Maternal and Child Health Journal (2020) 24:39–53

https://doi.org/10.1007/s10995-019-02815-3

A Virtual Resiliency Intervention Promoting Resiliency for Parents

of Children with Learning and Attentional Disabilities: A Randomized
Pilot Trial
Elyse R. Park1,2,4 · Giselle K. Perez1,4 · Rachel A. Millstein1,4 · Christina M. Luberto1,2,4 · Lara Traeger1,4 ·
Jacqueline Proszynski1,2 · Emma Chad‑Friedman1,2 · Karen A. Kuhlthau3,4

Published online: 24 October 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Objectives One in five children have a learning and attentional disability (LAD). Parents of children with LAD are vulner-
able to distress, but an evidence-based treatment has not been developed.
Methods From June 2016 to November 2017, we conducted a mixed methods study to adapt and assess the virtual delivery
of a mind-body group resiliency program, the Stress Management and Resiliency Training-Relaxation Response Resiliency
Program (SMART-3RP), to meet the needs of parents of children with LAD; this is an 8-session weekly group intervention.
In the first phase, we conducted 4 parent focus group interviews, 2 professional focus group interviews, and 5 professional
individual interviews, and 1 pilot group to adapt the SMART-3RP to target the needs of parents of children with LAD. In the
second phase, we conducted a pilot wait-list controlled study to assess the feasibility, acceptability, and preliminary efficacy
of a videoconferencing delivery of the adapted program. Parents were randomized to an immediate intervention group (IG)
or wait-list control group (WC). Surveys were administered at baseline (time 1), end of intervention for the IG or 3 months
post-baseline for the WC (time 2), and 3 months post treatment for the IG or end of intervention for the WC (time 3).
Results Qualitative findings illustrated high levels of parental stress, with primary stressors including navigating the edu-
cational system, interactions with other parents, familial concerns, and financial and professional sacrifices. We adapted
the manual to target these stressors and modified session logistics and delivery. Fifty-three parents (mean age = 46.8; 90.6%
female) participated nationally in the pilot trial. 62.5% of participants completed ≥ 6/8 sessions; 81.8% reported continued
daily/weekly relaxation response exercise practice. T1–T2 comparisons found that IG versus WC participants showed sig-
nificant improvements in distress [VAS], ∆M = − 1.95; d = .83 and resilience [CES], ∆M = 6.38; d = .83, as well as stress
coping [MOCS-A] ∆M = 8.69; d = 1.39; depression and anxiety [PHQ-4], ∆M = − 1.79; d = .71; social support [MOS-SSS],
∆M = 5.47; d = .71; and empathy [IRI], ∆M = 3.17; d = .77; improvements were sustained at the 3 month post intervention
follow-up.
Conclusion Pilot wait-list randomized trial findings showed promising feasibility, acceptability, and preliminary efficacy
for the SMART-3RP intervention adapted for parents of children with LAD. This virtually-delivered resiliency intervention
improved parents’ distress, resiliency, and stress coping, which were sustained.
Clinical Trials ID NCT02772432.

Keywords Family · Stress · Resilience · Distress · Learning and attentional disability · Children · Parents · Mind-body ·
Intervention

Electronic supplementary material The online version of this
article (https​://doi.org/10.1007/s1099​5-019-02815​-3) contains
supplementary material, which is available to authorized users.
* Elyse R. Park
epark@mgh.harvard.edu
Extended author information available on the last page of the article
Significance
This project seeks to improve the well-being of parents of
children with LAD, a subgroup of parents of children with
special health care needs. By improving stress coping and
resiliency, the intervention improved parental capacity to
maintain stability during ongoing stress and may reduce the

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Vol.:(0123456789)
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physiological impact of chronic stress on parents, which, in
turn, could have a positive impact on childrens’ well-being.
This study addresses parental well-being—specifically
related to distress and resilience. In regard to parental health,
the SMART-3RP intervention addresses one of the reporting
domains for the Maternal and Child Health Bureau’s State
Action Plan (State Action Plan 2018). In addition, children
with LAD are a subset of children with special health care
needs, a population served by state Title V Maternal and
Child Health Services.
Introduction
There is a growing population of children with learning
and attentional disabilities (LAD) (Cortiella and Horowitz
2014). Specific learning disabilities are defined as disorders
in understanding or in using spoken or written language, or
difficulties with reading, writing, listening, speaking, rea-
soning, or math. Attention disorders are defined as brain
disorders marked by ongoing inattention and/or hyperactiv-
ity that interferes with functioning (LDA 2018; APA 2013).
There are 2.3 million U.S. public school students who have
a LAD, accounting for 35% of all students receiving special
education services (US Department of Education 2017).
Simultaneously, there is a growing body of literature asso-
ciating elevated levels of parental stress with caring for chil-
dren with LAD. The high levels of parental stress among
these parents are paired with increases in vulnerability to
distress and clinical depression, low levels of self-efficacy in
caregiving, decreased physical activity, low levels of social
support, and poor perceived health (Bonifacci et al. 2016;
Chacko et al. 2017; Galloway et al. 2016; Tancred and Greeff
2015). A recent meta-analysis showed that parents of chil-
dren with ADHD, one of the most common LAD (Thomas
et al. 2014), experienced more stress than those of neurotypi-
cal children; additionally, severity of ADHD symptoms was
associated with parenting stress (Theule et al. 2013).
Heightened stress can negatively impact many aspects of
parents’ lives and is linked to poor psychosocial outcomes.
Per the National Center for Learning Disabilities, one third
of parents of children with LAD view parenting as a strug-
gle, experience financial difficulties, feel isolated, report
difficulties maintaining positive relationships with spouses
and/or children, feel unable to manage their own stress and
feelings of guilt, and express fear about their child’s future.
Another third of parents report feelings of denial about their
child’s LAD, as well as uncertainty about how to advocate
for their child (Cortiella and Horowitz 2014). Financially,
expenditures can be nearly 60% higher for families of chil-
dren with LAD relative to families with neurotypical chil-
dren (Gupte-Singh et al. 2017) due to the cost of additional
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Maternal and Child Health Journal (2020) 24:39–53
healthcare expenses, tutoring, specialty schooling and other
services.
Resiliency is a multidimensional construct that refers to
the ability to maintain adaptation and effective functioning
when faced with stressors, and it provides a framework for
understanding the adjustment to stress as a dynamic process.
Strategies that promote resiliency may help to buffer par-
ents from the stress related to caring for a child with LAD
(Song et al. 2014). Resiliency skills can facilitate paren-
tal responses to stress, which may improve their emotional
and physical well-being, and by extension, the well-being
of their children (Peris and Miklowitz 2015; Dennis et al.
2018). However, few intervention studies have focused on
the needs of parents of children with LAD; (Walcott et al.
2009; Ferrin et al. 2014, 2016) these studies were limited
in that they focused primarily on psychoeducation and did
not target parents’ unmet needs for psychosocial support
(Chien and Lee 2013). Allostasis refers to the capacity to
maintain stability of physiological systems in the face of
adversity. When exposed to chronic stressors, such as car-
ing for a child with LAD, individuals expend a great deal
of energy attempting to maintain allostasis, which can lead
to the metabolic wear and tear described as allostatic load
(McEwen 1998). Thus, interventions to promote resiliency
in this population could have a great impact on health and
quality of life.
The Stress Management and Resiliency Training-Relaxa-
tion Response Resiliency Program [SMART-3RP (Park et al.
2013)] was developed at the Massachusetts General Hospital
where it is delivered in clinical group settings. The SMART-
3RP is guided by the diathesis-stress model, which posits
that resilience is the outcome of an individual’s experiences
and environment in combination with one’s inherent coping
ability (Hankin and Abela 2005). It has shown feasibility,
acceptability, and preliminary efficacy in pilot trials among
medical patients [chronic pain (Vranceanu et al. 2014), neu-
rofibromatosis, and lymphoma (Perez et al. 2018)], and clini-
cal providers [palliative care providers (Perez et al. 2015)
and hospital medical interpreters (Park et al. 2017)]. The
SMART-3RP is an 8-session (plus intake session) group pro-
gram, which is delivered in-person and virtually (See Online
Appendix 1). This model views adjustment to ongoing, daily
stress, such as that experienced by parents of children with
LAD, as a dynamic process which is achieved by practicing
a set of 3 core skills: (1) Relaxation Response (RR) elicita-
tion, (2) Stress Awareness and Management, and (3) Adap-
tive Strategies (see Fig. 1). The program therefore builds
resilience through cultivation of relaxation response (RR)
(Benson et al. 1974) elicitation strategies (e.g., breath aware-
ness, single pointed meditation, mindful awareness, guided
imagery, contemplation), stress management (cognitive
behavioral strategies), and growth enhancement (positive
Maternal and Child Health Journal (2020) 24:39–53
Fig. 1  SMART-3RP model
psychology, post-traumatic growth) processes in response
to ongoing, chronic stressors.
Treatment programs that both address the distinct psycho-
social needs of parents of children with LAD and strategies
to manage the chronic stressors associated with parenting
a child with a LAD have the potential to improve parents’
emotional and physical well-being as well as benefit parent-
child relationships (Mackler et al. 2015; Woodman et al.
2015). Thus, to examine how to intervene upon parental
stress for these parents, we conducted a 2-phase explora-
tory mixed methods study, which consisted of (1) individual
and focus group interviews with parents, professionals, and
clinicians from across the United States to inform the tar-
geting of an evidence-based mind-body group intervention,
the SMART-3RP, for parents of children with LAD, and
(2) a pilot group and then wait-list randomized pilot trial to
assess the feasibility, acceptability, and preliminary efficacy
of the targeted SMART-3RP group for parents of children
with a LAD.
Methods
This study was conducted at an academic medical center
in Boston, with participants recruited nationally, from
June 2016 to November 2017. Institutional Review Board
approval was obtained from Partners Human Research
41
Committee (PHRC) at Massachusetts General Hospital.
COREQ guidelines were followed for Phase 1 (Tong et al.
2007).
Phase 1: Qualitative Study
Through focus group interviews with parents of children
with LAD, clinicians, professionals from LAD advocacy
and teaching organizations, we identified the psychoso-
cial needs of parents of children with learning disabilities,
including (a) the types of concerns that parents find most
difficult and stressful, (b) areas of concern that lack support
and resources, and (c) areas of need for education and skill
training.
Participants and Recruitment: Qualitative Phase
Using data from different perspectives (triangulation) to
strengthen the study’s validity (Patton 1999), we enrolled
professional LAD experts from organizations and parents
of children with LAD (Denzin 2006). We operationalized
LAD as any Specific Learning Disability (i.e. Dysgraphia,
Dyslexia, Dyscalculia, Auditory Processing Disorder, Non-
Verbal learning disabilities, Visual Perceptual/ Visual Motor
Deficit, Dyspraxia, Aphasia) or attention disorder (i.e. Atten-
tion Deficit Hyperactivity Disorder; ADHD) (APA 2013).
Eligible professionals were (1) mental health clinicians and
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42
researchers, professionals at advocacy organizations, and
schools that specialized in LAD. Eligible parent participants
were at least 18 years old and identified as having at least
one child of any age with a diagnosed LAD (See Online
Appendix 2). We distributed study flyers online through
local and national organizations, schools (public, private,
special needs), support service centers, online advocacy
groups, and Special Education Advisory Councils to recruit
professionals. We also made calls to schools and organiza-
tions to describe our study and request that they post our
flyers and refer members of their community to our study.
Parents contacted the study coordinator to be screened and
consented. Enrolled parents were asked to complete a soci-
odemographic survey prior to their phone-based interview,
and they received $25 remuneration for their participation.
Data Collection
Semi-structured interview guides were developed and
piloted for the professional and parent interviews. The
interview guide was piloted internally and consisted of the
following domains: (1) types of parental stress/experiences
of stress, (2) impacts of stress, (3) resources available to
parents, (4) types of skills training and modality desired, and
(5) barriers to participation in a resiliency group and was
piloted internally. From June–July 2016, we conducted in-
depth individual interviews with 5 clinicians, 1 focus group
with professionals from a professional LAD organization
(n = 6), 1 focus group with a school specialized for children
with LAD (n = 3), and 4 focus groups with parents of chil-
dren with LAD (n = 11), which provided us with the forma-
tive data needed (Guest et al. 2016). Group interviews lasted
approximately 60 min; each individual interview lasted
approximately 30 min. All interviews were audio recorded
and transcribed. Transcripts were reviewed by study inves-
tigators for quality. Content analyses of the interviews were
an iterative process of developing and applying a framework
codebook that was developed and revised through a series of
coding and review. Two study staff members independently
coded all data using NVivo 11, using the framework to iden-
tify themes in the interviews. Analyses compared parent and
expert findings. The coders met with the lead investigator
to resolve discrepancies among coders. An agreement of
Kappa = 0.93 was reached.
Findings and Intervention Adaptation
Qualitative findings illustrated high levels of parental
stress associated with caring for children with LAD.
Sources of stress identified by parents and professionals
included navigating the educational system to advocate for
the child’s needs; communicating with other parents and
family members while feeling judged and misunderstood;
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Maternal and Child Health Journal (2020) 24:39–53
feeling isolated; financing additional resources to support
the child; and making professional sacrifices in exchange
for the flexible hours to meet their children’s needs. Both
parents and professionals identified stress as contributing
to emotional and physical exhaustion, social isolation, and
strained familial relationships, including marital tension
and frustration among siblings of the child with LAD. No
skills-based psychosocial programs were identified by
either group. Parents utilized few emotional or informa-
tional support systems, but they endorsed interest in these
resources and had a great interest in interacting with other
parents. There was general agreement that a skills-based
resiliency intervention could provide useful skills for par-
ents to manage their stressors and that the convenience of
virtually delivery, given parents’ time constraints, would
be of interest to parents.
Using these qualitative data, we adapted the original
SMART-3RP resiliency program to specifically target
the stressors identified during the interviews. Modifica-
tions were made to the content of each session to make
each exercise more relevant and relatable to these parents.
For instance, we introduced RR training with attention to
problem-solving ways that a busy parent might find time
to practice the RR each week, and we introduced cogni-
tive coping strategies using an example scenario that many
focus group parents mentioned as stressful (e.g., their child
not being invited to a classmate’s birthday party). Other
changes were made to digitize the manual and make it
more user friendly for delivery over videoconferencing.
For instance, we adapted several individual- and pair-
based session exercises to be completed by all group par-
ticipants together via videoconference. Additionally, we
conducted a group intake session to introduce the program,
enhance group rapport, and facilitate goal setting. Alto-
gether, group participants thus met for a total of 9 weeks
(intake session + 8 intervention sessions).
Prior to conducting the randomized wait-list-controlled
trial, we first tested the adapted manual via an open pilot
with 3 parents who met eligibility criteria. The study team
met weekly with the group facilitator after each group ses-
sion to discuss videoconferencing and session logistics (e.g.,
length and order of sessions; relevance of session content).
After each session the group facilitator elicited feedback
from participants on session content, logistics (e.g., length
of sessions, videoconferencing trouble shooting), and satis-
faction. Additional modifications were subsequently made
to enhance program structure (e.g., confirm 90-min structure
and need for group intake visit to support group cohesion),
video delivery (e.g., strategies to support connectivity of the
video platform and quality of the group screen presentation;
modification of in-person exercises to be suitable for the
screen), and targeted program content (relevance/relatability
of examples used in program workbook)
Maternal and Child Health Journal (2020) 24:39–53
Phase 2: Wait‑List Control Pilot
Participants and Recruitment
Recruitment methods and eligibility criteria were the same
as in Phase 1 (see Online Appendix 3), with the addition
of ability to participate in an intervention delivered via
videoconferencing.
Interested parents completed a pre-screen survey accessed
using a link embedded in recruitment materials, or they con-
tacted the study research coordinator who screened parents
over the phone. Eligible parents were scheduled for a phone
consent and orientation to the telemedicine platform. All
parents were 18 years or older, proficient in English and
willing to engage in an online intervention. Phase 1 quali-
tative interview participants were excluded. To focus the
group on stressors specific to caring for a child of any age
with LAD, parents were excluded if they had a child with
a severe emotional or physical disorder, or intellectual dis-
ability. This was determined using two screening questions
asking parents to report whether (1) their child requires spe-
cial help at home with personal care (i.e. bathing, dressing,
eating) beyond what is needed by most children their age
or (2) their child’s health requires that the child be left only
with a person trained to handle medical emergencies.
Design
This pilot study was a randomized wait-list controlled
trial. Participants were randomly assigned to participate
in the adapted Stress Management and Resiliency Training
– Relaxation Response Resiliency Program (SMART-3RP)
either immediately after enrollment (IG) or after 3 months
of waiting (WC) (see Fig. 2). All participants completed
3 sets of questionnaires at time 1 (enrollment), time 2
(intervention group: end of intervention; wait-list control:
3 months post-enrollment), time 3 (intervention group:
3-months post treatment; wait-list control: end of inter-
vention). All questionnaires were administered via email
through a secure, electronic data capture tool (REDCap).
Each study participant signed written, informed consent
Fig. 2  Study design
43
over videoconferencing. Participants received $20 remu-
neration for each follow-up survey completed.
Intervention Delivery
The SMART-3RP intervention consisted of an initial
group intake session and 8 intervention sessions that met
once a week for 1.5 h each, during a daytime or even-
ing session. In each session, participants learned ways to
elicit the RR, as well skills based on cognitive behavioral
therapy and positive psychology theory. Active participa-
tion was an integral part of the sessions. Between ses-
sions participants engaged in RR practice and worked on
learned skills and exercises. All groups were facilitated
by a licensed clinical psychologist and delivered via the
Vidyo telehealth platform, which is a HIPAA-compliant,
hospital-approved videoconferencing platform that facili-
tates synchronous face-to-face group interactions among
patients and providers. All participants could thus see,
hear, and interact with each other in real time throughout
each session.
Measures
Measures were collected on intervention constructs within
the stress management and growth enhancement processes.
Parent Baseline Characteristics: Sociodemographic
and Parental Stress
Sociodemographics
The demographic questionnaire is a 10-item self-report
survey that collects information about parent age, gen-
der, race, ethnicity, relationship and employment status.
Child variables, such as age, specific LAD diagnosis, and
number of children living in the household, were also
collected.
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Parental Stress: The Parental Stress Scale (Berry and Jones
1995)
The parental stress scale is an 18-item measure that uses
a 5-point scale to assess positive and negative experiences
of parenting as well as parental stress levels. Respondents
are asked to report how strongly they agree or disagree
with each item [disagree (1) to strongly agree (5)]. Positive
items include topics on emotional benefits, self-enrichment,
and personal development, whereas negative items explore
demands on resources, opportunity costs, and restrictions.
Positive items are reverse scored. Scores range from 18 to
90, with higher scores indicating greater parental stress.
Scale internal reliability in the current study was good
(Cronbach’s alpha = 0.83)
Primary Outcomes
Feasibility
Program feasibility was assessed using enrollment rates
across the four major U.S. regions, intervention session
attendance, and program retention. Session attendance tar-
get was set at 6 out of 8 group sessions (Fjorback et al. 2011;
Rosenzweig et al. 2010).
Acceptability: Post Intervention
We asked both groups post-intervention (T2 for intervention
group, T3 for wait-list control) how often they practiced the
RR; additionally, we asked for open-ended feedback about
the program’s length, structure and session content; par-
ticipants’ comfort with the material; thoughts about content
they found to be most helpful; and suggested program and
content changes.
Distress: Visual Analogue Scale (VAS)—Distress
The VAS-Distress is a 1-item scale which asks responders to
rate their level of distress on a scale of 0–10. A higher score
indicates more distress. The VAS-Distress has been shown
to be positively correlate with other measures of distress,
such as the Hospital Anxiety and Depression Scale (Lesage
et al. 2012).
Resiliency: Current Experience Scale (CES)
The CES is a 25-item measure of resilience adapted from
the Post-Traumatic Growth Inventory (PTGI) (Tedeschi and
Calhoun 1996) to reflect current functioning in the domains
of appreciation for life (AL), adaptive perspectives (AP),
personal strength (PS), spiritual connectedness (SC), relat-
ing to others (RO), and an additional four items (Yanez et al.
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Maternal and Child Health Journal (2020) 24:39–53
2011) to assess current adaptive health behaviors (HB) that
are not part of the PTGI. The CES is scored on a scale from
0 to 125 with higher scores indicating greater resilience. As
it reflects current functioning, it can be administered across
multiple time-points to assess for change over time, thus
capturing resilience as a dynamic growth process (Deshields
et al. 2016; Luberto et al. 2017). The CES has been shown
to be correlated with other measures of psychological well-
being (Luberto et al. 2017). The CES also demonstrated
good internal reliability in the current study (Cronbach’s
alpha = 0.89).
Exploratory Outcomes: Stress Management and Use
of Adaptive Strategies
Stress Reactivity and Coping: Measure of Current Status
(MOCS‑A)
The Measure of Current Status Part A (MOCS) (Carver
2006) is a 13-item self-report measure developed to assess
participants’ current self-perceived status on several skills:
the ability to relax at will, recognize stress-inducing situa-
tions, restructure maladaptive thoughts, be assertive about
needs, and choose appropriate coping responses as needed.
Scores can range from 0 to 52, and higher scores are cor-
related with greater self- perceived proficiency with these
skills. This scale has demonstrated good psychometric prop-
erties in cancer survivors (Penedo et al. 2013; Antoni et al.
2006) and in medical interpreters (Park et al. 2017). Addi-
tionally, it demonstrated adequate internal reliability in the
current study (Cronbach’s alpha = 0.79).
Worry: Penn State Worry Questionnaire (PSWQ)
The Penn State Worry Questionnaire (PSWQ) (Meyer et al.
1990) assesses the tendency towards worry in individuals. It
is rated on a 5-point scale from 1 (‘not at all typical of me’)
to 5 (‘very typical of me’). Three items were administered,
and the total score ranged from 3 to 15, with higher scores
indicating less worry. The PSWQ has been shown to corre-
late with other measures of anxiety and worry (Brown et al.
1992; Dear et al. 2011). Scale internal reliability was also
good in the current study (Cronbach’s alpha = 0.85).
Depression and Anxiety: The Patient Health
Questionnaire‑4 (PHQ‑4)
The Patient Health Questionnaire-4 (PHQ-4) (Kroenke et al.
2009) is a 4-item brief self-report measure that assesses
symptoms of depression and anxiety to assist clinicians in
the diagnosis and treatment of the disease. The measure
was created using two anxiety items from the Generalized
Anxiety Disorder-7 item (GAD-7) (Spitzer et al. 2006) and
Maternal and Child Health Journal (2020) 24:39–53
two depression items from the PHQ-8 (Kroenke et al. 2009)
to allow for quick measurement of symptoms based on the
diagnostic criteria for major depressive disorder in the Diag-
nostic and Statistical Manual Fourth Edition (DSM-IV). The
scale has been validated in primary care settings (shown to
have good reliability and validity among the general popu-
lation) (Löwe et al. 2010). Scale internal reliability in the
current study was good (Cronbach’s alpha = 0.78).
Social Support: MOS Social Support Survey (MOS‑SSS)
The Medical Outcome Study Social Support Survey (MOS-
SSS) (Sherbourne and Stewart 1991) is a 19-item self-report
survey that measures the functional aspects of social support
based on four dimensions: tangible support (material aid
and assistance); affectionate support (love and affection);
positive social interaction (engaging in entertaining activi-
ties with others); and emotional/informational support (feed-
back, guidance and information). Total scores range from
19 to 95, and higher scores reflect higher levels of social
support. The MOS is a widely used measure of social sup-
port that has been translated and tested with diverse popula-
tions; it demonstrated adequate reliability and validity in a
U.S. sample of patients with chronic illness (Sherbourne and
Stewart 1991). Scale internal reliability in the current study
was good (Cronbach’s alpha = 0.98).
Positive Affect: Positive and Negative Affect
Schedule‑Positive Subscale (PANAS‑P)
The Positive and Negative Affect Schedule (PANAS) (Wat-
son et al. 1988) is comprised of two 10-item mood scales;
this study used the 10-item positive subscale with scores
ranging between 10 and 50. The PANAS-P measures posi-
tive constructs as both states and traits. The scale is shown
to be highly internally consistent. The PANAS-P has strong
reported validity with such measures as general distress and
dysfunction, depression, and state anxiety. The PANAS-P
has been used widely in research on mind-body interven-
tions (West et al. 2004; Raghavendra et al. 2009; Danhauer
et al. 2009; Merz et al. 2013). Scale internal reliability in
the current study was good (Cronbach’s alpha = 0.80) and
is in line with other studies that have reported high internal
consistency (Morrison and Heimberg 2013; Kessing et al.
2014). The PANAS has also been used when evaluating the
effects of mind-body interventions (Sherbourne and Stewart
1991; Vadiraja et al. 2009; Danhauer et al. 2009).
Empathy: Interpersonal Reactivity Index (IRI)
The IRI is a validated 28-item self-assessment of cognitive
and affective components of empathy (Davis 1980). It is
scored based on 4 sub-scales; we used the 7 item sub-scale
45
on Perspective Taking which assesses the extent to which
individuals spontaneously (try to) adopt others’ points of
view. Respondents were asked to rate the degree (0 = does
not describe me well − 4 = describes me very well) to which
an item describes them, such as, “I try to look at every-
body’s side of a disagreement before I make a decision.”
Items are summed, scores ranging between 7 and 35 with
higher scores indicating greater perspective taking. Scale
internal reliability in the current study was good (Cronbach’s
alpha = 0.88) and is in line with other studies demonstrating
its high reliability (Hawk et al. 2013; Molina-Lucas et al.
2017).
Mindfulness: The Cognitive and Affective Mindfulness
Scale‑Revised (CAMS‑R)
The CAMS-R (Feldman et al. 2007) is a 12-item scale
that measures everyday mindfulness, and it focuses on the
degree to which examinees experience their thoughts and
feelings. The CAMS-R is useful for studies examining the
association of mindfulness with an individual’s personal-
ity traits or examining mindfulness as a predictor of adjust-
ment, behavior, or response to treatment. Items are rated on
a 4-point Likert scale from 1 (rarely/not at all) to 4 (almost
always). The CAMS-R exhibited acceptable convergent and
discriminant validity with other measures of mindfulness,
emotional clarity, avoidance, and over-engagement. Scores
range between 12 and 48 and higher mindfulness scores
were significantly correlated with lower distress scores as
measured by the subscales of the Mood and Anxiety Symp-
toms Questionnaire (r = − .23 to − .44), suggesting good
construct validity (Hawk et al. 2013). The CAMS-R dem-
onstrates appropriate reliability and validity (Feldman et al.
2007), which is further supported in our study (Cronbach’s
alpha = 0.78).
Randomization
We asked participants for their daytime or evening time pref-
erences prior to randomizing them to the IG or WG from
November 2016 to September 2017, balancing for group
size. Participants were randomized using a random plan gen-
erator, with 1:1 randomization.
Statistical Analyses
To assess study feasibility, we assessed enrollment, interven-
tion session attendance (≥ 6) and retention at time 2 (75%
response; intervention group: end of intervention; wait-list
control: 3-month post-enrollment) and time 3 (intervention
group: 3-months post end-of intervention; wait-list con-
trol: end of intervention). Study completers and non-com-
pleters at time 2 were compared on baseline demographic
13
46
characteristics using independent samples t tests for continu-
ous variables and χ2 tests or Fisher’s exact tests for categor-
ical variables. To assess study acceptability, we reviewed
participant self-report survey feedback (e.g., satisfaction
with the number and length of intervention sessions, com-
fort level with group sessions, and continued RR practice)
and open-ended qualitative program feedback. To explore
preliminary efficacy of the intervention to improve our pro-
posed psychosocial outcomes, we first characterized the two
randomized groups (intervention group and wait-list control)
by baseline demographic factors and reviewed baseline psy-
chosocial data for univariate distributions. We then used all
available data to test between-group (intervention group ver-
sus wait-list control) differences in change scores from time
1 to time 2 (intervention group: end of intervention; wait-list
control: 3-month post-enrollment) using independent sam-
ples t tests. Using the intent-to-treat principle, we replicated
the analysis using multiple imputation (Rubin 2004) (five
imputed datasets) to address missingness at time 2.
We followed our main preliminary efficacy analyses with
a series of paired samples t tests using all available data, to
further characterize results. First, we evaluated changes in
scores from time 1 to time 2 within each randomized group.
To further explore intervention efficacy, we evaluated the
combined change from pre- to post-intervention across inter-
vention group condition participants (using time 1 to time 2
data) and wait-list control participants (using time 2 to time
3 data). Finally, we explored potential maintenance of inter-
vention benefits by evaluating change in scores from time 2
to time 3 within the intervention group only. Additionally,
to support a future larger scale trial, including identification
of a potential moderator of intervention effects, we explored
whether greater parenting stress at baseline was associated
with greater changes in our proposed psychosocial outcomes
among participants (before intervention and end of interven-
tion) using Pearson correlations. Analyses were conducted
using IBM SPSS version 23.
Results
Participants
Participants (Table 1) were primarily female (90.6%), mar-
ried/in a domestic partnership (90.6%) and non-Hispanic
white (88.5%), with a mean age of 47 years (SD = 5.6). Most
participants had obtained a college degree (96.2%) and over
two-thirds (69.8%) were currently employed full or part-
time for wages. Participants reported having one (73.6%)
or two to three (24.5%) children with a LAD, across a wide
range of ages (ages 3–24); their children were affected by
dyslexia or other learning difficulties (43.4%), attention dif-
ficulties (20.8%) or both (35.8%). The sample represented
13
Maternal and Child Health Journal (2020) 24:39–53
parents from across the United States, including the North-
east (33%), South (26%), West (26%), and Mid-West (13%)
regions.
Feasibility
Among 123 parents who expressed interest in study partici-
pation, 54 (45.3%) enrolled in the study and were randomly
assigned to the intervention group (n = 31) or wait-list con-
trol (n = 23) condition (Fig. 3). Primary reasons for non-
enrollment include inability to reach parent for subsequent
screening (n = 37), and lack of parent interest following
initial contact (n = 27). Four were determined ineligible.
Among enrollees, one participant withdrew prior to complet-
ing the time 1 survey, leaving a total of 53 study participants.
Participants (n = 53) attended a median of 6 out of 8 ses-
sions; 62.5% of participants completed ≥ 6/8 sessions, and
participation rates were similar across both groups. Among
enrolled participants, 40 (75.5%) completed the time 2 sur-
vey and 35 (66.0%) completed the time 3 survey. The larg-
est proportion of dropout (38.7%) occurred in the interven-
tion group condition between time 1 and time 2, with one
group conducted in the late spring which overlapped with
the end of the school year. Study completers (n = 40) and
non-completers (n = 13) did not differ by demographic fac-
tors assessed at enrollment.
Acceptability
Using the post-intervention survey, participants reported
being comfortable in the group sessions, and 93.9% said
the sessions were the right length. Regarding the number
of sessions, 66.7% reported that 8 were the right number of
sessions, and 30.3% said that there were too few sessions.
Eighty-one percent of participants practiced relaxation elic-
itation exercises daily to a few times a week across both
the intervention and wait-list groups. Overall qualitative
responses to the program and video delivery were positive.
Albeit there were occasional technical glitches, the conveni-
ence of the virtual platform greatly outweighed any minor
problems. There was also a sense that participants were used
to technical challenges; furthermore, individuals’ comfort
level with the technology grew over time. One participant
said, “I loved the virtual delivery since I am so far away
and we do not have many resources for parents in my rural
state. This was a ‘god send’ for me”. Many noted forming
a “connection” with the group. Parents expressed enjoy-
ing the group sharing, learning about others, and having a
sense of “community” and “accountability.” They expressed
appreciation for learning and reinforcing coping skills. Many
parents expressed a desire for continuation of the group ses-
sions; specific suggestions for a tapered interval approach
(monthly sessions) were made.
Maternal and Child Health Journal (2020) 24:39–53 47

Table 1  Parent characteristics at Variables n (%) or M ± SD p

study enrollment (total n = 53;
intervention group n = 31, Total Intervention Waitlist
waitlist control n = 22)
Age 47 ± 5.7 47 ± 6.2 47 ± 4.9 .59
Female 48 (90.6) 26 (83.9) 22 (100.0)
Hispanic/Latino 2 (3.8) 1 (3.2) 1 (4.5) .67
Race+ .66
White 48 (90.6) 28 (90.3) 20 (90.9)
Asian 2 (3.8) 1 (3.2) 1 (4.5)
Black or African American 2 (3.8) 1 (3.2) 1 (4.5)
Marital status# .63
Married/living as married 48 (90.6) 27 (87.1) 21 (95.5)
Divorced/separated 2 (3.8) 1 (3.2) 1 (4.5)
Never married 2 (3.8) 2 (6.5) 0 (0.0)
Education level
Some college/technical school 1 (1.9) 1 (3.2) 0 (0.0) 1.00
College graduate 51 (96.2) 29 (93.5) 22 (100.0)
Geographic location .97
Northeast 18 (34.0) 10 (32.3) 8 (36.4)
South 14 (26.4) 8 (25.8) 6 (27.3)
West 14 (26.4) 9 (29.0) 5 (22.7)
Mid-west 7 (13.2) 4 (12.9) 3 (13.6)
Employment status
Employed/self-employed 37 (69.8) 20 (64.5) 17 (77.3) .54
Not employed/self-employed 15 (28.3) 10 (32.3) 5 (22.7)
Number of children with ­LADa .76
1 39 (73.6) 23 (74.2) 16 (72.7)
2–3 13 (24.5) 7 (22.6) 6 (27.3)
Age of child(ren) (years)a
3–11 28 (52.8) 16 (51.6) 12 (54.5) 1.00
12–16 27 (50.9) 16 (51.6) 11 (50.0) 1.00
≥ 17 4 (7.5) 3 (9.7) 1 (4.5) .63
LAD diagnos(es) .11
Dyslexia/learning difficulties 23 (43.4) 17 (54.8) 6 (27.3)
Attentional 11 (20.8) 6 (19.4) 5 (22.7)
Both 19 (35.8) 8 (25.8) 11 (50.0)
Parental stress 46.7 ± 9.4 47.4 ± 9.8 45.7 ± 8.9 .52

Missing n = 1 for all variables except age, gender and LAD diagnosis; LAD = learning and attentional dis-
abilities
+ p value indicates White versus other
# p value indicates married/living as married versus other
a
% parents who have at least 1 child in the age category. If parent has > 1 child in same age category, parent
is still counted only once for that category

Exploratory Outcomes: Stress Management and Use
of Adaptive Strategies
Sociodemographic factors did not differ between interven-
tion and wait-list control groups. Based on between-group
differences in change scores from time 1 to time 2 (Table 2;
primary analyses), the intervention group showed greater
improvements in the primary outcomes (distress [VAS]:
∆M = − 1.95, CI = − 3.44, − .46, p = .01, d = .83; and resil-
ience [CES]: ∆M = 6.38, CI = 1.36, 11.40, p = .01, d = .83);
and several secondary outcomes (stress coping [MOCS-A]:
∆M = 8.69, CI = 4.72, 12.65, p ≤ .001, d = 1.39; depres-
sion and anxiety [PHQ-4]: ∆M = − 1.79, CI = − 3.42, − .15,
p = .03, d = .71; social support [MOS-SSS]: ∆M = 5.47,
CI = .46, 10.48, p = .03, d = .71; empathy [IRI]: ∆M = 3.17,
CI = .46, 5.88, p = .02, d = .77; and mindfulness [CAMS-R]:

13
48
Fig. 3  Study enrollment
∆M = 3.45, CI = .86, 6.05, p = .01, d = .86) relative to the
wait-list control groups, with medium to large effect sizes for
all differences. The intervention group also showed medium
effect sizes in worry (PSWQ) and positive affect (PANAS-
P) relative to the wait-list control groups, although these
differences did not reach statistical significance. Results
of pooled analyses using multiple imputation to address
time 2 data missingness showed a similar pattern of results,
such as that the intervention group continued to show
13
Maternal and Child Health Journal (2020) 24:39–53
greater improvements in all proposed outcomes (p’s < .05)
except for worry (PSWQ) and positive affect (PANAS-P)
(p’s = .13), relative to the wait-list control group (Supple-
mental Table 1).
Within group differences in change scores from time 1 to
time 2 (Table 3), the intervention group showed improve-
ments from time 1 (enrollment) to time 2 (end of interven-
tion) in our proposed primary outcomes (distress [VAS]
and resilience [CES]) and several exploratory outcomes,
Maternal and Child Health Journal (2020) 24:39–53 49

Table 2  Between-group Variables M (SD) M diff 95% CI t p d

differences in change scores
from enrollment (time 1) to Intervention Waitlist
end of treatment (intervention
group)/three months post- Distress (VAS) − 1.47 (2.44) .48 (2.23) − 1.95 − 3.44,− .46 − 2.65 .01 .83
enrollment (waitlist control) Resiliency (CES) 7.67 (7.33) 1.29 (8.03) 6.38 1.36,11.40 2.57 .01 .83
(time 2) of intervention group Stress reactivity/stress cop- 7.74 (7.59) − .95 (4.57) 8.69 4.72,12.65 4.44 <.001 1.39
and waitlist control participants ing (MOCS-A)
Worry (PSWQ) − 1.33 (1.85) <.001 (2.70) − 1.33 − 2.86,.19 − 1.77 .09 .57
Depression/anxiety (PHQ-4) − 1.83 (2.53) − .05 (2.50) − 1.79 − 3.42,− .15 − 2.21 .03 .71
Social support (MOS-SSS) 5.28 (8.25) − .19 (7.19) 5.47 .46,10.48 2.21 .03 .71
Positive affect (PANAS-Pos) 2.39 (4.98) − .10 (4.07) 2.48 − .45,5.42 1.71 .10 .55
Empathy (IRI) 1.83 (3.70) − 1.33 (4.52) 3.17 .46,5.88 2.37 .02 .77
Mindfulness (CAMS-R) 2.83 (4.11) − .62 (3.88) 3.45 .86,6.05 2.70 .01 .86

Bold values indicate p < .05

d = Cohen’s d (effect size); sample sizes for analyses reflect available data from study completers at time 2
for the intervention group (n = 19) and waitlist control (n = 21) groups

Table 3  Within-group changes from time 1(enrollment) to time 2 including stress coping (MOCS-A), depression and anxi-
(intervention group: end of treatment, waitlist control: 3 months post- ety (PHQ-4), social support (MOS-SSS), worry (PSWQ),
enrollment) of participants of intervention group and waitlist control
and mindfulness (CAMS-R); positive affect (PANAS-P)
participants
and empathy (IRI) approached significance (p = .058 and
Variables M (SD) t p p = .051 respectively). In comparison, the wait-list control
Time 1 Time 2 group did not show changes in any of the proposed outcomes
during this time.
Distress (VAS)
Analyses of pre-intervention to end of intervention
Intervention 5.3 (2.0) 3.8 (1.8) 2.64 .017
change using all available data (Table 4; n = 36; interven-
Waitlist 5.1 (2.2) 5.6 (1.8) -.98 .34
tion group: time 1 to time 2, wait-list control: time 2 to
Resiliency (CES)
time 3) showed participant improvements in all primary
Intervention 77.3 (10.7) 85.0 (8.7) − 4.44 <.001
and exploratory outcomes (p’s ≤ .01) except for positive
Waitlist 81.9 (13.6) 83.2 (14.0) − .73 .47
affect (PANAS-P). Exploration of the association of base-
Stress reactivity/coping (MOCS-A)
line parental stress with pre/post change scores for the psy-
Intervention 23.2 (8.0) 30.9 (6.1) − 4.44 <.001
chosocial outcomes showed a significant association with
Waitlist 22.1 (6.8) 21.2 (6.7) .96 .35
change in distress. Higher baseline parenting stress scores
Worry (PSWQ)
was negatively associated with VAS distress change scores
Intervention 7.6 (2.1) 6.2 (2.1) 3.06 .007
(r = − .37, p = .018).
Waitlist 8.5 (3.6) 8.5 (3.3) <.001 1.00
To assess maintenance of intervention improvements,
Depression/anxiety (PHQ-4)
results of within-group analysis of change in proposed psy-
Intervention 4.4 (2.1) 2.6 (1.6) 3.08 .007
chosocial outcomes only in the intervention group from time
Waitlist 3.6 (2.4) 3.6 (2.9) .09 .93
2 to time 3 (end of intervention to 3-months post end-of
Social support (MOS-SSS)
intervention) showed that the intervention group’s time 2
Intervention 71.9 (16.7) 77.2 (14.7) − 2.71 .015
values did not change at time 3 (p ’s ≥ .29; Table 5).
Waitlist 72.7 (18.4) 72.5 (17.4) .12 .91
Positive affect (PANAS-Pos)
Intervention 33.1 (6.0) 35.4 (5.4) − 2.03 .058
Discussion
Waitlist 34.5 (4.2) 34.4 (5.2) .11 .92
Empathy (IRI)
Parents of children with LAD are a growing population with
Intervention 18.8 (6.4) 20.7 (4.5) − 2.10 .051
unmet needs, yet a targeted psychosocial program to address
Waitlist 18.9 (4.9) 17.5 (4.9) 1.35 .19
these needs has not been developed. Thus, we modified a
Mindfulness (CAMS-R)
resiliency program to target the needs of parents of children
Intervention 38.9 (4.7) 41.8 (3.3) − 2.93 .009
with LAD and tested the intervention in a 2-phase pilot rand-
Waitlist 41.7 (6.0) 41.0 (5.5) .73 .47
omized wait-list controlled study. Through a mixed methods
Bold values indicate p < .05 exploration, we established that a virtually delivered group

13
50 Maternal and Child Health Journal (2020) 24:39–53

Table 4  Within-group changes Variables M (SD) t p

from pre-intervention to end
of treatment using all available Pre-intervention End of intervention
data (intervention group: time 1
to time 2; waitlist control: time Distress (VAS) 5.3 (1.8) 4.2 (2.0) 2.96 .005
2 to time 3 Resiliency (CES) 80.3 (13.2) 84.7 (11.2) − 3.21 .003
Stress reactivity/stress coping 22.7 (7.4) 30.4 (6.3) − 6.32 < .001
(MOCS-A)
Worry (PSWQ) 7.9 (2.8) 6.6 (2.7) 2.82 .008
Depression/anxiety (PHQ-4) 3.7 (2.5) 2.3 (1.7) 3.53 .001
Social support (MOS-SSS) 73.8 (16.1) 77.5 (15.2) − 2.70 .01
Positive affect (PANAS-Pos) 34.3 (5.5) 35.8 (5.5) − 1.93 .06
Empathy (IRI) 18.6 (5.6) 20.8 (4.0) − 3.04 .005
Mindfulness (CAMS-R) 40.4 (5.3) 42.1 (4.2) − 2.59 .01

Bold values indicate p < .05

Sample sizes for analyses reflect available data from study completers from time 1 to time 2 for the inter-
vention group (n=19) and from time 2 to time 3 for the waitlist control (n = 17)

Table 5  Within-group changes from time 2 (end of treatment) to time continued treatment following the intervention. Importantly,
3 (3-months post end-of treatment) in the intervention group the program successfully generated improvements in distress
Variables M (SD) t p and resilience as well as several secondary outcomes (stress
coping, depression and anxiety, social support, and empa-
Time 2 Time 3
thy). These improvements were maintained 3 months follow-
Distress (VAS) 3.9 (1.8) 4.4 (1.7) − .86 .40 ing program completion; most parents reported continued
Resiliency (CES) 84.8 (8.9) 84.1 (10.0) .33 .75 practice of their relaxation elicitation strategies.
Stress reactivity/stress coping 30.5 (6.0) 31.4 (6.5) − .53 .60 Despite the unmet needs of these parents nationally, a
(MOCS-A) resiliency treatment had not previously been conducted with
Worry (PSWQ) 6.3 (2.2) 6.2 (2.6) .11 .92 parents of children with LAD. This is a missed opportu-
Depression/anxiety (PHQ-4) 2.8 (1.6) 2.3 (1.9) 1.10 .29 nity as parents, across socioeconomic levels, are increas-
Social support (MOS-SSS) 76.6 (14.8) 74.1 (15.1) .94 .36 ingly using the internet to seek support and information for
Positive affect (PANAS-Pos) 35.5 (5.6) 34.7 (4.7) .61 .55 their parenting needs (Plantin and Daneback 2009). A recent
Empathy (IRI) 20.4 (4.5) 20.4 (4.6) .14 .89 review of technology-assisted interventions for parents dem-
Mindfulness (CAMS-R) 42.1 (3.1) 42.4 (3.2) − .62 .55 onstrated the feasibility and acceptability of video-confer-
Sample sizes for analyses reflect available data from study completers encing interventions for a variety of parent training manage-
at time 3 for the intervention group (n = 18) ment; these studies intervened with parents of children with
Autism Spectrum Disorder, children with medical problems,
and parents who struggled with substance abuse and mental
resiliency program was feasible and acceptable, and showed illness (Hall and Bierman 2015). Although our session par-
preliminary efficacy. We successfully engaged parents from ticipation rates were relatively high, supporting feasibility
all four major regions of the country (Northeast, Southern, of the virtual modality, there were some challenges with
Midwest, and West) with the majority of parents residing in using virtual delivery. Specifically, factors such as parents
the Northeast. multitasking during groups, interruptions from children/pets,
Our qualitative findings reinforced that parents caring and technical issues (sound problems, getting disconnected,
for children with a range of LAD are in need of additional unable to log on, etc.) at time interrupted session flow. How-
psychosocial support. Overall, parents of children with LAD ever, importantly, these issues were easily handled by the
experienced high levels of relationship stress that would ben- group facilitator and by having a study coordinator on call
efit from increases in social support, communication skills, for each group so that group leaders did not have to interrupt
and resiliency training. Parents of children with LAD who the group flow to provide technical support.
enrolled in our pilot trial indeed exhibited high levels of This study has some limitations of note. This is a pilot
parental stress (parenting stress: M = 47.5, SD = 10.1 com- study and thus not a nationally representative sample.
pared to population norm M = 37.1) (Berry and Jones 1995). All measures were self-reported. One intervention group
Parents engaged in this video-delivered platform, participat- conducted in the late spring had a noticeably high drop-
ing in the majority of sessions, and many parents requested out, which we believe was likely due to end of school year

13
Maternal and Child Health Journal (2020) 24:39–53
activities and transitions. We enrolled mainly mothers,
and this was a relatively homogenous, highly educated (all
but two participants were college educated) sample; cur-
rent findings may thus not extend to fathers and parents of
diverse backgrounds. The lack of racial/ethnic heterogene-
ity in our sample may be attributed to the general under-
identification of LAD among racial/ethnic communities
(Reilly et al. 2015) and subsequent lack of access to special
education services. It is possible that our recruitment efforts
may have not adequately reached this population. It is also
possible that racial/ethnic minorities experienced additional
burdens and barriers that made it more challenging to par-
ticipate (Konkel 2015). The requirement to have access to
the internet and an electronic device with a camera may have
also reduced diversity in study enrollment.
Our study has several implications for future work. Quali-
tative findings, which highlighted parents’ perspectives
on the struggles of children with LAD and their siblings,
indicate that intervening with LAD children and their sib-
lings could be beneficial. In addition, marital strain was a
common theme in the qualitative findings, suggesting the
possible need for dyadic or family interventions in future
work. We would also seek to recruit from broader and more
diverse populations. As parents with the highest levels of
baseline parenting stress showed smaller improvements in
distress following intervention participation, tailoring the
intervention, or intervention dose, based on level of parental
stress, may be considered to determine whether a subgroup
of parents need more intensive intervention. Additionally,
future studies should explore the value of monthly follow-
up sessions, for long-term skill maintenance, as well as cost
analyses of intervention delivery.
This study addresses parental well-being—specifically
related to distress and resilience. In addressing paren-
tal health, the SMART-3RP intervention targets one of
the reporting domains for the Maternal and Child Health
Bureau’s State Action Plan (State Action Plan 2018). In
addition, children with LAD are a subset of children with
special health care needs, a population served by state Title
V Maternal and Child Health Services. In sum, this stress
management and resiliency intervention, delivered nation-
ally, showed promise in reducing distress, increasing coping
skills, and promoting social support, among parents of chil-
dren with an LAD. Future work will focus on assessing the
effectiveness and implementation of this intervention with
a larger and more diverse population.
Funding Funding for this research was provided by the Marino Health
Foundation (no grant number). All authors declare that he/she have
no conflict of interest. All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
51
standards. Informed consent was obtained from all individual partici-
pants included in the study.
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Affiliations
Elyse R. Park1,2,4 · Giselle K. Perez1,4 · Rachel A. Millstein1,4 · Christina M. Luberto1,2,4 · Lara Traeger1,4 ·
Jacqueline Proszynski1,2 · Emma Chad‑Friedman1,2 · Karen A. Kuhlthau3,4
1 3
Department of Psychiatry, Massachusetts General Hospital,
Boston, MA, USA
2 4
The Benson-Henry Institute for Mind Body Medicine
at Massachusetts General Hospital, Boston, MA, USA
53
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Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Department of Pediatrics, Massachusetts General Hospital,
Boston, MA, USA
Harvard Medical School, Boston, MA, USA
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