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Context: Acceptance and Commitment Therapy (ACT) is an emerging treatment for improving psychological well-being. Objective: To summarize research evaluating the effects of ACT on psychological well-being in children with special health care needs (SHCN) and their parents. Data Sources: An electronic literature search was conducted in PubMed, Web of Science, Ovid/EMBASE and PsycINFO (January 2000–April 2021). Study Selection: Included were studies that assessed ACT in children with SHCN (ages 0–17y) and/or parents of children with SHCN and had a comparator group. Data Extraction: Descriptive data were synthesized and presented in a tabular format, and data on relevant outcomes (e.g., depressive symptoms, stress, avoidance and fusion) were used in the meta-analyses to explore the effectiveness of ACT (administered independently with no other psychological therapy) compared to no treatment. Results: Ten studies were identified (child (7) and parent (3)). In children with SHCN, ACT was more effective than no treatment at helping depressive symptoms (standardized mean difference [SMD] = −4.27, 95% CI: −5.20, −3.34; p < 0.001) and avoidance and fusion (SMD = −1.64, 95% CI: −3.24, −0.03; p = 0.05), but not stress. In parents of children with SHCN, ACT may help psychological inflexibility (SMD = −0.77, 95% CI: −1.07, −0.47; p < 0.01). Limitations: There was considerable statistical heterogeneity in three of the six meta-analyses. Conclusions: There is some evidence that ACT may help with depressive symptoms in children with SHCN and psychological inflexibility in their parents. Research on the efficacy of ACT for a variety of children with SHCN and their parents is especially limited, and future research is needed.

Introduction Individuals with disabilities (approximately 20% of the population) experience discrimination and health disparities. Medical school must equip students with expertise to care for patients with disabilities and to identify ableism. Yet, few schools provide curricula that offer a sociopolitical lens for understanding this topic. We developed a disability and ableism curriculum to address this gap. Methods We developed a mandatory 2-hour session for first-year medical students at University of California San Francisco. Activities included: privilege awareness, student-led discussions, and intervention brainstorming for overcoming health care barriers/biases. The session was evaluated through pre/postsurveys, as well as a follow-up survey 1 year later. Results In feedback collected during 2018 and 2019, students described the session as meaningful and relevant. Faculty facilitators reported that the session provoked powerful student-centered learning, leadership, and widespread participation. On average the students rated the session 4.6 on a 5-point scale. Pre- and postsession data analysis indicated significant increases in students' self-reported understanding of ableism (p < .001) and confidence in assessing barriers to care for patients with disability (p < .001). One year later, students reported that the session had influenced their conceptualization of providing care to patients with disabilities. Discussion Through innovative and participatory activities, this small-group session introduced students to important topics such as ableism, the social model of disability, disability history and culture, and health disparities. Our work suggested that creating curricula to equip students with structural frameworks for understanding disability—a topic underrepresented in medical curricula—stimulated student interest and commitment.

Objectives: Due to high incidence of medical student and physician burnout, medical education needs to include skills for life-work balance. Patients complain that clinicians depend on technology during clinic visits, and use less touch. To address this educational need, we designed an 18-hour curriculum that combines massage (to reduce anxiety and teach skillful touch) and meditation (for burnout prevention). We explored whether learning basics of massage and meditation could give medical students tools for self-care and skillful touch. Methods: The curriculum was implemented as an elective at the Medical School since 14 years. We collected 181 anonymous student evaluations and conducted pre-post surveys to evaluate the curriculum. We assess mindful bodily awareness (by Multidimensional Assessment of Interoceptive Awareness questionnaire) and conducted thematic analysis of students' comments. Results: Students appeared highly satisfied with the class (4.94 [Range 1-5]) and reported confidence in being able to apply massage and meditation in their personal and professional life. They commented on the importance of skillful touch and gained more confidence in using touch in clinical care. The pre-post survey showed improvements in interoceptive bodily awareness. Students felt that they developed new skills for self-care and stress management, experienced a sense of community among peers, and stated that the class provided necessary teaching complementary to the mandatory medical school curriculum. Conclusions: A course of Meditation and Massage may be a valuable complementary elective to medical school education, supporting self-care and stress management in preparation for a demanding profession, and may improve palpatory examination skills.

When Moses is described (Numbers 12:3) as being more humble than any other person on the face of the earth, and when God is described as being humble, we are forced to dissociate Jewish notions of humility from any connotations of meekness or diffidence. Biblical and rabbinic texts reveal that the essential consideration in assessing a person’s humility is not that person’s relative assertiveness or timidity but rather with how much he or she subjugates personal self-interest to higher purposes. As articulated within the Jewish tradition of self-development called Mussar, humility inheres in directing one’s will toward sensitive service of the needs and wants of others within one’s social sphere as well as in line with one’s allegiance to the divine. Virtuous humility expresses itself in everyday contexts in the measure of the “space” (be that in the physical, emotional, verbal, financial, or another realm) that a person occupies. The ideal is to take up just as much space as is necessary to fulfill one’s mission of service in his or her life, neither more nor less. Moses fits (as well as defines) this paradigm.

Congenital heart disease is a significant cause of infant mortality. Epidemiology and social context play a crucial role in conditioning disease burden and modulating outcomes, while diagnosis and treatment remain resource intensive. This review will address the role of social demographics, environmental exposure, epigenetics and nutrition in the aetiology of congenital heart disease. We then discuss the determinant effect of social factors on the provision and outcomes of care for congenital heart disease and implications for practice. It is our hope that enhanced knowledge of the intersection of social determinants of health and congenital heart disease will facilitate effective preventative strategies at the individual and population levels to optimize heart health outcomes across the life course.

Journeying to sacred places is an ancient yet contemporarily popular tradition in the Hindu society of India. At the outset of this thesis, the philosophical foundations and general patterns of pilgrimage practice in West Bengal, India, where fieldwork was conducted, are discussed. Case studies of three West Bengali pilgrimage centres — Tarakeswar, Navadvip and Tarapith, which are Śaiva, Vaiṣṇava and Śākta sacred places, respectively — reveal the considerable diversity in the regional pilgrimage tradition. In analysing each of these centres, ethnographic data on the social and economic organisation of specialised religious places, roles of sacred specialists, beliefs regarding the deities, patterns of ritual, and social characteristics and behaviour of pilgrims are presented. The literature on pilgrimage is reviewed in search of theoretical tools for the task of generalising about pilgrimage, inclusive of the evident diversity. Analysis and criticism of existing theories indicates that analysts have focused on limited aspects of pilgrimage practice which conform to disciplinary boundaries rather than seeking the patterned consistencies which define the full institution. Comparison of the three case studies reveals that the variation in religious patterns in the centres relates to wider traditions of religious culture in Bengal: the several strands of pilgrimage tradition generally replicate the sub-traditions of Bengali Hinduism and patterns of belief and practice in any sacred place are closely associated with the religious tradition of the regional cult which dominates that centre. It is possible, however, to identify two levels at which the diversity of the pilgrimage institution is founded in systematic conceptual unity. Both levels concern the meaning of pilgrimage within prevalent patterns of Bengali Hinduism. The explicit meaning of pilgrimage in the conscious thought of participants emphasises the journey to the deity's terrestrial abode in search of interaction with the divine. Implicit within this patterned behaviour are important Hindu metaphysical concepts — the implicit ideology of pilgrimage — which invest pilgrimage with meaning derived from abstract Hindu religious thought.

There is a high prevalence of serious mental illness and substance use disorders in people who are experiencing homelessness. Many individuals without housing are not well served within the existing outpatient mental health services system, and without tailored interventions, many cannot or do not access ongoing psychiatric care. Team-based and integrated approaches that address housing, mental and physical health, substance use, and benefits and entitlements are recommended to engage and support these individuals. Services spanning an individual’s trajectory from street to shelter to housing can help foster recovery. This chapter illustrates the importance of specialized clinical approaches for this population and discusses both evidence-based practices and unique best practice interventions for clinicians working with people experiencing homelessness.

It has been recognized that families of children with life-limiting health conditions struggle with significant financial demands, yet may not have awareness of resources available to them. Additionally, health care providers may not be aware of the socioeconomic needs of families they care for. This article describes a mixed-methods study examining the content validity and utility for health care providers of a poverty screening tool and companion resource guide for the pediatric palliative care population. The study found high relevance and validity of the tool. Significant barriers to implementing the screening tool in clinical practice were described by participants, including: concerns regarding time required, roles and responsibilities, and discomfort in asking about income. Implications for practice and suggestions for improving the tool are discussed. Screening and attention to the social determinants of health lie within the scope of practice of all health care providers. Social workers can play a leadership role in this work.

BACKGROUND: Caring for a child with a chronic medical condition can adversely affect parental health and well-being. Family-centered care requires clinical teams to consider novel ways of providing holistic care to the entire family by understanding the unique challenges of caring for a child with a chronic medical condition. Addressing parental well-being not only improves parental capacity to care for their child, but may also optimize long-term health outcomes for the child themselves. Acceptance and Commitment Therapy (ACT) is an established behavioural therapy that has been used with caregivers in the paediatric setting. Through ACT, individuals learn skills to increase psychological flexibility, cognitive diffusion, and mindfulness. ACT aims to help with coping and adjustment, but its impact has not been systematically appraised in parents of children with chronic medical conditions. OBJECTIVES: To synthesize available research evidence on the efficacy of ACT for parents of children with medical conditions. DESIGN/METHODS: A comprehensive literature search (December 2008 to October 2018) in PubMed, Cochrane Library, EMBASE, Web of Science, and Google Scholar was conducted. Abstracts were included if: 1) they were original articles and 2) they assessed the efficacy and outcomes of ACT on parents caring for children with chronic medical conditions. RESULTS: In total, 66 abstracts were identified. Nine publications describing ACT as an intervention aimed at improving parent-oriented outcomes met the final inclusion criteria. Five studies were randomized control trials. Medical conditions included children with: chronic pain (n=4), acquired brain injuries (n=2), autism spectrum disorder (n=1), cerebral palsy (n=1), and life-threatening illness (cancer or life-saving cardiac surgery) (n=1). All nine studies found improvements in caregiver related outcomes following ACT treatment. Improvements were seen in psychological flexibility (n=5), family functioning (n=3), parenting (n=1), and depression (n=2). Significant, medium to large effect sizes were found for measures of psychological flexibility, dysfunctional parenting styles (laxness and over reactivity). A medium effect size was found for family functioning. CONCLUSION: ACT improved outcomes for parents caring for children with chronic medical conditions. The majority of studies concentrated in paediatric patients with chronic pain or neurologic conditions. Less is known about the efficacy of ACT in improving parent-related outcomes in other paediatric disease groups however, further research in this area is warranted.

Objective To determine if there is an association between longer breast-feeding duration and dental caries in healthy urban children. Methods We conducted a cross-sectional study of urban children aged 1 to 6 years recruited through The Applied Research Group for Kids (TARGet Kids!) practice-based research network between September 2011 and August 2013. The main outcome measure was parental report of dental caries. Results The adjusted predicted probability of dental caries was 7%, 8%, 11%, and 16% with total duration of breast-feeding duration of 12, 18, 24, and 36 months, respectively. In the adjusted logistic regression analyses, relative to breast-feeding 0 to 5 months, the odds of dental caries with total breast-feeding duration >24 months was 2.75 (95% confidence interval 1.61–4.72). Conclusions Among healthy urban children, longer breast-feeding duration was associated with higher odds of dental caries. These findings support heightened awareness and enhanced anticipatory guidance for preventive dental care, particularly among children who breast-feed beyond 2 years of age.

Primary paediatric health care is the foundation for preventative child health. In light of the recent obesity epidemic, paediatricians find themselves at the frontline of identification and management of childhood obesity. However, it is well recognized that evidence based approaches to obesity prevention and subsequent translation of this evidence into practice are critically needed. This paper explores the role of primary care in obesity prevention and introduces a novel application and development of a primary care research network in Canada--TARGet Kids!--to develop and translate an evidence-base on effective screening and prevention of childhood obesity.

Background: The daily calculation of an infant’s fluid requirements is a necessary and key component of the care of preterm infants in order to ensure physiological stability and adequate caloric and nutritional intake. However, there is little research on this practice to date. Objectives: To describe the total fluid intake (TFI) prescriptions for 32–35 completed weeks gestational age infants in a Level II nursery and neonatal intensive care unit of a single centre and to examine the impact of the different prescription practices on

The objective of this study was to evaluate the association of vitamin D intake and serum levels with fracture risk in children under 6 years of age. A case-control study was conducted in Toronto, Ontario, Canada. Cases were recruited from the fracture clinic at the Hospital for Sick Children, and matched controls were obtained from the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height, and season. Fracture risk was estimated from conditional logistic regression, with adjustment for skin type, fracture history, waist circumference, outdoor free play, neighborhood income, soda consumption, and child's birth weight. A total of 206 cases were recruited during May 2009–April 2013 and matched to 343 controls. Serum 25-hydroxyvitamin D concentration (per 10-nmol/L increment: adjusted odds ratio (aOR) = 0.95, 95% confidence interval (CI): 0.88, 1.03) and intake of cow's milk (2 cups/day vs. 2 cups/day: aOR = 1.39 (95% CI: 0.85, 2.23)) were not significantly associated with reduced odds of fracture. A statistically significant association was observed between child use of vitamin D supplements and decreased odds of fracture (yes vs. no: aOR = 0.42, 95% CI: 0.25, 0.69). Vitamin D supplementation, but not serum 25-hydroxyvitamin D level or milk intake, was associated with reduced fracture risk among these healthy young children.

Objective To prevent iron deficiency, 2014 Canadian recommendations for healthy term infants from 6 to 24 months recommend iron-rich complementary foods such as meat and meat alternatives 2 or more times a day. The purpose of our study was to evaluate the association between meat and meat-alternative consumption and iron status in young children and the association between red meat consumption and iron status among children meeting recommendations. Methods Healthy children aged 12 to 36 months were recruited. A cross-sectional study was conducted. Meat and meat-alternative consumption was measured using the NutriSTEP questionnaire. Adjusted multivariable regression analyses were used to evaluate an association between meat consumption and serum ferritin, and iron deficiency (serum ferritin Results A total of 1043 children were included. Seventy-three percent of children met the recommended daily intake of meat and meat alternatives, and 66% ate red meat in the past 3 days. Eating meat and meat alternatives was not associated with serum ferritin (0.13 μg/L, 95% confidence interval −0.05, 0.31, P = .16), but it was associated with a decreased odds of iron deficiency (odds ratio 0.97, 95% confidence interval 0.94, 0.99, P = .03). Associations between red meat consumption and iron status were not statistically significant. Statistically significant covariates associated with increased odds of iron deficiency included longer breast-feeding duration, daily cow's milk intake of >2 cups, and a higher body mass index z score. Conclusions Daily cow's milk intake of >2 cups, longer breast-feeding duration, and a higher body mass index z score were modifiable risk factors associated with iron deficiency. Eating meat according to recommendations may be a promising additional target for the prevention of iron deficiency in early childhood.