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Cunningham NR, Adler MA, Barber Garcia BN, Abounader T, Miller AK, Monzalvo M, Hashemi I, Cox R, Ely SL, Zhou Y, DeLano M, Mulderink T, Reeves MJ, Peugh JL, Kashikar-Zuck S, Coghill RC, Arnetz JE, Zhu DC. Study protocol for a pilot clinical trial to understand neural mechanisms of response to a psychological treatment for pain and anxiety in pediatric functional abdominal pain disorders (FAPD). PLoS One 2024; 19:e0299170. [PMID: 38498587 PMCID: PMC10947640 DOI: 10.1371/journal.pone.0299170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/23/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions of childhood and are made worse by co-occurring anxiety. Our research team found that the Aim to Decrease Pain and Anxiety Treatment (ADAPT), a six-session coping skills program using cognitive behavioral therapy strategies, was effective in improving pain-related symptoms and anxiety symptoms compared to standard care. In follow-up, this current randomized clinical trial (RCT) aims to test potential neural mechanisms underlying the effect of ADAPT. Specifically, this two-arm RCT will explore changes in amygdalar functional connectivity (primary outcome) following the ADAPT protocol during the water loading symptom provocation task (WL-SPT). Secondary (e.g., changes in regional cerebral blood flow via pulsed arterial spin labeling MRI) and exploratory (e.g., the association between the changes in functional connectivity and clinical symptoms) outcomes will also be investigated. METHODS We will include patients ages 11 to 16 years presenting to outpatient pediatric gastroenterology care at a midwestern children's hospital with a diagnosis of FAPD plus evidence of clinical anxiety based on a validated screening tool (the Generalized Anxiety Disorder-7 [GAD-7] measure). Eligible participants will undergo baseline neuroimaging involving the WL-SPT, and assessment of self-reported pain, anxiety, and additional symptoms, prior to being randomized to a six-week remotely delivered ADAPT program plus standard medical care or standard medical care alone (waitlist). Thereafter, subjects will complete a post assessment neuroimaging visit similar in nature to their first visit. CONCLUSIONS This small scale RCT aims to increase understanding of potential neural mechanisms of response to ADAPT. TRIAL REGISTRATION ClinicalTrials.gov registration: NCT03518216.
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Affiliation(s)
- Natoshia R. Cunningham
- Department of Family Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan State University, Grand Rapids, Michigan, United States of America
| | - Michelle A. Adler
- Department of Family Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan State University, Grand Rapids, Michigan, United States of America
| | - Brittany N. Barber Garcia
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan State University, Grand Rapids, Michigan, United States of America
- Helen DeVos Children’s Hospital Pediatric Behavioral Health, Grand Rapids, Michigan, United States of America
| | - Taylor Abounader
- School of Professional Psychology, Wright State University, Dayton, Ohio, United States of America
| | - Alaina K. Miller
- School of Professional Psychology, Wright State University, Dayton, Ohio, United States of America
| | - Mariela Monzalvo
- School of Professional Psychology, Wright State University, Dayton, Ohio, United States of America
| | - Ismaeel Hashemi
- Department of Pediatric Gastroenterology, Novant Health, Wilmington, North Carolina, United States of America
| | - Ryan Cox
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan State University, Grand Rapids, Michigan, United States of America
- Helen DeVos Children’s Hospital Pediatric Gastroenterology, Grand Rapids, Michigan, United States of America
| | - Samantha L. Ely
- Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit, Michigan, United States of America
| | - Yong Zhou
- Corewell Health Radiology, Grand Rapids, Michigan, United States of America
| | - Mark DeLano
- Corewell Health Radiology, Grand Rapids, Michigan, United States of America
- Department of Radiology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
| | - Todd Mulderink
- Corewell Health Radiology, Grand Rapids, Michigan, United States of America
- Department of Radiology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, United States of America
| | - James L. Peugh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
| | - Susmita Kashikar-Zuck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
| | - Robert C. Coghill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
| | - Judith E. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan State University, Grand Rapids, Michigan, United States of America
| | - David C. Zhu
- Department of Radiology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, United States of America
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Huang X, Jia N, Zhang Y, Hao Y, Xiao F, Sun C, Cui X, Wang F. Effect of cognitive-behavior therapy for children with functional abdominal pain: a meta-analysis. BMC Gastroenterol 2024; 24:62. [PMID: 38310252 PMCID: PMC10838415 DOI: 10.1186/s12876-024-03120-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/01/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Cognitive-Behavior Therapy (CBT) is the validated non-pharmacological treatment for chronic pain in pediatric patients. While some suggested CBT were comparable to the usual care in reducing children's functional abdominal pain. This meta-analysis was designed to systematically review the literature for RCTs that investigated the efficacy of CBT in children with functional abdominal pain (FAP). METHODS PubMed, Embase, and the Cochrane library were searched for papers published up to October 2022. Studies applying different CBT delivery methods (in-person, web-based, phone-based) were included in this meta-analysis to evaluate the comprehensive effectiveness of CBT compared with usual care. Weighted and standardized mean difference with the 95% confidence intervals were used for the synthesis of the results. Primary outcome was the decrease of functional disability inventory (FDI) and the secondary outcomes were the decrease of severity in pain intensity, depression, anxiety, gastrointestinal symptoms, and improvement in physical quality of life (QoL). RESULTS A total of 10 RCTs with 1187 children were included in the final analysis. The results showed that CBT resulted in better effect in reducing functional disability inventory (SMD=-2.282, 95%CI: -4.537 to -0.027, P = 0.047), pain intensity (SMD=-0.594, 95%CI: -1.147 to -0.040, P = 0.036), and improving QoL (SMD = 14.097, 95%CI: 0.901 to 27.292, P = 0.036) compared with the control groups. Comparable effects were observed in the severity of depression (SMD=-0.493, 95%CI: -1.594 to 0.608, P = 0.380), anxiety (SMD=-0.062, 95%CI: -0.640 to 0.517, P = 0.835), and gastrointestinal symptoms (SMD=-1.096 95%CI: -2.243 to 0.050, P = 0.061) between CBT and usual treatment. CONCLUSIONS We observed the differences in post-treatment FAP and pain intensity for children receiving CBT compared with children receiving treatment as usual. CBT in the setting of FAP demonstrates promising developments and highlights the need for future research.
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Affiliation(s)
- Xiaolan Huang
- Experiment center, Capital Institute of Pediatrics, Beijing, China
| | - Nan Jia
- Experiment center, Capital Institute of Pediatrics, Beijing, China
| | - Yan Zhang
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, 100000, China
| | - Yanyan Hao
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, 100000, China
| | - Fei Xiao
- Experiment center, Capital Institute of Pediatrics, Beijing, China
| | - Chunrong Sun
- Experiment center, Capital Institute of Pediatrics, Beijing, China
| | - Xiaodai Cui
- Experiment center, Capital Institute of Pediatrics, Beijing, China
| | - Fei Wang
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, 100000, China.
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Santucci NR, Beigarten AJ, Khalid F, El-Chammas KI, Graham K, Sahay R, Fei L, Rich K, Mellon M. Percutaneous Electrical Nerve Field Stimulation in Children and Adolescents With Functional Dyspepsia-Integrating a Behavioral Intervention. Neuromodulation 2024; 27:372-381. [PMID: 37589640 PMCID: PMC10869640 DOI: 10.1016/j.neurom.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/25/2023] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Functional dyspepsia (FD) includes postprandial distress and epigastric pain syndrome. Percutaneous electrical nerve field stimulation (PENFS) in addition to behavioral interventions (BI) has shown benefits in children with functional abdominal pain but not specifically in FD. We aimed to assess the efficacy of PENFS for treating FD and compare the outcomes with those who received the combination of PENFS + BI. MATERIALS AND METHODS Charts of patients with FD who completed four weeks of PENFS were evaluated. A subset of patients received concurrent BI. Demographic data, medical history, and symptoms were documented. Outcomes at different time points included subjective symptom responses and validated questionnaires collected clinically (Abdominal Pain Index [API], Nausea Severity Scale [NSS], Functional Disability Inventory [FDI], Pittsburgh Sleep Quality Index [PSQI], Children's Somatic Symptoms Inventory [CSSI], Patient-Reported Outcomes Measurement Information Systems [PROMIS] Pediatric Anxiety and Depression scales). RESULT Of 84 patients, 61% received PENFS + BI, and 39% received PENFS alone. In the entire cohort, API (p < 0.0001), NSS (p = 0.001), FDI (p = 0.001), CSSI (p < 0.0001), PSQI (p = 0.01), PROMIS anxiety (p = 0.02), and depression (p = 0.01) scores improved from baseline to three weeks and at three months. Subjective responses showed nausea improvement (p = 0.01) and a trend for improvement in abdominal pain (p = 0.07) at week three. Abdominal pain subjectively improved at week three and three months (p = 0.003 and 0.02, respectively), nausea at week three and three months (p = 0.01 and 0.04, respectively), and a trend for improvement in sleep disturbances at week three and three months (p = 0.08 and p = 0.07, respectively) in the PENFS + BI group vs PENFS alone. CONCLUSION Abdominal pain, nausea, functioning, somatization, sleep disturbances, anxiety, and depression improved at three weeks and three months after PENFS in pediatric FD. Subjective pain and nausea improvement were greater in the PENFS + BI group than in the group with PENFS alone, suggesting an additive effect of psychologic therapy.
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Affiliation(s)
- Neha R Santucci
- Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
| | - Alan J Beigarten
- Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Fatima Khalid
- Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Khalil I El-Chammas
- Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Kahleb Graham
- Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Rashmi Sahay
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristin Rich
- Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Mellon
- Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Sayegh CS, Chavannes M, Moss IK, Featherstone RE, Urquiza I. The impact of integrating behavioral health services into pediatric subspecialty care: A systematic review. J Pediatr Gastroenterol Nutr 2024; 78:8-16. [PMID: 38291688 PMCID: PMC10832298 DOI: 10.1002/jpn3.12060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 02/01/2024]
Abstract
Pediatric gastroenterology patients are at risk for co-occurring behavioral health concerns, such as depression and anxiety, compared with youth without medical conditions. The objective of this systematic review was to assess the scientific literature supporting the hypothesis that integrating behavioral health services into gastroenterology clinics could improve patient psychosocial well-being. We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science, PsycINFO, and CINAHL databases and gray literature to identify studies reporting the impact of behavioral health integration on the psychosocial well-being of pediatric gastroenterology patients. Two independent coders evaluated each study for inclusion and extracted data regarding patient demographics, study design, behavioral health integration approaches, and psychosocial outcomes. Results were synthesized using narrative review procedures. Eighteen studies met the inclusion criteria. Most reported outcomes from research grant-funded randomized controlled trials or open trials investigating behavioral health interventions based on Cognitive-Behavioral Therapy, primarily with youth with irritable bowel disease or functional gastrointestinal disorders. Within the highest-quality, comparable studies, nearly 80% reported at least one statistically significant treatment effect on patient psychosocial well-being. Many studies used rigorous methods that minimize bias, but did not provide models for sustainable, programmatic behavioral health integration outside the bounds of a research study. The studies included in this review suggest that behavioral integration could have the potential to positively impact gastroenterology patients' psychosocial functioning. However, more research is needed to investigate the appropriate intensity of behavioral health services and evaluate models for integrating behavioral healthcare in pediatric gastroenterology settings beyond the research-funded clinical trial context.
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Affiliation(s)
- Caitlin S. Sayegh
- Division of Adolescent and Young Adult Medicine, Children’s Hospital Los Angeles, Los Angeles, USA
- Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Mallory Chavannes
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles, Los Angeles, USA
| | - Ilana K. Moss
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles, Los Angeles, USA
| | - Robert E. Featherstone
- Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California
| | - Isabel Urquiza
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
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Ma M, Yang M, Li Y, Hou L, Li M, Wang X, Li Z, Guo K, Liu X, Cheng Y, Niu J, Yang K. Cognitive behavioural therapy for functional abdominal pain disorders in children and adolescents: A systematic review of randomized controlled trials. Behav Res Ther 2023; 169:104397. [PMID: 37696176 DOI: 10.1016/j.brat.2023.104397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/23/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Abstract
AIM Although Cognitive behavioural therapy (CBT) potentially holds efficacy in addressing functional abdominal pain disorders (FAPDs) amongst children and adolescents, the persistent efficacy is uncertain. METHODS We searched three databases to identify related randomized controlled trials (RCTs). Meta-analysis was performed using RevMan and Stata. Subgroup analyses were mainly conducted based on follow-up time. The GRADE approach was used to evaluate the certainty of the evidence. RESULTS A total of 14 RCTs evaluating 858 patients were included. All RCTs were rated as having a high risk of bias. Compared with control groups, CBT was associated with improvement of general functional impairment (standardized mean difference (SMD) = -0.77, 95% CI [-1.12, -0.42], p < 0.05), higher treatment success (relative risk (RR) = 2.35, 95% CI [1.50, 3.69], p < 0.05), improvement of abdominal pain symptoms (SMD = -0.48, 95% CI [-0.73, -0.23], p < 0.05), QoL (SMD = 0.42, 95% CI [0.20, 0.64], p < 0.05), and psychological states (SMD = -0.95, 95% CI [-1.62, -0.27], p < 0.05). CONCLUSION This meta-analysis provides low to moderate quality evidence that CBT could significantly improve clinical outcomes and QoL for children and adolescents with FAPDs with improvement persisting until short-term follow-up. However, there were discrepancies regarding CBT's effects at mid- and long-term follow-up across different outcomes. More high-quality and longer-duration studies are thus warranted to explore the effectiveness of CBT in the future. SYSTEMATIC REVIEW REGISTRATION ON PROSPERO CRD42022369353.
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Affiliation(s)
- Mina Ma
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China
| | - Minyan Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China
| | - Yanfei Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China
| | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China
| | - Meixuan Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China
| | - Xinyi Wang
- School of the Second Clinical Medicine, Lanzhou University, Lanzhou, Gansu, PR China
| | - Zijun Li
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China; Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, PR China
| | - Ke Guo
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China; Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, PR China
| | - Xian Liu
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, PR China
| | - Yuanyuan Cheng
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, PR China
| | - Junqiang Niu
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China; Department of Traditional Chinese Medicine, School of the First Clinical Medicine, Lanzhou University, Lanzhou, Gansu, PR China.
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, PR China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, PR China; Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, PR China.
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Puckett-Perez S, Gresl B. Psychological treatment for pediatric functional abdominal pain disorders. Curr Opin Pediatr 2022; 34:516-520. [PMID: 35993286 DOI: 10.1097/mop.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss up-to-date psychological treatment strategies for functional abdominal pain disorders (FAPDs) with practical implications for primary care providers who are the "front line" of treatment for pediatric FAPD. RECENT FINDINGS Positive diagnosis, pain education, and access to multidisciplinary care improve outcomes for FAPD patients. Cognitive behavioral therapy (CBT) and hypnosis continue to have the strongest evidence in psychological treatments, but educational interventions and other nonpharmacological approaches show promise as well. There are innovative programs that combine these tools into group or internet-based treatments to expand access to care. Additionally, nonpharmacological tools, including neurostimulation and virtual reality programs, are increasing in popularity. SUMMARY FAPD is prevalent across pediatric practices, yet there is no standard medical or dietary approach, and there are many barriers to diagnosis and treatment. It is important for patients to have positive encounters around diagnosis and education, access to multidisciplinary care, and integrated psychological support. Consistently, studies show that psychology continues to be a vital component of care. This review discusses supported uses of psychology, innovative programming for increasing access to care, and how primary care providers can incorporate lessons learned from psychology in FAPD care. VIDEO ABSTRACT http://links.lww.com/MOP/A67 .
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Affiliation(s)
- Stevie Puckett-Perez
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Medical Center Dallas, Children's Health, Department of Psychiatry, University of Texas Southwestern (UTSW), Dallas, Texas, USA
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Santucci NR, King C, El-Chammas KI, Wongteerasut A, Damrongmanee A, Graham K, Fei L, Sahay R, Jones C, Cunningham NR, Coghill RC. Effect of percutaneous electrical nerve field stimulation on mechanosensitivity, sleep, and psychological comorbidities in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2022; 34:e14358. [PMID: 35293081 PMCID: PMC11093756 DOI: 10.1111/nmo.14358] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/21/2021] [Accepted: 02/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Percutaneous electrical nerve field stimulation (PENFS) improves symptoms in adolescents with functional abdominal pain disorders (FAPDs). However, little is known about its impact on sleep and psychological functioning. We evaluated the effects of PENFS on resting and evoked pain and nausea, sleep and psychological functioning, and long-term outcomes. METHODS Patient ages 11-19 years with FAPD requiring PENFS as standard care were recruited. Evoked pain was elicited by a Water Load Symptom Provocation Task (WL-SPT) before and after four weeks of treatment. Pain, gastrointestinal symptoms, sleep, somatic symptoms, and physical and psychological functioning were assessed. Actigraphy was used to measure daily sleep-wake patterns. KEY RESULTS Twenty patients (14.3 ± 2.2 years old) with FAPD were enrolled. Most patients were females (70%) and white (95%). During pain evoked by WL-SPT, visual analog scale (VAS) pain intensity and nausea were lower following PENFS compared with baseline (p = 0.004 and p = 0.02, respectively). After PENFS, resting VAS pain unpleasantness (p = 0.03), abdominal pain (p < 0.0001), pain catastrophizing (p = 0.0004), somatic complaints (0.01), functional disability (p = 0.04), and anxiety (p = 0.02) exhibited significant improvements, and some were sustained long-term. Self-reported sleep improved after PENFS (p's < 0.05) as well as actigraphy-derived sleep onset latency (p = 0.03). CONCLUSIONS AND INFERENCES We demonstrated improvements in resting and evoked pain and nausea, sleep, disability, pain catastrophizing, somatic complaints, and anxiety after four weeks of PENFS therapy. Some effects were sustained at 6-12 months post-treatment. This suggests that PENFS is a suitable alternative to pharmacologic therapy.
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Affiliation(s)
- Neha R Santucci
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher King
- Behavioral Medicine and Clinical Psychology (BMCP), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Khalil I. El-Chammas
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Anundorn Wongteerasut
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alisara Damrongmanee
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kahleb Graham
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rashmi Sahay
- Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cheryl Jones
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Robert C Coghill
- Behavioral Medicine and Clinical Psychology (BMCP), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Gordon M, Sinopoulou V, Tabbers M, Rexwinkel R, de Bruijn C, Dovey T, Gasparetto M, Vanker H, Benninga M. Psychosocial Interventions for the Treatment of Functional Abdominal Pain Disorders in Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:560-568. [PMID: 35404394 PMCID: PMC9002716 DOI: 10.1001/jamapediatrics.2022.0313] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Functional abdominal pain disorders (FAPDs) can severely affect the life of children and their families, with symptoms carrying into adulthood. Management of FADP symptoms is also a financial and time burden to clinicians and health care systems. OBJECTIVE To systematically review various randomized clinical trials (RCTs) on the outcomes of cognitive behavioral therapy (CBT), educational support, yoga, hypnotherapy, gut-directed hypnotherapy, guided imagery, and relaxation in the management of FAPDs. DATA SOURCES PubMed, MEDLINE, Embase, PsycINFO, and Cochrane Library. STUDY SELECTION All RCTs that compared psychosocial interventions with any control or no intervention, for children aged 4 to 18 years with FAPDs. DATA EXTRACTION AND SYNTHESIS Pairs of the authors independently extracted data of all included studies, using a predesigned data extraction sheet. One author acted as arbitrator. Risk of bias was assessed using the Cochrane risk of bias tool, and certainty of the evidence for all primary outcomes was analyzed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURES Primary outcomes were treatment success, pain frequency, pain intensity, and withdrawal owing to adverse events. Dichotomous outcomes were expressed as risk ratio (RR) with corresponding 95% CIs. Continuous outcomes were expressed as mean difference (MD) or standardized MD with 95% CI. RESULTS A total of 33 RCTs with 2657 children (median [range] age, 12 [7-17] years; 1726 girls [67.3%]) were included. Twelve studies compared CBT with no intervention, 5 studies compared CBT with educational support, 3 studiescompared yoga with no intervention, 2 studies compared hypnotherapy with no intervention, 2 studies compared gut-directed hypnotherapy with hypnotherapy, and 2 studies compared guided imagery with relaxation. Seven studies evaluated other unique comparisons (eg, visceral osteopathy vs normal osteopathy). Per the GRADE framework, owing to risk of bias, there was moderate certainty in evidence that CBT was associated with higher treatment success numbers (n = 324 children; RR, 2.37; 95% CI 1.30-4.34; number needed to treat [NNT] = 5), lower pain frequency (n = 446 children; RR, -0.36; 95% CI, -0.63 to -0.09), and lower pain intensity (n = 332 children; RR, -0.58; 95% CI, -0.83 to -0.32) than no intervention. Owing to high imprecision, there was low certainty in evidence that there was no difference between CBT and educational support for pain intensity (n = 127 children; MD, -0.36; 95% CI, -0.87 to 0.15). Owing to risk of bias and imprecision, there was low certainty in evidence that hypnotherapy resulted in higher treatment success compared with no intervention (n = 91 children; RR, 2.86; 95% CI, 1.19-6.83; NNT = 5). Owing to risk of bias and imprecision, there was low certainty in evidence that yoga had similar treatment success to no intervention (n = 99 children; RR, 1.09; 95% CI, 0.58-2.08). CONCLUSIONS AND RELEVANCE Results of this systematic review and meta-analysis suggest that CBT and hypnotherapy may be considered as a treatment for FAPDs in childhood. Future RCTs should address quality issues to enhance the overall certainty of the results, and studies should consider targeting these interventions toward patients who are more likely to respond.
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Affiliation(s)
- Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | | | - Merit Tabbers
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Robyn Rexwinkel
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Clara de Bruijn
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Terence Dovey
- Department of Life Sciences, Brunel University London, London, United Kingdom
| | - Marco Gasparetto
- Department of Pediatric Gastroenterology, The Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | | | - Marc Benninga
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Amsterdam University Medical Centers, Amsterdam, the Netherlands
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9
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Kalomiris AE, Ely SL, Love SC, Mara CA, Cunningham NR. Child-Focused Cognitive Behavioral Therapy for Pediatric Abdominal Pain Disorders Reduces Caregiver Anxiety in Randomized Clinical Trial. J Pain 2022; 23:810-821. [PMID: 34902549 PMCID: PMC9086118 DOI: 10.1016/j.jpain.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/16/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022]
Abstract
Pediatric functional abdominal pain disorders (FAPD) are associated with elevated anxiety in youth and their caregivers, both contributing to an adverse impact on functioning in youth with FAPD. While a CBT approach (ie, Aim to Decrease Anxiety and Pain Treatment [ADAPT]) is known to improve health outcomes for youth, it is unknown if child-focused treatment improves caregiver anxiety. This secondary analysis of a larger randomized clinical trial examined if child-focused CBT (ADAPT) for pain and anxiety also impacts caregiver anxiety and explored the relation between caregiver anxiety and child symptoms (ie, pain, disability, anxiety) after treatment. A total of 79 caregiver-child dyads were randomized to ADAPT plus treatment as usual (TAU) or TAU only. Caregiver anxiety and child outcomes (pain, disability, anxiety) were assessed at baseline and approximately 8 weeks later. Caregivers of children who completed ADAPT+TAU demonstrated lower anxiety compared to those who only received TAU. Moreover, regardless of treatment assignment, caregivers with greater anxiety had children who reported more pain and anxiety, but not functional disability at post-assessment. Results suggest a brief, child-focused intervention targeting pain and anxiety may also improve caregiver anxiety. As such, suggestions to improve future treatments are offered. PERSPECTIVE: Caregiver anxiety symptoms diminished after their child with functional abdominal pain completed a course of child-focused CBT targeting pain and anxiety. Further, caregiver anxiety was related to child-reported symptoms (pain and anxiety) after treatment. Therefore, improved caregiver mental health via a child-focused CBT may also improve pediatric outcomes.
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Affiliation(s)
- Anne E Kalomiris
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Samantha L Ely
- Department of Family Medicine, Michigan State University, Grand Rapids, Michigan
| | - Sarah C Love
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Constance A Mara
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
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10
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Miller AK, Ely SL, Barber Garcia BN, Richardson P, Cunningham NR. Engagement during a Mixed In-Person and Remotely Delivered Psychological Intervention for Youth with Functional Abdominal Pain Disorders and Anxiety. Children 2021; 8:775. [PMID: 34572207 PMCID: PMC8466519 DOI: 10.3390/children8090775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/19/2021] [Accepted: 08/31/2021] [Indexed: 12/02/2022]
Abstract
Functional abdominal pain disorders (FAPD) are common disabling pain conditions frequently associated with co-occurring mental health problems such as anxiety. Psychological therapies such as cognitive behavioral therapy (CBT) have been shown to be effective. Therefore, it is important to understand participant engagement (i.e., use of intervention tools) to such approaches, and if engagement impacts treatment response. The Aim to Decrease Anxiety and Pain Treatment (ADAPT) is an effective psychological treatment approach using a blend of in-person sessions and interventionist phone support with self-paced web modules to manage pain and anxiety. The current study used a mixed-methods approach to investigate micro-level and macro-level participant engagement during the ADAPT program. In-person/phone session attendance was high (>95%) although scheduling adjustments were common (25.5%). Varied levels of engagement with web tools were observed. Thematic analysis also revealed variability in patterns of use. Additionally, while participants indicated they generally understood how to use certain skills (e.g., problem solving, detective thinking), and these skills were effective in managing symptoms during treatment, these activities were generally underutilized. Further, participant engagement did not predict response to the ADAPT intervention. These findings are important as the demand for accessible psychotherapeutic tools to manage pain and anxiety is likely to remain high.
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11
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Richardson PA, Parker DM, Chavez K, Birnie KA, Krane EJ, Simons LE, Cunningham NR, Bhandari RP. Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19. Children (Basel) 2021; 8:children8090764. [PMID: 34572195 PMCID: PMC8469364 DOI: 10.3390/children8090764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022]
Abstract
Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.
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Affiliation(s)
- Patricia A. Richardson
- Departments of Pediatric Psychology and Pediatric Pain and Palliative Medicine, Helen DeVos Children’s Hospital, Grand Rapids, MI 49503, USA
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA
- Correspondence:
| | - Delana M. Parker
- Department of Psychiatry, Dell Medical School and Dell Children’s Medical Center, University of Texas at Austin, Austin, TX 78712, USA;
| | - Krystal Chavez
- Department of Digital Health, Stanford Children’s Health, Palo Alto, CA 94304, USA;
| | - Kathryn A. Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Elliot J. Krane
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine and Stanford Children’s Health, Stanford, CA 94305, USA; (E.J.K.); (L.E.S.); (R.P.B.)
| | - Laura E. Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine and Stanford Children’s Health, Stanford, CA 94305, USA; (E.J.K.); (L.E.S.); (R.P.B.)
| | - Natoshia R. Cunningham
- Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA;
| | - Rashmi P. Bhandari
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine and Stanford Children’s Health, Stanford, CA 94305, USA; (E.J.K.); (L.E.S.); (R.P.B.)
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12
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Dutta RA, Ely SL, Cunningham NR. The Utility of an Anxiety Screening Measure in Youth With Functional Abdominal Pain Disorders and Clinical Characteristics Associated With Presence of Anxiety. Clin J Pain 2021; 37:616-622. [PMID: 34108362 PMCID: PMC8479873 DOI: 10.1097/ajp.0000000000000952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Anxiety is common in youth with functional abdominal pain disorders (FAPD) and is related to increased pain-related impairment. However, it is unknown if self-reported anxiety on a clinical screener represents a true anxiety disorder diagnosis in youth with FAPD. Further, little is known about clinical characteristics in youth with FAPD and comorbid anxiety (ANX). Therefore, we evaluated whether the clinical cutoff on the Screen for Anxiety and Related Disorders (SCARED) corresponded with the presence of an anxiety disorder. We predicted a more clinically complex profile (eg, increased pain-related impairment, psychological problems, and family risk factors) in youth with FAPD+ANX compared with youth with FAPD alone. MATERIALS AND METHODS Participants completed measures of anxiety, functional disability, pain intensity, pain catastrophizing, and mood, and underwent a semistructured diagnostic interview to assess for psychological disorders. Caregivers completed family characteristics and caregiver distress measures. Analyses of group differences were conducted using χ2 and multivariate tests. RESULTS The SCARED appears to be a good proxy for an anxiety disorder in youth with FAPD, particularly for generalized anxiety disorder and social anxiety disorder. Youth with FAPD+ANX reported higher rates of pain-related disability and depressive symptoms compared with those with FAPD alone, but other clinical characteristics and family risk factors were comparable across groups. DISCUSSION Findings support the use of the SCARED as a proxy for an anxiety disorder diagnosis in youth with FAPD and suggest youth with FAPD+ANX may have a more complex clinical profile categorized by greater mental health and health-related impairment as compared with youth with FAPD alone.
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Affiliation(s)
- Richa Aggarwal Dutta
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19107
| | - Samantha L. Ely
- Department of Family Medicine, Michigan State University, 15 Michigan Street NE, Grand Rapids, Michigan 49503
| | - Natoshia R. Cunningham
- Department of Family Medicine, Michigan State University, 15 Michigan Street NE, Grand Rapids, Michigan 49503
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13
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Cunningham NR, Ely SL, Barber Garcia BN, Bowden J. Addressing Pediatric Mental Health Using Telehealth During Coronavirus Disease-2019 and Beyond: A Narrative Review. Acad Pediatr 2021; 21:1108-1117. [PMID: 34118499 PMCID: PMC8413840 DOI: 10.1016/j.acap.2021.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/11/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023]
Abstract
The pediatrician serves as a frontline provider addressing patients' medical and mental health needs, yet coronavirus disease-2019 (COVID-19) is reshaping the way physicians deliver care. Pediatricians are increasingly faced with the challenge of delivering care, including mental health care, remotely. Given the rapidly evolving literature, we performed a narrative review of the use of telehealth for mental health care for pediatric populations during the COVID-19 pandemic. Areas of focus included 1) pediatric primary care settings, 2) special pediatric populations (eg, eating disorders, autism), 3) access and engagement in telehealth care, and 4) training opportunities available for mental health providers. Themes that emerged across studies included the importance of meeting patients' needs (eg, access to technological resources) to optimize success in using telehealth tools and challenges around provider access to support tools for use during telehealth. Thus, we provided a summary of evidence-based tools (including COVID-19 specific resources) for improving the remote delivery of mental health care by pediatricians. We also reviewed future directions including trials currently underway to enhance understanding of future telehealth applications for pediatric mental health care.
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Affiliation(s)
- Natoshia R. Cunningham
- Department of Family Medicine, Michigan State University (NR Cunningham and SL Ely), Grand Rapids, Mich,Address correspondence to Natoshia R. Cunningham, PhD, Department of Family Medicine, Michigan State University, 15 Michigan St NE, Grand Rapids, MI 49503
| | - Samantha L. Ely
- Department of Family Medicine, Michigan State University (NR Cunningham and SL Ely), Grand Rapids, Mich
| | - Brittany N. Barber Garcia
- College of Human Medicine, Michigan State University (BNB Garcia and J Bowden), Grand Rapids, Mich,Spectrum Health, Helen DeVos Children's Hospital (BN Barber Garcia and J Bowden), Grand Rapids, Mich
| | - Jennifer Bowden
- College of Human Medicine, Michigan State University (BNB Garcia and J Bowden), Grand Rapids, Mich,Spectrum Health, Helen DeVos Children's Hospital (BN Barber Garcia and J Bowden), Grand Rapids, Mich
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