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Abstract While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g., access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education.

Background Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings. Methods The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility. Results Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important ( n  = 10, 76.9%), acceptable ( n  = 11; 84.6%), and feasible ( n  = 7, 53.8%). Interpretation Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study’s findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap.

Background Youths with juvenile idiopathic arthritis (JIA) often experience pain, which reduces their quality of life. A diversity of pain management options exists for these patients, but few discussions happen in clinical settings. Our team is developing a web-based patient decision aid (PDA) to help youths with JIA, parents, and their health care providers (HCPs) make informed and preference-based decisions about pain management options. Objective The objective of this study was to develop a paper-based prototype of the web-based PDA and to assess its acceptability. Methods We developed a paper-based prototype of the PDA, called the JIA Option Map, using an iterative process following the International Patient Decision Aid Standards and based on the Ottawa Decision Support Framework. We held three consensus meetings and a follow-up online survey followed by discussions among team members to agree on the format and content of the PDA. We then evaluated acceptability through interviews with 12 youth with JIA (aged 8–18 years), 12 parents, and 11 HCPs. Participants from rheumatology clinics in Canada and the USA reviewed the PDA and assessed its usefulness, content, and format. Interviews were audiotaped, transcribed verbatim, and analyzed using simple descriptive content analysis. Results The PDA contains an assessment of pain and current treatments, a values-clarification exercise, a list of 33 treatment options with evidence-based information, and a goal-setting exercise. All participants agreed that it would be a useful tool for making decisions about pain management. Participants appreciated the incorporation of scientific evidence and visuals to demonstrate the benefits of treatment options but suggested describing the source of the evidence more thoroughly. Participants suggested adding complementary medicine and nutrition to the available treatment options and removing options that are primarily used to reduce inflammation. Most participants preferred an interactive web-based version of the PDA that would show a few options consistent with their preferences, followed by a discussion with HCPs. Conclusion The PDA was deemed acceptable to all participants, with a few modifications. This feedback was used to improve the PDA by simplifying and clarifying the information and adjusting the number of treatment options presented. Work is underway to develop an interactive web-based version with an algorithm to present options tailored to each user. Plain Language Summary Youths with juvenile idiopathic arthritis (JIA) often feel pain and try many pain treatments such as medications and physical or psychological treatments. Choosing treatments can be hard for families, and health care providers do not always provide information on pain treatments. Our team is developing the JIA Option Map, a tool that presents information on pain treatments based on personal preferences. The tool takes patients through a five-step process where they describe their pain, express their preferences, and learn about more than 30 pain treatments. Patients can then choose treatments and make a plan to use them. This paper explains how a paper-based version of the tool was developed and whether it is suitable for youths, parents, and health care providers. The tool was developed by holding meetings with youths with JIA, health care providers, and researchers to agree on the content and format. We also interviewed youths with JIA, parents, and health care providers to test whether it was suitable. All participants felt that the tool was suitable and that it would be useful for making decisions about pain treatments. Participants liked the idea of using a web-based tool with coaching by health care providers. Work is underway to develop this improved version of the JIA Option Map.

Résumé Les dispensateurs de soins pédiatriques sont souvent le premier point de contact des enfants et des adolescents aux prises avec des problèmes de santé mentale, mais ils ne possèdent pas nécessairement les ressources (p. ex., l’accès à une équipe multidisciplinaire) ni la formation nécessaires pour procéder à leur dépistage ou à leur prise en charge. Le présent document de principes conjoint décrit les principaux rôles et les principales compétences à maîtriser pour évaluer et traiter les problèmes de santé mentale chez les enfants et les adolescents, de même que les facteurs qui optimisent le plus possible l’évolution de la santé mentale dans ces groupes d’âge. Il contient des conseils fondés sur des données probantes à propos du dépistage des préoccupations en matière de santé mentale chez les jeunes et leur famille ainsi qu’à propos des échanges sur le sujet. Les interventions préventives et thérapeutiques dont l’efficacité est démontrée en milieu communautaire sont abordées. Le présent document de principes, qui est fondamental, traite également des changements à l’enseignement de la médecine ainsi qu’aux systèmes et aux politiques de santé qui s’imposent pour améliorer la pratique clinique et les efforts de revendications au Canada, y compris les modèles de rémunération appropriés, les approches des soins abordées étape par étape, le financement gouvernemental ciblé, l’enseignement et la formation professionnelle.

Background Juvenile idiopathic arthritis (JIA) is a common pediatric rheumatic condition and is associated with symptoms such as joint pain that can negatively impact health-related quality of life. To effectively manage pain in JIA, young people, their families, and health care providers (HCPs) should be supported to discuss pain management options and make a shared decision. However, pain is often under-recognized, and pain management discussions are not optimal. No studies have explored decision-making needs for pain management in JIA using a shared decision making (SDM) model. We sought to explore families’ decision-making needs with respect to pain management among young people with JIA, parents/caregivers, and HCPs. Methods We conducted semi-structured virtual or face-to-face individual interviews with young people with JIA 8–18 years of age, parents/caregivers and HCPs using a qualitative descriptive study design. We recruited participants online across Canada and the United States, from a hospital and from a quality improvement network. We used interview guides based on the Ottawa Decision Support Framework to assess decision-making needs. We audiotaped, transcribed verbatim and analyzed interviews using thematic analysis. Results A total of 12 young people ( n  = 6 children and n  = 6 adolescents), 13 parents/caregivers and 11 HCPs participated in interviews. Pediatric HCPs were comprised of rheumatologists ( n  = 4), physical therapists ( n  = 3), rheumatology nurses ( n  = 2) and occupational therapists ( n  = 2). The following themes were identified: (1) need to assess pain in an accurate manner; (2) need to address pain in pediatric rheumatology consultations; (3) need for information on pain management options, especially nonpharmacological approaches; (4) importance of effectiveness, safety and ease of use of treatments; (5) need to discuss young people/families’ values and preferences for pain management options; and the (6) need for decision support. Themes were similar for young people, parents/caregivers and HCPs, although their respective importance varied. Conclusions Findings suggest a need for evidence-based information and communication about pain management options, which would be addressed by decision support interventions and HCP training in pain and SDM. Work is underway to develop such interventions and implement them into practice to improve pain management in JIA and in turn lead to better health outcomes.

Summary We investigated the safety and efficacy of 90 mg/m 2 bendamustine HCL, administered intravenously on days 1 and 2 every 28 days in 10 women with platinum and taxane resistant epithelial ovarian cancer. There were no objective tumor responses observed; 2 patients had stable disease. Plasma samples collected at pre-treatment and end of cycle one were analyzed for changes in circulating total cytokeratin 18 and caspase cleaved cytokeratin 18 as exploratory early biomarkers of bendamustine-induced tumor cell death. All patients had measureable levels of both total and cleaved caspase 3 cytokeratin 18, but no relationship with response was possible due to the lack of clinical benefit in treated patients. Due to the high incidence of adverse events and absence of objective responses, only ten patients were treated as predefined by the Simon Two-Stage Design in the protocol. Overall, the regimen was not well tolerated and was associated with fatigue and a greater number of gastrointestinal side effects as compared to previously reported experiences in different patient populations. However, our study subjects did experience less bone marrow suppression. The lack of tolerability could reflect the degree of tumor burden within the peritoneal cavity as well as the high number of prior regimens (median of 5) received by the patients participating in this study.

Abstract Introduction/Background Suicide remains the second leading cause of death in Canadian children and youth (Public Health Agency of Canada, 2019). Recent studies show that 50-80% individuals who die by suicide have had contact with a healthcare provider within one month prior to their death (Ahmedani et. al., 2014; Vasiliadis et. al., 2015). Unfortunately, these patients often present solely with physical complaints and infrequently discuss suicidal thoughts and plans unless asked directly. Those with medical conditions are also at a higher risk of experiencing mental health difficulties. Following a critical incident in our hospital, the corporate leadership committee addressed opportunities for improvement, and recommended the integration of routine suicide screening into standard care for all pediatric patients admitted to hospital. Objectives Prior to implementation of the transformative Head to Toe (term coined by a family caregiver during stakeholder interviews) initiative, suicide screening was routinely part of the admission assessment in the inpatient mental health units and for patients presenting to the emergency department with mental health concerns. In February 2019 we began a step-wise implementation of the Head to Toe suicide screening for all youth 12 and older admitted to the medical and surgical inpatient units at out institution using a psychometrically validated tool, the Ask Suicide Screening Questionnaire (ASQ) (Horowitz et. al, 2012). Design/Methods During the admission process, the nurse administers the ASQ and documents patients’ eligibility for screening and their responses on the ASQ items in the electronic health record. If a patient positively endorses an ASQ item(s) the nurse communicates this to the most responsible physician, who initiates a consult to mental health. Youth who endorse a positive screen receive a brief mental health risk assessment within 24 hours conducted by a mental health nurse. Patients who disclose active suicidal thoughts on the ASQ are assessed directly by psychiatry as soon as possible and actions are taken to ensure patient safety. A framework was developed for continuous evaluation of key components of the Head to Toe practice. Since the end of July 2019, when all medical/surgical units went live with the Head to Toe project, we have monitored compliance with the screening protocol on a daily, weekly, and monthly basis. Results We are the first pediatric hospital in Canada to implement systematic screening for suicide risk in medically or surgically hospitalized children and youth. Initial data indicate that during the first six months of the full implementation of the Head to Toe suicide screening, 72% (396) of eligible patients were screened with 14% (57) of these identified as having thoughts of suicide or a previous attempt and proceeding to further mental health assessment. Daily review of compliance rates on each unit allows us to identify omissions in patient screening and provide one-on-one support to staff to facilitate timely completion of the ASQ, while the weekly and monthly compliance reports are reviewed with unit staff and leadership to identify and address factors impeding compliance with Head to Toe care pathways and monitor change in adherence patterns. This ensures the sustainability of the Head to Toe initiative and provides opportunities for celebrating successes. We are also currently collecting qualitative feedback from youth and families about their experiences participating in the Head to Toe process. Conclusion This presentation will describe the steps to ensure successful implementation of suicide screening in our hospital setting, the challenges encountered and possible solutions. The hope is that this new practice will reduce emergency hospital visits for mental health crises and facilitate early access to mental health services. This initiative can be used to support other hospitals in implementing their own suicide prevention screening programs, along with informing policy about ways to help prevent suicide in youth populations.

PurposeIBD manifest themselves in children and adolescents in up to 1/3 of those who will eventually develop these conditions. The chronic nature of the disease and treatments is often a significant stressor for children and families. Failure to address psychosocial issues may lead to greater risk for poor treatment adherence and disease relapse, higher heath care utilization, and increased psychiatric co-morbidity. As such, improvement in health care providers' capacity to systematically identify factors contributing to case complexity in a simplified reproducible manner offers significant potential for improving outcomes for children/youth with IBD.The adult INTERMED (Steifel et al., 2006) is a clinical decision-support tool that provides indicators of biological, psychological, social and health care needs, as well as an overall index of case complexity. The tool is efficient to administer and successfully detects psychosocial needs, referral to effective services and improved health care practices and outcomes. However, no comparable validated tools exist for use with children. To address the unique developmental and social contexts of children, a pediatric adaptation of the Intermed tool (PIM) was developed The PIM adopts a life-chart methodology to identify of areas of high need and risk. The focus of the present study was to examine the psychometric properties of the new PIM tool in children/youth diagnosed with IBD.Description of ProjectChildren and parents participated in a semi-structured interview with a clinical nurse who then rated the 34-PIM items. To examine the construct validity of each PIM domain (biological, psychological, social, caregiver/family, health system) participants completed questionnaires assessing social and psychological functioning, parent/family stress, and quality of life. Information about disease status, and health care utilization was obtained from medical chart review.ResultsInitial results from 48 patients indicate very good item inter-rater reliability for the PIM (mean reliability = 0.82). The Cronbach alphas for the overall complexity scale and for each of the domain scores were very acceptable (ranging from .56-.90). Correlational analyses suggest a high degree of validity for each of the PIM domains. PIM Biological score related significantly to PCDAI scores (r = 0.72) and child functional disability (r = 0.53). The PIM Psychological score was highly correlated with childhood depression (r = 0.55) and externalizing problems (r = 0.46). Higher PIM social needs were significantly related to decreased social and academic competence (r = −0.58 and 0.66, respectively) and less community participation (r = 0.39). PIM Family was significantly related to family life stress and decreased resources (r = 0.44) and greater parenting stress (r = 0.30). Finally, the overall PIM Complexity Score was associated with greater health care utilization (more calls to IBD nurse (r = 0.30) /extra GI outpatient visits (r = 0.32)), as well as IBD specific Quality of Life (r = −0.41).ConclusionsThe PIM is an easily administered, psychometrically reliable and valid tool for identifying the psychosocial and health care needs of children with IBD, to facilitate individualized care planning. We speculate that early identification and intervention of health stressors will provide opportunities for improved care.

PurposeIBD manifest themselves in children and adolescents in up to 1/3 of those who will eventually develop these conditions. The chronic nature of the disease and treatments is often a significant stressor for children and families. Failure to address psychosocial issues may lead to greater risk for poor treatment adherence and disease relapse, higher heath care utilization, and increased psychiatric co-morbidity. As such, improvement in health care providers' capacity to systematically identify factors contributing to case complexity in a simplified reproducible manner offers significant potential for improving outcomes for children/youth with IBD.The adult INTERMED (Steifel et al., 2006) is a clinical decision-support tool that provides indicators of biological, psychological, social and health care needs, as well as an overall index of case complexity. The tool is efficient to administer and successfully detects psychosocial needs, referral to effective services and improved health care practices and outcomes. However, no comparable validated tools exist for use with children. To address the unique developmental and social contexts of children, a pediatric adaptation of the Intermed tool (PIM) was developed The PIM adopts a life-chart methodology to identify of areas of high need and risk. The focus of the present study was to examine the psychometric properties of the new PIM tool in children/youth diagnosed with IBD.Description of ProjectChildren and parents participated in a semi-structured interview with a clinical nurse who then rated the 34-PIM items. To examine the construct validity of each PIM domain (biological, psychological, social, caregiver/family, health system) participants completed questionnaires assessing social and psychological functioning, parent/family stress, and quality of life. Information about disease status, and health care utilization was obtained from medical chart review.ResultsInitial results from 48 patients indicate very good item inter-rater reliability for the PIM (mean reliability = 0.82). The Cronbach alphas for the overall complexity scale and for each of the domain scores were very acceptable (ranging from .56-.90). Correlational analyses suggest a high degree of validity for each of the PIM domains. PIM Biological score related significantly to PCDAI scores (r = 0.72) and child functional disability (r = 0.53). The PIM Psychological score was highly correlated with childhood depression (r = 0.55) and externalizing problems (r = 0.46). Higher PIM social needs were significantly related to decreased social and academic competence (r = −0.58 and 0.66, respectively) and less community participation (r = 0.39). PIM Family was significantly related to family life stress and decreased resources (r = 0.44) and greater parenting stress (r = 0.30). Finally, the overall PIM Complexity Score was associated with greater health care utilization (more calls to IBD nurse (r = 0.30) /extra GI outpatient visits (r = 0.32)), as well as IBD specific Quality of Life (r = −0.41).ConclusionsThe PIM is an easily administered, psychometrically reliable and valid tool for identifying the psychosocial and health care needs of children with IBD, to facilitate individualized care planning. We speculate that early identification and intervention of health stressors will provide opportunities for improved care.