A Cluster Randomized Controlled Trial of a Primary Care Provider-Delivered Social Media Counseling Intervention

PURPOSE

Evidence and clinical policy support that providers screen and counsel for media use for youth, but most pediatricians lack this training. The purpose of this study was to test a primary care provider (PCP)-delivered intervention to promote safe social media use among youth.

METHODS

We enrolled pediatric PCP practices for this clinical trial to test a social media counseling intervention (SMCI) between 2011 and 2013. Youth were recruited during clinic visits; follow-up interviews were conducted at 6 months. Outcomes included media behaviors and caregiver communication. Multivariate regression models examined associations between social media counseling and PCP counseling score. Multivariate logistic regression evaluated four social media behavior outcomes.

RESULTS

A total of 120 practices enrolled; PCPs in the SMCI were more likely to provide social media counseling (B = 1.43, 95% confidence interval [CI]: 1.1-1.7). Youth whose PCP received the SMCI were twice as likely to report a decrease in online "friending" of strangers (adjusted odds ratio = 2.23, 95% CI 1.17-4.25) and were more likely to report communication with their caregivers about their social media use (adjusted odds ratio = 1.2; 95% CI: 1.1-1.4) compared to youth whose PCPs were in the active control group.

DISCUSSION

Youth whose PCP had received social media counseling training reported a higher receipt of counseling about social media and improved safety behaviors.

Cross-sectional online survey of clinicians' knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use

OBJECTIVE

To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.

DESIGN

A 2016 cross-sectional survey.

SETTING

Academic departments and community-based internal medicine, family medicine and paediatrics practices.

PARTICIPANTS

Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.

RESULTS

Participants were asked what percentage of their 10-17 years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17 years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.

CONCLUSIONS

This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.

Parents' Sources of Adolescent Sexual Health Information and Their Interest in Resources From Primary Care

OBJECTIVE

To examine sources of information used by parents to facilitate parent-adolescent communication about sexual and reproductive health (SRH), parents' preferences for receiving SRH information through primary care, and factors associated with parents' interest in primary-care-based SRH information (ie, resources recommended or offered in the primary care setting).

METHODS

In this cross-sectional study, a nationally representative sample of 11-17-year-old adolescents and their parents (n = 1005 dyads) were surveyed online; 993 were retained for these analyses. Parents were asked about their use of 11 resources to help them talk with their adolescents about SRH and rated the likelihood of using specific primary-care-based resources. We used multivariable logistic regression to examine characteristics associated with parent interest in primary-care-based SRH resources.

RESULTS

Only 25.8% of parents reported receiving at least a moderate amount of SRH information from primary care; half (53.3%) reported receiving no SRH information from their adolescent's provider. Parents received the most information from personal connections (eg, spouse/partner, friends). Most parents (59.1%) reported being likely to utilize a primary-care-based resource for SRH information. Parents who previously received SRH information from primary care sources had greater odds of reporting they would be likely to utilize a primary-care-based resources (AOR = 4.06, 95% CI: 2.55-6.46).

CONCLUSIONS

This study provides insights into parents' sources of information for communicating with their adolescents about SRH and ways primary care practices might increase support for parents in having SRH conversations with their adolescents. Future studies are needed to establish clinical best practices for promoting parent-adolescent communication about SRH.

Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs

PURPOSE

Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians.

METHODS

We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers.

RESULTS

SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs.

CONCLUSIONS

Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

Correlates of Sexual and Reproductive Health Discussions During Preventive Visits: Findings From a National Sample of U.S. Adolescents

PURPOSE

This study examines characteristics of healthcare delivery, providers, and adolescents associated with provider-adolescent discussions about sexual and reproductive health (SRH) during preventive visits.

METHODS

Data were from a 2019 national internet survey of U.S. adolescents ages 11-17 years and their parents. Adolescents who had a preventive visit in the past 2 years (n = 853) were asked whether their provider discussed each of eight SRH topics at that visit: puberty, safe dating, gender identity, sexual orientation, whether or not to have sex, sexually transmitted infections including human immunodeficiency virus, birth control methods, and where to get SRH services. Eight multivariable logistic regression models were examined (one for each SRH topic as the outcome), with each model including modifiable healthcare delivery and provider characteristics, adolescent beliefs, behaviors, and demographic characteristics as potential correlates.

RESULTS

Provider-adolescent discussions about SRH topics at the last preventive visit were positively associated with face-to-face screening about sexual activity for all eight topics (range of adjusted odds ratios [AORs] = 3.40-9.61), having time alone with the adolescent during that visit (seven topics; AORs = 1.87-3.87), and ever having communicated about confidentiality with adolescents (two topics; AORs = 1.88-2.19) and with parents (one topic; AOR = 2.73). Adolescents' perception that a topic was important to discuss with their provider was associated with provider-adolescent discussions about seven topics (AORs = 2.34-5.46).

CONCLUSIONS

Findings that provider-adolescent discussions about SRH during preventive visits were associated with modifiable practices including time alone between providers and adolescents and screening about sexual activity can inform efforts to improve the delivery of adolescent SRH services within primary care.

Sexual and Reproductive Health Discussions During Preventive Visits

OBJECTIVES

To quantify adolescent- and parent-perceived importance of provider-adolescent discussions about sexual and reproductive health (SRH), describe prevalence of provider confidentiality practices and provider-adolescent discussions about SRH topics during preventive visits, and identify missed opportunities for such conversations.

METHODS

We used data from a national Internet survey of 11- to 17-year-old adolescents and their parents. Data were weighted to represent the noninstitutionalized US adolescent population. Adolescents who had a preventive visit in the past 2 years and their parents reported on perceived importance of provider-adolescent discussions about SRH topics: puberty, safe dating, gender identity, sexual orientation, sexual decision-making, sexually transmitted infections and HIV, methods of birth control, and where to get SRH services. Adolescents and parents reported whether they had ever discussed confidentiality with the adolescent's provider. Adolescents reported experiences at their most recent preventive visit, including whether a provider spoke about specific SRH topics and whether they had time alone with a provider.

RESULTS

A majority of adolescents and parents deemed provider-adolescent discussions about puberty, sexually transmitted infections and HIV, and birth control as important. However, fewer than one-third of adolescents reported discussions about SRH topics other than puberty at their most recent preventive visit. These discussions were particularly uncommon among younger adolescents. Within age groups, discussions about several topics varied by sex.

CONCLUSIONS

Although most parents and adolescents value provider-adolescent discussions of selected SRH topics, these discussions do not occur routinely during preventive visits. Preventive visits represent a missed opportunity for adolescents to receive screening, education, and guidance related to SRH.

Pediatric Resident Training in Tobacco Control and the Electronic Health Record

Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study

OBJECTIVES

We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice.

METHODS

We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months.

RESULTS

Clinicians trained in the 5As intervention delivered more screening (β = 1.0605, P < .0001) and counseling (β = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking.

CONCLUSIONS

Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.

Understanding Primary Care Providers' Perceptions and Practices in Implementing Confidential Adolescent Sexual and Reproductive Health Services

PURPOSE

Substantial gaps exist between professional guidelines and practice around confidential adolescent services, including private time between health-care providers and adolescents. Efforts to provide quality sexual and reproductive health services (SRHS) require an understanding of barriers and facilitators to care from the perspectives of primary care providers working with adolescents and their parents.

METHODS

We conducted structured qualitative interviews with a purposive sample of pediatricians, family physicians, and nurse practitioners (n = 25) from urban and rural Minnesota communities with higher and lower rates of adolescent pregnancy. Provider interviews included confidentiality beliefs and practices; SRHS screening and counseling; and referral practices.

RESULTS

The analysis identified two key themes: (1) individual and structural factors were related to variations in SRH screening and counseling and (2) a wide range of factors influenced provider decision-making in initiating private time. A nuanced set of factors informed SRHS provided, including provider comfort with specific topics; provider engagement and relationship with parents; use of adolescent screening tools; practices, policies, and resources within the clinic setting; and community norms including openness with communication about sex and religious considerations regarding adolescent sexuality. Factors that shaped providers' decisions in initiating private time included adolescent age, developmental stage, health behaviors and other characteristics; observed adolescent-parent interactions; parent support for private time; reason for clinic visit; laws and professional guidelines; and cultural considerations.

CONCLUSIONS

Findings suggest opportunities for interventions related to provider and clinic staff training, routine communication with adolescents and their parents, and clinic policies and protocols that can improve the quality of adolescent SRHS.

The Unmet Need for Discussions Between Health Care Providers and Adolescents and Young Adults

PURPOSE

The aims of the study were to identify factors related to (1) adolescents and young adults (AYA) desire to discuss health topics; (2) whether discussions occurred at their last medical visit; and (3) the gap (unmet need) between desire and actual discussion.

METHODS

We used data from a nationally representative, cross-sectional online survey of AYA aged 13-26 years (n = 1,509) who had had a visit in the past 2 years. Bivariate analyses examined 11 topics. Multivariable regression identified health care factors and demographic factors related to unmet need across four salient topics (HIV/sexually transmitted infections, alcohol and drug use, tobacco, and contraception).

RESULTS

Across 11 topics, unmet need averaged 28% and ranged as high as 60%; unmet need generally increased with AYA age. In multivariable analyses, ever having discussed confidentiality with a health care provider was associated with greater desire to discuss three of four salient topics, increased discussions (four of four topics), and reduced unmet need (two topics). Patient use of a clinical checklist/questionnaire at the last medical visit was associated with an increase in discussions (four topics) and reduced unmet need (four topics). Longer office visits were associated with an increase in discussions (three topics) and reduced unmet need (two topics). Older and minority youth had greater desire for discussions and unmet need.

CONCLUSIONS

A considerable gap exists between young people's desire to discuss health topics with their health care providers and actual practice.

The Effects of Nicotine on Development

Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

Motivational Interviewing: A High-Yield Interactive Session for Medical Trainees and Professionals to Help Tobacco Users Quit

Introduction

Motivational interviewing (MI) is a collaborative patient-focused counseling technique that is effective in promoting smoking cessation but is not consistently taught/practiced in training.

Methods

This training session was implemented in a pediatric residency training program and also given four times to pediatric practitioners as part of a 2-day tobacco training sponsored by the American Academy of Pediatrics (AAP). Pediatric residents (N = 33) participated in a 1-hour interactive session focused on addressing tobacco. Knowledge was assessed with pre- and 6-month postsurveys. Retention of skills was evaluated between 6 and 9 months posttraining by resident performance on two scenarios with standardized patients, which was scored utilizing the Behavior Change Counseling Index (BECCI), by two MI-trained physicians. AAP trainees (N = 115) participated in tobacco trainings with a session dedicated to MI; sessions were evaluated by pre- and posttests.

Results

Residents who completed the session (n = 12) performed significantly better on eight of 10 items of the BECCI and on the overall BECCI score (p < .001) compared with those who had not completed the session (n = 12). Feedback on AAP training sessions (N = 115) indicated that practitioners felt able to perform MI and incorporate MI into practice. The percentage of trainees who felt comfortable counseling about tobacco doubled from pre- to posttraining.

Discussion

A hands-on MI training session provided pediatric residents and practicing clinicians with knowledge and skills to address tobacco use with patients/families. The session is easily incorporated into different training environments.

Discussion of Potentially Sensitive Topics With Young People

OBJECTIVES

To identify modifiable factors that facilitate discussion of potentially sensitive topics between health care providers and young people at preventive service visits after Patient Protection and Affordable Care Act implementation.

METHODS

We used data from a national internet survey of adolescents and young adults (13-26 years old) in the United States. Questionnaire construction was guided by formative research and Fisher's Information-Motivation-Behavioral Skills model. Those who had seen a regular health care provider in the past 2 years were asked about 11 specific topics recommended by national medical guidelines. Four multivariable regression models were used to identify independent predictors of discussions of (1) tobacco use, (2) drug and/or alcohol use, (3) sexually transmitted infections or HIV, and (4) the number of topics discussed.

RESULTS

Fewer than half of young people reported having discussed 10 of 11 topics at their last visit. Predictors were similar across all 4 models. Factors independently associated with health discussions included the following: ever talked with a provider about confidentiality (4/4 models; adjusted odds ratio [aOR] = 1.85-2.00), ever had private time with a provider (1 model; aOR = 1.50), use of health checklist and/or screening questionnaire at last visit (4 models; aOR = 1.78-1.96), and time spent with provider during last visit (4 models). Number of years that young men had seen their regular provider was significant in 1 model. Other independent factors were positive youth attitudes about discussing specific topics (3/3 models) and youth involvement in specific health risk behaviors (3/3 models).

CONCLUSIONS

Discussions about potentially sensitive topics between health care providers and young people are associated with modifiable factors of health care delivery, particularly provider explanations of confidentiality, use of screening and/or trigger questionnaires, and amount of time spent with their provider.

Parent and Adolescent Attitudes Towards Preventive Care and Confidentiality

PURPOSE

Little is known about whether parents and adolescents agree in their attitudes towards preventive care, private time, and confidentiality for adolescent care.

METHODS

We surveyed a nationally representative sample of 1,209 13-18 year-old U.S. adolescents and their parents. Parent and adolescents attitudes towards preventive services, private time, and confidentiality were compared. Parent-youth dyad agreement was measured using Cohen's kappa and Spearman coefficients and modeled for association with demographic variables.

RESULTS

Parents are more likely than adolescents to think preventive services are important (71% vs. 48%; p < .001). Parent-youth attitudes were weakly to moderately correlated (Cohen's kappa coefficient = .22; p < .001). Parents and adolescents report similar ages for when teens should start having private time (median 16 years for both) and many think this age should be at 18, the legal age of adulthood). Fewer than half believe confidentiality should be provided for 10 services, ranging from routine care to abortion care (parents range: 12.8%-52.3%; adolescents: 24.0%-58.8%). While most adolescents agreed with their parents, teens were more likely to report wanting confidential access than parents. Older age, Hispanic ethnicity, having divorced parents and higher family income were associated with both adolescent/parent and adolescent endorsement of confidentiality.

CONCLUSIONS

Adolescents and parents generally agree about the importance of preventive services, private time, confidentiality, and what should and should not be confidential. On average, parents value clinical preventive services more than youth, and youth value confidentiality more than parents. Both believe private time should start at ages older than those recommended in clinical guidelines.

Clinician Telephone Training to Reduce Family Tobacco Use: Analysis of Transcribed Recordings

BACKGROUND

Family tobacco use and exposure are significant threats to the health of children and their families. However, few pediatric clinicians address family tobacco use and exposure in a routine and effective manner. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention was developed to tackle this gap between clinical need and clinical practice.

OBJECTIVE

To review the main considerations and questions that clinicians and office staff expressed during telephone training to participate in CEASE.

METHODS

This study was conducted in pediatric practices in 5 US states. Practices were recruited by the American Academy of Pediatrics (10 intervention, 10 control). Ten training calls were recorded and transcribed. The data was then coded inductively based on themes found in the transcripts.

RESULTS

The data revealed that clinicians and staff were concerned about prescribing, dosing, and insurance coverage of nicotine replacement therapy; motivation for and methods to help families become tobacco-free; and the impact of the intervention on practice operations.

CONCLUSION

While the majority of clinicians and office staff were interested and enthusiastic about helping families become tobacco-free, they expressed concerns that could threaten implementation of family tobacco control strategies.

Obstacles to community participation among youth with spinal cord injury

OBJECTIVE

Examine caregiver-report of obstacles to community participation for youth with spinal cord injury (SCI), and explore relationships between obstacles and child, caregiver, and community characteristics.

DESIGN

Two hundred and one primary caregivers of youth with SCI ages 7-17 years were interviewed at three pediatric SCI centers within a single-hospital system. Caregivers answered an open-ended question assessing obstacles to youth participation. A mixed-methods approach was incorporated, where qualitative methods analyzed caregiver-reported obstacles, and exploratory multivariate analyses examined relationships between obstacles and demographic variables.

RESULTS

Caregivers were primarily mothers (74%), married (69%), employed (54%), had college experience (67%), and lived in small towns (55%). Youths' mean age was 12.60 years at interview and 7.19 years at injury, 70% had paraplegia, and 55% had complete injuries. Analyses revealed that youth participation was limited by obstacles across six domains: community, disability-related, practical concerns, child-internal, social, and other. Child, caregiver, and community characteristics were related to overall report of obstacles, and report of community obstacles, disability-related obstacles, and practical concerns. Caregiver college experience and small town living predicted overall report of obstacles. Having a child injured at a younger age, caregiver college experience, and small town living predicted community obstacles. Having a child with an incomplete injury and recent medical complication predicted disability-related obstacles. Caregiver employment predicted practical concerns.

CONCLUSION

Youth from small towns, those injured younger, those with incomplete injuries, and those experiencing recent medical complications may need additional supports and resources to maximize participation. Clinicians should work with caregivers to identify and problem-solve obstacles to youth participation.

Assessing patterns of participation and enjoyment in children with spinal cord injury

AIM

To determine patterns of participation and levels of enjoyment in young people with spinal cord injuries (SCI) and to assess how informal and formal participation varies across child, injury-related, household, and community variables.

METHOD

One hundred and ninety-four participants (106 males, 88 females; mean age 13y 2mo, SD 3y 8mo, range 6-18y) with SCI and their primary caregivers completed a demographics questionnaire and a standardized measure of participation (the Children's Assessment of Participation and Enjoyment, [CAPE]) at three pediatric SCI centers in a single hospital system in the United States. Their mean age at injury was 7 years 2 months (SD 5y 8mo, range 0-17y); 71% had paraplegia, and 58% had complete injuries.

RESULTS

Young people participated more often in informal activities (t((174))=29.84, p<0.001) and reported higher enjoyment with these (t((174))=2.01, p=0.046). However, when engaging in formal activities, they participated with a more diverse group (t((174))=-16.26, p<0.001) and further from home (t((174))=-16.08, p<0.001). Aspects of informal participation were related to the child's age, sex, and injury level, and formal participation to the child's age and caregiver education. Caregiver education was more critical to formal participation among young people with tetraplegia than among those with paraplegia (F((4,151))=2.67, p=0.034).

INTERPRETATION

Points of intervention include providing more participation opportunities for young people with tetraplegia and giving caregivers the resources necessary to enhance their children's formal participation.