevant TDF-coded analysis framework. RESULTS Barriers were identified across several TDF domains, through all stages of the patient journey. Lack of confidence, relevance, and level of experience were most common prereferral, and connection to and awareness of genetics services and contextual factors were barriers in the referral stage. Perception of professional role, knowledge, and beliefs about effects on families were barriers postreferral. Associated enablers were also identified, including seeing value in genetic diagnosis, support from other health care professionals, supervision, and relationships with genetics services. CONCLUSIONS Results of this qualitative study highlight barriers and enablers to incorporating genetics into speech-language pathology clinical practice. These findings will assist in the development of theory-informed implementation strategies to support SLPs into the future. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.24112800.
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Affiliation(s)
| | - Anna Jarmolowicz
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - David J Amor
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stephanie Best
- Australian Genomics, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Victorian Comprehensive Cancer Centre Alliance, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Angela T Morgan
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, St. Lucia, Australia
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Perry J, Redfield S, Oza A, Rouse S, Stewart C, Khela H, Srinivasan T, Albano V, Shearer E, Kenna M. Exome Sequencing Expands the Genetic Diagnostic Spectrum for Pediatric Hearing Loss. Laryngoscope 2023; 133:2417-2424. [PMID: 36515421 DOI: 10.1002/lary.30507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/29/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Genetic testing is the standard-of-care for diagnostic evaluation of bilateral, symmetric, sensorineural hearing loss (HL). We sought to determine the efficacy of a comprehensive genetic testing method, exome sequencing (ES), in a heterogeneous pediatric patient population with bilateral symmetric, bilateral asymmetric, and unilateral HL. METHODS Trio-based ES was performed for pediatric patients with confirmed HL including those with symmetric, asymmetric, and unilateral HL. RESULTS ES was completed for 218 probands. A genetic cause was identified for 31.2% of probands (n = 68). The diagnostic rate was 40.7% for bilateral HL, 23.1% for asymmetric HL, and 18.3% for unilateral HL, with syndromic diagnoses made in 20.8%, 33.3%, and 54.5% of cases in each group, respectively. Secondary or incidental findings were identified in 10 families (5.52%). CONCLUSION ES is an effective method for genetic diagnosis for HL including phenotypically diverse patients and allows the identification of secondary findings, discovery of deafness-causing genes, and the potential for efficient data re-analysis. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2417-2424, 2023.
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Affiliation(s)
- Julia Perry
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shelby Redfield
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrea Oza
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Clinical Genomics, Invitae, San Francisco, California, USA
| | - Stephanie Rouse
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Candace Stewart
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Harmon Khela
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tarika Srinivasan
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Albano
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eliot Shearer
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Dikow N, Ditzen B, Kölker S, Hoffmann GF, Schaaf CP. From newborn screening to genomic medicine: challenges and suggestions on how to incorporate genomic newborn screening in public health programs. MED GENET-BERLIN 2022. [DOI: 10.1515/medgen-2022-2113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Newborn screening (NBS) programs are considered among the most effective and efficient measures of secondary prevention in medicine. In individuals with medical conditions, genomic sequencing has become available in routine healthcare, and results from exome or genome sequencing may help to guide treatment decisions. Genomic sequencing in healthy or asymptomatic newborns (gNBS) is feasible and reveals clinically relevant disorders that are not detectable by biochemical analyses alone. However, the implementation of genomic sequencing in population-based screening programs comes with technological, clinical, ethical, and psychological issues, as well as economic and legal topics. Here, we address and discuss the most important questions to be considered when implementing gNBS, such as “which categories of results should be reported” or “which is the best time to return results”. We also offer ideas on how to balance expected benefits against possible harms to children and their families.
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Affiliation(s)
- Nicola Dikow
- Institute of Human Genetics , Heidelberg University , Heidelberg , Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Center for Psychosocial Medicine , University Hospital Heidelberg , Heidelberg , Germany
| | - Stefan Kölker
- University Hospital Heidelberg , Center for Pediatric and Adolescent Medicine, Clinic I , Heidelberg , Germany
| | - Georg F. Hoffmann
- University Hospital Heidelberg , Center for Pediatric and Adolescent Medicine, Clinic I , Heidelberg , Germany
| | - Christian P. Schaaf
- Institute of Human Genetics , Heidelberg University , Heidelberg , Germany
- Baylor College of Medicine , Houston , Texas , USA
- Jan and Dan Duncan Neurological Research Institute , Texas Children’s Hospital , Houston , Texas , USA
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Powell SN, Byfield G, Bennetone A, Frantz AM, Harrison LK, James-Crook ER, Osborne H, Owens TH, Shaw JL, O’Daniel J, Milko LV. Parental Guidance Suggested: Engaging Parents as Partners in Research Studies of Genomic Screening for a Pediatric Population. Front Genet 2022; 13:867030. [PMID: 35401676 PMCID: PMC8990237 DOI: 10.3389/fgene.2022.867030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 01/21/2023] Open
Abstract
Recent advances in genomic sequencing and genomic medicine are reshaping the landscape of clinical care. As a screening modality, genetic sequencing has the potential to dramatically expand the clinical utility of newborn screening (NBS), though significant barriers remain regarding ethical, legal, and social implications (ELSI) and technical and evidentiary challenges. Stakeholder-informed implementation research is poised to grapple with many of these barriers, and parents are crucial stakeholders in this process. We describe the formation and activities of a Community Research Board (CRB) composed of parents with diverse backgrounds assembled to participate in an ongoing research partnership with genomic and public health researchers at the University of North Carolina. The mission of the CRB is to provide insight into parental perspectives regarding the prospect of adding genomic sequencing to NBS and collaboratively develop strategies to ensure its equitable uptake. We describe how these contributions can improve the accessibility of research and recruitment methods and promote trust and inclusivity within diverse communities to maximize the societal benefit of population genomic screening in healthy children.
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Affiliation(s)
- Sabrina N. Powell
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Grace Byfield
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Annabelle M. Frantz
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Langston K. Harrison
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Heather Osborne
- Community Research Board Member, Mooresville, NC, United States
| | | | | | - Julianne O’Daniel
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Laura V. Milko
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,*Correspondence: Laura V. Milko,
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Halley MC, Young JL, Fernandez L, Kohler JN, Bernstein JA, Wheeler MT, Tabor HK. Perceived utility and disutility of genomic sequencing for pediatric patients: Perspectives from parents with diverse sociodemographic characteristics. Am J Med Genet A 2022; 188:1088-1101. [PMID: 34981646 DOI: 10.1002/ajmg.a.62619] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/04/2021] [Accepted: 12/05/2021] [Indexed: 12/30/2022]
Abstract
Given the limited therapeutic options for most rare diseases diagnosed through genomic sequencing (GS) and the proportion of patients who remain undiagnosed even after GS, it is important to characterize a broader range of benefits and potential harms of GS from the perspectives of families with diverse sociodemographic characteristics. We recruited parents of children enrolled in the Undiagnosed Diseases Network. Parents completed an in-depth interview, and we conducted a comparative content analysis of the data. Parents (n = 30) were demographically diverse, with 43.3% identifying as Hispanic, 33.3% primarily Spanish-speaking, and widely variable household income and education. Parents reported minimal changes in their child's health status following GS but did report a range of other forms of perceived utility, including improvements in their child's healthcare management and access, in their own psychological well-being, and in disease-specific social connections and research opportunities. Parents who received a diagnosis more frequently perceived utility across all domains; however, disutility also was reported by both those with and without a diagnosis. Impacts depended on multiple mediating factors, including parents' underlying expectations and beliefs, family sociodemographic characteristics, individual disease characteristics, and prior healthcare access. Our study suggests that the perceived utility of GS varies widely among parents and may depend on multiple individual, sociodemographic, and contextual factors that are relevant for pre- and post-GS counseling, for value assessment of GS, and for policymaking related to access to new genomic technologies.
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Affiliation(s)
- Meghan C Halley
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer L Young
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Liliana Fernandez
- Stanford Center for Undiagnosed Diseases, Stanford University, Stanford, California, USA
| | - Jennefer N Kohler
- Stanford Center for Undiagnosed Diseases, Stanford University, Stanford, California, USA
| | | | - Jonathan A Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew T Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Holly K Tabor
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA.,Department of Medicine (and by courtesy, Department of Epidemiology), Stanford University, Stanford, California, USA
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