OBJECTIVES:To evaluate caregivers' confidence in accurately reporting rehabilitation service use for paediatric traumatic brain injury (TBI) and to determine their preferences for measure scope, granularity and administration. DESIGN:This qualitative descriptive study conducted remote, semistructured individual interviews with caregivers to examine their confidence in and preferences for reporting rehabilitation service use to inform measure development. The interview guide was refined through pilot interviews (n=2) excluded from analysis. Subsequent interviews were transcribed verbatim and analysed using thematic analysis with hybrid deductive-inductive coding. SETTING:Health Insurance Portability and Accountability Act (HIPAA)-compliant videoconference platform. PARTICIPANTS:Participants were recruited using maximum variation sampling to promote diversity across factors associated with rehabilitation service use. 14 caregivers met the following inclusion criteria and consented to participate: primary caregiver of a child aged 0-18 years who sustained a TBI requiring hospitalisation within the past 3 years; caregiver communicates in English. Sampling continued until data saturation was reached. RESULTS:Three themes pertaining to the study objectives were identified: (1) Caregivers are confident in their ability to accurately report their child's rehabilitation service use and satisfaction by setting with approximate dosage; (2) Caregivers' confidence in their ability to accurately report service use varies by setting and (3) Caregivers endorsed completing a comprehensive measure of rehabilitation service use with embedded definitions and structured prompts and preferred electronic administration for remote completion. CONCLUSIONS:Findings support the acceptability and potential feasibility of a caregiver-report measure of rehabilitation service use across the care continuum following their child's TBI. Next steps will include prototyping the Rehabilitation Use Measure and iteratively refining it through expert feedback and cognitive interviews with caregivers.

Objectives:Current approaches to objective measurement of sleep disturbances in children overlook the period prior to sleep, or the settling down time. Using machine learning techniques, we identified key features that characterize differences in activity during the settling down period that differentiate children with sensory sensitivities to tactile input (SS) and children without sensitivities (NSS). Methods:Actigraphy data were collected from children with SS (n = 17) and children with NSS (n = 18) over 2 weeks (a total of 430 evenings). The settling down period, indicated using caregiver report and actigraphy indices, was isolated each evening and seven features (mean magnitude, maximum magnitude, kurtosis, skewness, Shannon entropy, standard deviation, and interquartile range) were extracted. 10-fold cross-validation with random forests were used to determine accuracy, sensitivity, and specificity of differentiating groups. Results:We could accurately differentiate groups (accuracy = 83%, specificity = 83%, sensitivity = 84%). Feature importance maps identify that children with SS have higher maximum bouts of activity (U = -2.23, p = 0.026) during the settling down time and a higher variance in activity for the children with SS (e.g., interquartile range, Shannon entropy) that sets them apart from their peers. Conclusion:We present a novel use of machine learning techniques that successfully uncovered differentiating features within the settling down period for our groups. These differences have been difficult to capture using standard sleep and rest-activity metrics. Our data suggests that activity during the settling down period may be a unique target for future research for children with SS.

BACKGROUND:The objective of this retrospective observational study was to examine disparities in health care utilisation for children with Down syndrome (DS). METHODS:Outpatient Medicaid claims from 2016 to 2018 were used to examine the utilisation of therapy services and annual Medicaid payments for children with DS based on sex, race and age. Multilevel logistic regression was used to analyse the relationship of therapy utilisation with sex, race and age. Gamma-distributed log link model was used to analyse the relationship between annual Medicaid payments and race. RESULTS:The cohort consisted of 17 813 children with DS aged 21 and under. There was no significant difference in utilisation of therapy services between sexes. The likelihood of receiving therapy services decreased for Black or other race individuals compared to White. White individuals had higher annual Medicaid payments than Black or other race individuals. The likelihood of receiving therapy services increased for children 3-17 years old when compared to children aged 0-2 years old. DISCUSSION:There are significant disparities in therapy utilisation for children with DS related to race and age. Increased annual Medicaid payments for White individuals may indicate that they are receiving more outpatient services than the Black/other populations. Decreased therapy utilisation for ages 18-21 years corresponds with the transition to adulthood. The decreased likelihood of receiving therapy services for ages 0-2 is concerning due to the importance of early intervention. Further research is needed to evaluate factors contributing to disparities in outpatient utilisation for children with DS.

Research ObjectivesTo determine optimal scope, granularity, and administration of a caregiver-reported measure of their child's rehabilitation service use following pediatric traumatic brain injury (TBI).DesignQualitative descriptive study.SettingCommunity.ParticipantsUsing maximum variability sampling strategy we recruited a diverse sample of participants through trauma registries and brain injury follow-up clinics across the United States. Participants were caregivers of children aged 0-18 years who sustained a complicated mild to severe TBI within < 4 years. Caregivers < 18 years or non-English speaking were excluded.InterventionsNot applicable.Main Outcome MeasuresThemes pertaining to dimensions of rehabilitation service use caregivers were confident they could accurately report, factors impacting confidence, and preference for measure administration were identified via thematic analysis of semi-structure, individual interviews.ResultsSaturation was achieved according to a prior criteria after completing 14 interviews. Participants primarily lived in metropolitan areas (79%), but varied in time since injury, TBI severity, child age, and caregiver gender and education. Thematic analysis yielded the following findings: 1. Caregivers can confidently report settings where rehabilitation services occurred (i.e., yes/no any services) with approximate dosage (frequency, duration, and amount), as well as if/how families were engaged and their satisfaction with services; 2. Caregivers were most confident reporting on outpatient/community settings and least confident reporting on the school setting; and 3. Differentiating service types (e.g., occupational versus physical therapy) is the service use dimension caregivers were least confident reporting. Caregivers largely recommended electronic, asynchronous measure administration, however, several noted their understanding of rehabilitation and confidence reporting improved throughout the interview process.ConclusionsCaregivers are willing and confident in their ability to complete a rehabilitation service use measure, depending on the specificity of the measure. Though differentiating types of services is difficult, caregivers were able to provide otherwise detailed reports of service use across the continuum of care up to 3 years post-injury. Next steps will include prototyping and psychometric evaluation to determine reliability and validity of a caregiver-reported measure of rehabilitation service use.Author(s) DisclosuresR03HD101746 (Treble-Barna and Terhorst), K01HD097030 (Treble-Barna), K23HD106011 (Jarvis)

Objective To review patient-report/caregiver-report measures of rehabilitation service use following acquired brain injury (ABI).Data sources Medline, APA PsycINFO, Embase and CINAHL were searched on November 2021 and November 2022. Authors were contacted if measures were not included in manuscripts/appendices.Study selection Included articles were empirical research or a research protocol, available in English and described measures of patient report/caregiver report of rehabilitation service use post-ABI via quantitative or qualitative methods. Two reviewers independently screened 5290 records using DistillerSR. Discrepancies were resolved by team adjudication.Data extraction Data extraction was piloted with high levels of agreement (k=.94). Data were extracted by a single member with team meetings to seek guidance as needed. Data included administration characteristics (reporter, mode of administration, recall period), psychometric evidence and dimensions assessed (types of services, setting, frequency, duration, intensity, qualitative aspects).Data synthesis One hundred and fifty-two measures were identified from 85 quantitative, 56 qualitative and 3 psychometric studies. Psychometric properties were reported for four measures, all of which focused on satisfaction. Most measures inquired about the type of rehabilitation services used, with more than half assessing functional (eg, physical therapy) and behavioural health rehabilitation services, but fewer than half assessing community and academic reintegration (eg, special education, vocational rehabilitation) or cognitive (eg, neuropsychology) services. Fewer than half assessed qualitative aspects (eg, satisfaction). Recall periods ranged from 1 month to ‘since the ABI event’ or focused on current use. Of measures that could be accessed (n=71), many included a limited checklist of types of services used. Very few measures assessed setting, frequency, intensity or duration.Conclusions Despite widespread interest, the vast majority of measures have not been validated and are limited in scope. Use of gold-standard psychometric methods to develop and validate a comprehensive patient-report/caregiver-report measure of rehabilitation service use would have wide-ranging implications for improving rehabilitation research in ABI.

IMPORTANCE:Insufficient sleep is common among children seeking occupational therapy services but is rarely a focus of therapy despite sleep's critical impact on health. OBJECTIVE:To examine pediatric occupational therapists' experiences, views, and confidence in addressing sleep concerns in their practice as well as barriers to and supports for doing so. DESIGN:A qualitative descriptive study with thematic analysis of data from 1-hr virtual interviews. Rapport building, multiple-coder analysis, and member checking were used to ensure reliability and validity. SETTING:Interviews were conducted remotely at each participant's preferred time and location. PARTICIPANTS:Pediatric occupational therapists (N = 20) practicing across multiple settings in the United States were recruited through emails directed to their place of work and social media posts. A goal of 20 participants was set a priori with the goal of thematic saturation. OUTCOMES AND MEASURES:A semistructured interview guide. RESULTS:Participants were predominately cisgender (95%), female (85%), and White, non-Hispanic (90%). Overall, they voiced the importance of sleep but reported almost never writing sleep-related goals. Reported barriers that affected the participants' ability to fully address sleep in practice included therapists' lack of confidence and knowledge and low caregiver buy-in. CONCLUSIONS AND RELEVANCE:The findings identify themes on the basis of which actionable steps toward promoting occupational therapists as sleep champions can be developed. Future implications include increasing sleep education opportunities, enhancing awareness of sleep health's impact on goal areas, and facilitating discussions about occupational therapy's role within the medical system and family system in supporting sleep. Plain-Language Summary: This qualitative study identifies what helps and hinders occupational therapists in addressing the sleep health concerns of their clients. We give occupational therapy clinicians and educators key supports to seek out or barriers to address.

Abstract Introduction Children with sensory hypersensitivities have poorer subjective sleep health than their peers. However, traditional actigraphy variables (e.g., sleep efficiency, sleep duration) do not adequately capture these sleep deficits. In qualitative interviews, caregivers of children with sensory hypersensitivities identified the settling down period prior to sleep as a major family stressor, potentially indicating a novel target for intervention. We applied machine learning techniques to thoroughly characterize and discriminate differences in the settling down period for children with and without sensory hypersensitivities. Methods Children (ages 6-10) with sensory hypersensitivities (n=20) and children without sensory hypersensitivities (n=29) wore the GT9X Actigraph continuously for 2 weeks and caregivers completed daily sleep diaries. Settling down period (caregiver reported start of settling down until actigraphy indicated sleep onset) was isolated for each night and 7 features were extracted from the activity data (mean magnitude, maximum magnitude, kurtosis, skewness, Shannon entropy, standard deviation, interquantile range). Ten-fold cross-validation with random forests were used to determine the accuracy, sensitivity, and specificity of differentiating groups. Results We achieved an 83% accuracy in classifying children with sensory hypersensitivities versus those without hypersensitivities (sensitivity = 84%; specificity = 82%). Feature importance maps showed that the most important feature for differentiating groups was maximum activity count magnitude during the settling down period; children with sensory hypersensitivity had higher maximum bouts of activity during settling down. The hypersensitive group also showed a higher variance in activity during settling down, as demonstrated by greater interquartile range (variance within the time window), standard deviation of activity, and Shannon entropy (the amount of uncertainty in the time window). Conclusion Our novel machine learning analysis successfully uncovered objective features within the settling down period that differentiate children with sensory hypersensitivity from their peers. Our data highlights exciting new potential targets for intervention: children with sensory hypersensitivities have larger and sporadic bouts of activity during their settling down period that clearly set them apart from their peers without hypersensitivities. Support (if any) T32 HL082610, University of Pittsburgh School of Rehabilitation Science Doctoral Award (PI Hartman), Sensory Integration Education PhD Student Grant (PI Hartman).

Study objectives: This cross-sectional, observational study aimed to characterize and compare movement-based rest-activity rhythms (RARs) and sleep period variables of children with tactile hypersensitivities (SS) and non-sensitive peers (NSS) to expand the understanding of experienced differences in sleep. Methods: Children (ages 6-10) wore Actigraph GT9X watches for 2 weeks and caregivers completed daily sleep diaries. RARs and sleep period variables (e.g., sleep efficiency, duration, wake after sleep onset) were analyzed and localized means were plotted to visualize average rhythms for each group. Groups were compared using Student's t tests, or non-parametric alternatives, and Hedge's g effect sizes. Results: Fifty-three children and their families participated in this study (nSS = 21 nNSS = 32). The groups had similar RARs and sleep period variables. In both groups, sleep efficiency was low (SESS = 78%, SENSS = 77%) and total sleep time was short (TSTSS = 7 hrs 26 mins, TSTNSS- 7 h, 33 min) compared to national recommendations. Despite these similarities, children with SS took noticeably longer to settle down and fall asleep (53 min) than children with NSS (26 min, p = .075, g = 0.95). Conclusion: This study provides preliminary data describing RAR and sleep period variables in children with and without tactile hypersensitivities. While overall RAR and sleep variables were similar between groups, there is evidence that children with SS spend a longer time transitioning to sleep. Evidence is provided that wrist-worn actigraphy is tolerable and acceptable for children with tactile sensitivities. Actigraphy provides important, movement-based data that should be used in tandem with other measures of sleep health for future studies.

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings on work/employment interventions and participation outcomes for autistic adults.

Experiencing trauma has long-lasting effects on a child's well-being, which may affect their occupational performance. This scoping review synthesized research on community-based interventions for children who have experienced trauma to highlight occupational therapists' role in trauma-informed care. We searched PubMed and PTSDPubs, including community-based interventional trials that addressed childhood trauma and excluding studies specific to refugees, sex-trafficking, significant comorbid diagnoses, and reviews. Eleven articles met criteria. Psychotherapy-based interventions (e.g., trauma-informed cognitive behavioral therapy), play and art therapy, yoga, and equine-facilitated interventions reduced posttraumatic stress symptoms. One article measured the impact of these symptoms on a child's function. Occupational therapists working in community settings appear to be underutilized in the treatment of children who have experienced trauma. Future studies should examine occupational therapists' potential to work alongside mental health providers in the community to optimize functional outcomes for children who have experienced trauma.

Objectives: Poor sleep is evident for children with sensory (tactile) sensitivities (SS) using questionnaires, however standard actigraphy sleep and rest-activity rhythm outcomes do not capture sleep difficulties. Using machine learning techniques, we identified key features that characterize differences in activity during the settling down period that differentiate children with tactile sensitivities and children without sensitivities (NSS).Methods: Children with SS (n=17) and children with NSS (n=18) wore the GT9X Actigraph for 2 weeks and caregivers completed daily sleep diaries. The settling down period (caregiver reported start of settling down until actigraphy indicated sleep onset) was isolated each night and 7 features (mean magnitude, maximum magnitude, kurtosis, skewness, Shannon entropy, standard deviation, and interquartile range) were extracted. 10-fold cross-validation with random forests were used to determine accuracy, sensitivity, and specificity of differentiating groups.Results: We achieved 83% accuracy in differentiating groups (sensitivity=84%; specificity=82%). Feature importance maps indicate maximum magnitude of activity as the most important feature for differentiation, with children with SS having higher maximum bouts of activity (U=-2.23, p=.026). Other important discriminative features indicate higher variance in activity for the children with SS (e.g., interquartile range, Shannon entropy).Conclusion: We present a novel use of machine learning techniques that successfully uncovered differentiating features within the settling down period for our groups that have been difficult to capture using standard sleep and rest-activity metrics. Our data suggests that activity during the settling down period may be a unique target for future interventions for children with hypersensitivities.

BackgroundDespite high rates of obesity and weight-related conditions observed in children with Down syndrome, little is known about how to prevent these conditions.PurposeThe purpose of this study was to identify parent-perceived facilitators and barriers to health for toddlers (12–36 months old) with Down syndrome.Materials and methodsWe conducted in-depth, semi-structured interviews with the mothers of 25 toddlers with Down syndrome. All interviews were conducted using Zoom Video Technology, audio recorded and transcribed before being coded in NVivo software using a structured protocol. Thematic analysis was used to identify themes in perceived facilitators and barriers to health at the level of the child, family, and community. Data were triangulated using reflective journaling, video review of child meals, and member-checking techniques.ResultsWe identified unique themes for facilitators (on the move and sound sleep) and barriers (co-occurring conditions and eating behaviors) at the level of the child. At the level of the family and community, overarching themes that were viewed as either a facilitator or barrier, depending on the context, were identified (role models matter, time is critical, the importance of place, and social support).ConclusionThese themes can help clinicians and researchers tailor their health promotion interventions to meet the unique needs of children with Down syndrome by using strength-based approaches and providing families with the tools to overcome barriers.

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings on social participation interventions and participation outcomes for autistic1 adults.

Background The robotic assisted transfer device was developed as an updated lift technology to reduce adjustments in posture while increasing capabilities offered by transfer devices. The purpose of this study was to compare the trunk biomechanics of a robotic assisted transfer device and a mechanical floor lift in the transfer of a care recipient by a caregiver during essential transfer tasks. Methods Investigators enrolled 28 caregiver/care recipient dyads to complete 36 transferring tasks. Surface electromyography for the back muscles and motion data for trunk range of motion were collected for selected surfaces, phase, and direction tasks using a robotic assisted transfer device and a mechanical floor lift. Results Robotic assisted transfer device transfers required significantly smaller range of trunk flexion (P < 0.001), lateral bend (P < 0.001), and axial rotation (P = 0.01), in addition to smaller distance covered (P < 0.001), average instantaneous velocity (P = 0.01), and acceleration (P < 0.001) compared with a mobile floor lift. The robotic assisted transfer device transfers required significantly smaller peak erector spinae (left: P = 0.001; right: P < 0.001) and latissimus dorsi (right: P < 0.001) and integrated erector spinae left (P = 0.001) and latissimus dorsi right (P = 0.01) electromyography signals compared with the floor lift. Conclusions The robotic assisted transfer device provides additional benefits to mobile floor lifts which, coupled with statistically lower flexion, extension, and rotation, may make them an appealing alternative intervention.

Background: The sleep health of caregivers of children with Duchenne muscular dystrophy (DMD) is often overlooked in clinical practice and research. This study characterizes the sleep health of caregivers of children with DMD (4-17 years) compared to parents of age-matched, unaffected children. We explore potential contributors to parental sleep efficiency and hypothesize that child awakenings will have a considerable influence on parental sleep efficiency. Methods: In this observational study, parents and their children were asked to wear the ActiGraph GT9X Link at night for 1 month. From these data, actigraphy variables (eg, percent sleep efficiency, nocturnal awakenings) were calculated and averaged for parents and children. We also used the Pittsburgh Sleep Quality Index (PSQI) to measure subjective sleep quality. Main findings: Parents in the DMD group (n = 25, M = 84.5%) had significantly worse sleep efficiency compared to controls (n = 15, M = 87.8%, p = .048). This difference was sustained after controlling for parent age, child age, and average child awakenings (F(4, 23) = 2.68, p= .057, R2 = .32). Additionally, more parents in the DMD group scored as "poor sleepers" on the PSQI (above 5, 50%) compared to controls (23%), suggesting a strong, yet not statistically significant association between subjective poor sleep and group (x2(1) = 2.47, p = .116, OR = 3.33). Conclusion: Parents of children with DMD exhibit both objective and subjective differences suggesting their sleep is impaired. Interestingly, these sleep concerns are not significantly explained by child awakenings as hypothesized. Future research is needed to fully understand the prevalence and cause of poor sleep in a larger group of DMD caregivers as well as direct care for caregivers of children with disabilities. (c) 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Abstract Date Presented 04/02/2022 Children with Down syndrome are at significant risk for obesity. Families with young children with Down syndrome face significant barriers to promoting healthy habits early in life. OTs are uniquely qualified to help families overcome barriers and build healthy routines. The presentation will describe the development of the Facilitators and Barriers to Health for Young Children with Down syndrome (FaB Health Ds) survey and preliminary data describing facilitators and barriers to health for young children with Down syndrome. Primary Author and Speaker: Angela Caldwell Contributing Authors: Roxanna Bendixen, Aviva Must, Kishore Vellody, Lauren Terhorst

Objective: Actively actuated dynamic arm supports, such as the KINOVA O540, provide support for increased independence for individuals with upper limb weaknesses like young men with Duchenne muscular dystrophy. However, there is a significant need for a standardized method to evaluate the impact that dynamic arm supports have on functional activity within the community setting. Approach: This study uses accelerometry and motor performance data collected during a dynamic arm support device trial with young men with Duchenne muscular dystrophy. Using the accelerometry data during each task of the Performance of Upper Limb test, we used the Support Vector Machine (SVM) learning method to test device sensitivity (identification of use of the device) and success sensitivity (identification of success with each task). Main Results: Through this method, we demonstrate high levels of accuracy, sensitivity and specificity when identifying the use or non-use of the device within the data. Further, in the times of device use, this method categorizes the data into "success" and "failure" groups with high accuracy. Significance: This study provides a novel application of accelerometry in tandem with the use of a dynamic arm support device. Utilizing standardized movement items, we present an important first step towards remote monitoring of a dynamic arm support device in the natural setting. Through these results, we push the state of the science forward and aim in future work to use remote monitoring to capture change in goal areas and daily tasks during device trials.

Background Promoting health early in life is crucial to obesity prevention, but families in under-resourced communities face barriers to establishing healthy routines. The purpose of this pilot study was to examine the feasibility and preliminary effects of two dietary interventions for families in under-resourced communities. Methods Fifty-one caregivers of young children (aged 0–5 years) were recruited from six community centers located in heavily populated neighborhoods with high poverty rates (i.e., under-resourced neighborhoods) in southwestern Pennsylvania. A longitudinal pilot study was conducted to examine feasibility as a primary outcome and change in dietary variety (24-Hour Recall), risk of nutritional problems (Nutrition Screen for Every Preschooler), and parenting stress (Parenting Stress Index-Short Form) over time and between groups as secondary outcomes. Six sites were randomized to receive Cooking Matters for Parents, Mealtime PREP, or a combined program (Cooking Matters + Mealtime PREP). Cooking Matters for Parents is a six-week nutrition education program designed to help parents of young children plan and cook healthy meals on a budget. Mealtime PREP is a six-week routine-based intervention designed to promote healthy dietary variety among young children. We predicted that we could feasibly deliver both programs and the combined program as determined by a priori benchmarks (ability to recruit ≥ 8 participants per site; achieving an 80% intervention completion rate; being rated as an acceptable intervention by 95% of intervention completers, and treatment fidelity of ≥ 90%). Descriptive statistics and individual growth models were used to analyze data. Results Of 51 recruited participants, 49 were eligible, randomized by site, and included in the analyses. Fourteen were randomized to Cooking Matters, 13 to Mealtime PREP, and 22 to the combined program. Three of 4 feasibility benchmarks were met. Over time, improvements were observed in child dietary variety ( p < 0.01, SE = 0.99), child nutrition risk ( p = 0.01, SE = 0.61), and parenting stress ( p = 0.04, SE = 1.33). An additive benefit of the combined intervention was observed for dietary variety (p = 0.03, SE = 0.79). No adverse events were observed or reported. Conclusions Offering complementary dietary interventions in under-resourced communities is feasible and shows promise to improve child and parent health. Trial registration ClinicalTrials.gov (NCT03559907).