Mobilizing the psychology evidence base for the treatment of pediatric chronic pain: The development, implementation, and impact of the Comfort Ability Program

Abstract Over the past 20 years, our knowledge regarding evidence‐based psychological interventions for pediatric chronic pain has dramatically increased. Unfortunately, access to evidence‐based pain management interventions remains a challenge for many children and adolescents who suffer with persistent pain. Reducing patient burden and system‐level barriers to care are a central target of clinical innovations in pain treatment intervention. Psychological interventions are also increasingly focused on reducing biomedical biases that may inhibit attainment of services. While there are many new psychological interventions across an array of delivery platforms, few interventions have been systematically disseminated. This paper will highlight the translational research procedures that have informed the development and dissemination of the Comfort Ability Program (CAP), an interactive group‐based intervention teaching adolescents and their parents evidence‐based strategies to manage chronic or persistent pain. Now in its fifth year of dissemination, CAP has a demonstrated record of success with cross‐institutional implementation and sustainability at 18 hospitals across three countries. This paper reviews six dynamic and iterative phases of development, based on the Graham et al knowledge‐to‐action cycle (2006), that have guided the implementation and dissemination research for this program. The phases of CAP development include the following: (a) identifying knowledge and clinical gaps in care, (b) generating knowledge assets and implementation procedures, (c) evaluating clinical outcomes and system‐level processes, (d) developing and testing dissemination procedures, (e) expanding partnerships and monitoring knowledge use, and (f) sustaining knowledge use and continued innovation. This paper targets primarily health professionals and administrators and secondarily caregivers and the public at large.


KNOWLEDG E DISS EMINATION
Across pediatric care, there remain significant gaps between scientific knowledge and routine clinical practice. In pediatric healthcare research, where funding resources are scarce, it is essential to build a conduit through which evidence-based knowledge can actively inform clinical practice. Currently, it is estimated to take 17 years-an entire childhood-for evidence-based interventions to trickle into practice. 1,2 There are several issues that contribute to this problem.
From a research standpoint, the slow and arduous process of moving knowledge into practice via scientific publications and continuing education tools alone is insufficient to bring about systematic improvements in care. 1 From a clinical practice perspective, overburdened practitioners often lack the time, system-level support, and specific expertise to generate and implement new interventions that address critical gaps in care. Finally, at the institutional level, bureaucratic organizations and complex healthcare systems may lack the flexibility or initiative to spearhead practice innovation. Moreover, institutions may be hindered by implementation difficulties, relying on outmoded procedures for systematically implementing change.
The many challenges that thwart the knowledge-to-practice pipeline are, at a fundamental level, related to the lack of connectivity between two distinct populations: the evidence producers (scientists and researchers) and the evidence consumers (practitioners and healthcare institutions). 2 While a formidable challenge, this identified chasm simultaneously presents opportunities for innovative translational and implementation science designed with intent to address both the clinical gaps in care and the system-level demands that impede change. Pediatric psychologists who commonly straddle the two worlds of research and direct patient care may be particularly well-poised to develop, evaluate, and disseminate interventions that can effectively help to close this gap. 3 Closing the knowledge-to-practice gap in pediatric psychology means that clinical research must be tied to translational science.
When there is a shared focus on dissemination and implementation procedures, knowledge creation is enhanced. This systematic approach boosts knowledge dissemination by employing research-supported practices for sharing information with end-users and the evaluation of the process by which this information is integrated into care. One theoretical model that fully incorporates the rigors of the translational science process with the mobilization of knowledge is the "knowledge-to-action cycle" by Graham et al. Within Graham's model, knowledge creation occurs in a synergistic and evolving cycle that includes identification of the problem, adapting knowledge at the local context, assessing barriers to knowledge use, tailoring interventions and implementation procedures, monitoring knowledge use, evaluating outcomes, and sustaining knowledge use. Within this model, each phase of the knowledge creation process informs existing and future assets of the intervention. Moreover, the knowledge-to-action cycle describes how intervention effectiveness and implementation procedures are truly inter-related processes. In a rapidly expanding field such as pediatric psychology, the goal of intentionally designing interventions for successive modification based on new research, on patient and practitioner response, and on system-level needs is particularly compelling. (CAP) is a psychological intervention for adolescents with chronic pain and their parents, designed   expressly to addresses several identified knowledge-to-practice   gaps in the field of pediatric pain. CAP was developed to mobilize the   psychology research evidence base for pediatric chronic pain, pro-viding enhanced access to essential skills and strategies for patients and their parents. The main objective was to generate a targeted, patient-centered, engaging intervention that could be systematically replicated to optimize knowledge mobilization. The phases of development for this program, including both the clinical and translational science components, are illustrated in Figure 1. While CAP is closely aligned with Graham's theoretical knowledge-to-action cycle, the six phases in Figure 1 illustrate the real-world translational science practice that has unfolded as CAP progressed through knowledge creation, evaluation, and dissemination. At the center of the figure are CAP's assets, including the evidence-supported clinical content (patient workbooks, leader manuals), training protocols, program enhancements (website, online chats), and partners (CAP network sites and patient-partners). The outside spokes in this figure enumerate the phases of development of CAP over the last eight years. Notably, this figure highlights the hallmark feature of Graham's theoretical model, the cyclical and bidirectional flow of information that influences knowledge creation and dissemination throughout each phase of development. By adhering to this dynamic process, CAP assets, implementation procedures, and dissemination protocols can continue to be tailored for optimal impact. Importantly, while this article outlines a step-wise translational science paradigm that has shaped CAP's development, it also highlights the iterative and evolving process of translational science more broadly. The key phases of development that have informed the creation of CAP are described below. Each phase includes core knowledge mobilization strategies and goals, while integrating CAP's real-world experience with program development, research, and dissemination processes.

| IDENTIF YING G APS IN KNOWLEDG E AND C ARE , ACCE SS BARRIER S , AND PR AC TICE-INFORMED SOLUTIONS
The Comfort Ability Program was first developed in 2011 in response to a synthesis of the gap between scientific knowledge and practice in pediatric pain psychology. Specifically, there was a clear need for a psychological intervention that could provide accessible, non-stigmatizing, supportive, psychoeducation, and handon skills training. The program was further spurred by an urgent need to more efficiently provide psychological services to patients within the Pain Treatment Service at Boston Children's Hospital where long waitlists for psychological services were a significant impediment to care. Recognizing that the clinical and system-level challenges faced by one institution are often emblematic of more widespread difficulties, it was hoped that a well-designed intervention could be scaled for implementation in a larger ecosystem of care. As will be discussed below, the original framework for Comfort Ability Program was informed by systematically identifying and evaluating gaps in knowledge and care, thoughtful consideration of access barriers, and by taking an evidence-informed approach to the development of the delivery mechanism to maximize impact.

| Gaps in knowledge and care
Chronic and persistent pain in pediatrics is an increasingly common problem, with one in four adolescents experiencing at least one 3-month episode of pain at some point in their development. 4,5 Persistent pain is known to be associated with functional impairment for pediatric patients (eg, school absenteeism, poor quality of life, development of internalizing disorders, increased severity of pain), and with psychosocial and psychological impact on the child's family. 1,6,7 Youth with chronic pain are high consumers of medical services, 8 and when chronic pain is left untreated, there is increased risk for chronic pain in adulthood. 1 Given the well-established opioid epidemic for adults, [9][10][11] the risk associated with untreated chronic pain in adolescents is especially concerning. Notably, the financial impact of managing chronic pain has been overwhelming for the healthcare system in the United States, costing an estimated 19.5 billion dollars annually, and ranking among the top three most expensive pediatric healthcare problems in the world. 8,[12][13][14] Given all these factors, researchers and clinicians have made a widespread call to action for the implementation of evidence-informed, psychologically based pain management interventions as part of a multidisciplinary approach to care. 1,15 Indeed, psychological interventions are well known to reduce pain and improve both physical and psychological functioning for pediatric patients. [16][17][18][19] Specifically, interventions such as those based on behavioral therapy, cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction, and self-regulatory psychophysiological approaches such as biofeedback-assisted relaxation, are well-established and have been shown to be efficacious at reducing both pain intensity and disability and at improving psychological functioning. [16][17][18][19] Unfortunately, access to these types of psychological intervention remains challenging for many patients. Although a multidisciplinary treatment plan often includes recommendations for psychological services, research suggests that patients with pain much more commonly access physical therapy and medical intervention (ie, medications, additional testing) in multidisciplinary models of care. 20

| Access barriers
Working directly with a psychology provider who has expertise in pediatric pain psychology in a traditional one-on-one clinical practice can be an effective way for children with chronic pain to gain targeted intervention. Unfortunately, a primary access barrier is that there is a scarcity of pediatric behavioral health providers who have expertise in working with youth with chronic pain. Even when providers are available, there may be patient-centered barriers such as scheduling conflicts, geographic limitations, and insurance or cost factors to consider. 14,15,20 Another particularly challenging access barrier relates to biomedical biases and patient and parent exposure to psychological intervention.
Research demonstrates that a positive past engagement with psychology is highly predictive of future engagement. 21,22 In one study assessing engagement in psychological intervention for pain, parents' familiarity with psychological interventions (ie, biofeedback, hypnosis) was positively associated with their child's engagement in treatment and pre-

| Practice-informed solutions
In the development of CAP, practice-informed solutions were generated by asking the question, "How do we maximally share our evidence-base while minimizing the identified access barriers that restrict engagement?" This question guided the framework for the program, helping to establish a unique format to enhance accessibility and support.
A well-established way of making CBT and other empirically based interventions accessible to children and families, but still offering the personalization of working with a psychologist, as well as gaining support from peers, is using a brief group intervention.
Within the pediatric literature, brief (<6 hours) psychoeducational and CBT interventions have demonstrated promising gains on variables such as self-efficacy, self-management, pain catastrophizing, family functioning, psychosocial well-being, pain severity, school attendance, and feelings of hopefulness. [23][24][25] Additionally, as parent training unequivocally enhances child outcomes in pediatric pain, 18 one of CAP's key practice-informed goals was to design an intervention that simultaneously engaged parents and adolescents.
Condensing psychological interventions into a 1-day workshop format has the added benefit of reducing scheduling barriers, increasing the likelihood of attracting families from a greater geographic area, and reducing the likelihood that patients will receive only a partial "dose" of the intervention, as this can occur when patients miss one or more group sessions in a multi-week treatment approach. 26 Moreover, evidence suggests that initial therapeutic-related gains at 1-month follow-up could be maintained for as long as 1-year after an intensive day-long intervention. 25,27,28 Importantly, brief psychoeducational interventions have a high rate of satisfaction from participants and are known to have similar benefits to patients with pain as compared with other structured CBT interventions [29][30][31] .
To further reduce patient burden (ie, minimize loss of school and work time), increase participation, and minimize negative biases about psychology, research also suggests that CBT and psychoeducational interventions have been most effective when they are run on the weekends, are held outside of a mental health setting, and when they use non-diagnostic titles. 32,33 The synthesis of this important research led to the generation of the non-diagnostic name (The Comfort Ability) and the impetus to run the program on the weekend.
Comfort Ability Program was designed to address the needs of adolescents and families at various levels of readiness for change. It was initially designed as an entry-level intervention, offering widely applicable psychoeducation, neuroscience education, and skills training. In clinical practice, it can function as a stand-alone program, a roadmap for adolescents who are working with a mental health provider, or as a precursor for a more intense psychological treatment such as a day treatment program. Ongoing CAP research efforts are addressing the delivery of CAP across all such clinical situations and as intimate part of the knowledge synthesis and knowledge tool refinement.

| G ENER ATE K NOWLEDG E , A SS E TS , AND LOC AL IMPLEMENTATION PROCEDURE S
The Comfort Ability Program was developed to serve a large number of families presenting for care at the local level. This included families who had an adolescent (ages 10-17 years old) with a wide range of common types of persistent pain, such as headache, abdominal, neuropathic, and/or musculoskeletal pain, disease-related pain, postinjury pain, or other kinds of persistent pain. CAP was designed to serve as first-line intervention, or primary prevention for chronic pain, through targeted psychoeducation, neuroscience pain education, an array of cognitive behavioral therapy and other evidence-based intervention skills, parent training skills, and additional science-backed resources. Moreover, while CAP was nested within the Pain Treatment Service, it was intended to serve the whole hospital community. The goal was to enhance access to care more broadly. As such, CAP accepted direct referrals to the intervention from specialists such as neurologists, gastroenterologists, rheumatologists, and other specialty services where adolescents with persistent pain are likely to be treated. Figure 2 illustrates the general framework of CAP. In addition to the adolescent and parent workbooks (approximately 65 pages each), CAP program assets also include clinical leader's manual for each the adolescent and the parent programs (78 pages each). These manuals provide structured content for clinical administration, prompts for discussion within the group setting, and guidelines for managing potentially challenging clinical issues. They also provide suggested timelines for content delivery and resources for CAP clinicians.

| Evaluate clinical and system-based processes
Results from a single-arm study of 120 families confirmed that CAP was a highly feasible and acceptable intervention. 16

| DE VELOP AND IMPLEMENT D ISS EMINATI ON PRO CEDURE S WITH A S HARED FO CUS ON IN S TITUTI ONAL AND PROVIDER E XPERIEN CE
In 2014, CAP was approached by a Canadian children's hospital requesting the resources and support to launch the program in their institution. At that time, based on the testing and modification cycle as described above, CAP had readiness to explore dissemination. In entering this phase of the knowledge-to-action dissemination cycle,

| Institutional-level considerations
Early in the transfer process, it became evident that institutional-

| Provider-level considerations
Concomitant with the standardization of CAP implementation and dissemination processes, additional focus was placed on the process of training clinicians in the CAP clinical content and procedures.
CAP was written and designed by a pediatric psychologist with expertise in pain management. It was intended to amplify the clinical reach of pediatric psychologists embedded within healthcare systems by providing a highly structured, well-designed group-based program that honed and expanded the clinical skill set commonly

TA B L E 1 Focus on feedback -sample responses
Adolescent feedback "One of the biggest things I gained from this experience was the chance to finally meet others who are going through something. It was wonderful because each of us had sort of felt … alone." ~ age 13 "I got to learn different techniques that I could do by myself and that I could do with other people." ~age 15

Parent feedback
"We can't thank you all enough. We learned so much. Most importantly, my child sees that things will get better. The tools she gained in the workshop are helping her make daily steps to improving her pain." "This was so, so helpful! I've made so many notes today and learned so much. I'm going to go home and read my books again and I can't wait to talk to my daughter about these things." "Thank you for everything; my child and I learned a lot. I am happy to report that my child has been functioning much better since The Comfort Ability!" "My child continues his perfect school attendance streak since the program, despite headaches. We LOVE the scaffolded plans; they seem to be our lifeboat. THANK YOU." "This was an inspiring and useful experience for us and our daughter. As a matter of fact, after talking with the school nurse this morning, I was pleased to hear that my child had talked with her about techniques she learned [at the workshop]."

Provider feedback
"We cannot thank you enough for all of your support and time. This was a fabulous opportunity to refine our delivery and clinical skills, not only for CAP implementation moving forward, but for our ongoing work with patients and families who are affected by chronic pain." ~ Yale Child Study Center "Adopting the Comfort Ability program was a team effort. From our initial phone consultation with Dr. Coakley, through our on-site training experience at Boston Children's, further email and phone communications, to hosting our initial workshop and beyond, our Lurie Children's team has benefited from the expertise of the Comfort Ability network. The Boston Children's team provided resources and feedback for funding the program start-up and maintenance and they offered a package of materials for program marketing, participant registration and tracking, and program evaluation. Bolstered by this strong external support, our team generated enthusiasm internally among colleagues and administrators."

| E XPAND CLINI C AL , IN S TITUTI ONAL , AND PATIENT PARTNER S HIPS , AND BU ILD ENHAN CEMENTS
To date, CAP has created a network of 18 partnerships sites across

| Clinical partnerships
The growing CAP network is now among CAP's most valuable core assets. Building a network of shared knowledge users has generated essential opportunities for program enhancements and new ideas for innovation. CAP maintains connections with the partner sites with bidirectional communication between the CAP team and partner sites, as well as cross-communication between partners. The growing network, however, also presented a tremendous systemlevel challenge. In order to support the professional network, continue to build enhancements, and increase the number of patients served by the intervention at the local level, there was a need to expand the CAP clinical and development teams, a transition that required a comprehensive and strategic growth plan.

| Institutional partnerships
The

| Build enhancements
As a way to innovate, generate, and disseminate new knowledge, CAP is actively working on several projects, such as developing and testing disease/entity specific modules to enhance applicability (eg, youth with sickle cell disease, oncological processes, or gastrointestinal illness); expansion of online communities and peer mentorship programming; extending and diversifying CAP's peer and parent advisory boards; and increased visibility via ongoing education of professionals working with children who have chronic pain not only in the medical and mental health fields, but also in the community (eg, teachers). Moreover, in response to the COVID-19 pandemic, CAP has mobilized to generate additional online resources such as webinars for parents and teens with pain.
Additionally, CAP is piloting a virtual telehealth modification of the program this year.

| MONITOR AND SUS TAIN K NOWLEDG E US E , BU ILD NE T WORK REL ATI ON S HIP, AND CONTINUED INNOVATION
With a commitment to maintain and grow knowledge partners, CAP is simultaneously focused on sustaining knowledge use, creating opportunities to expand its network, and creating new innovations that foster improved clinical care in the psychological management of chronic pediatric pain. In addition to the evidence-based content and the patient/family-centered approach, CAP's systematic administration plan has made it an attractive clinical service for many institutions.

| Monitor and sustain knowledge use
Given that evidence-based knowledge and best practices in the field continue to evolve, sustained knowledge use as it pertains to CAP is not a static process. CAP requests that all sites maintain treatment fidelity with intermittent self-assessment using a CAP fidelity checklist. More substantially, as CAP license agreements were initially five years in duration, many of CAP's early partner sites will soon be ready for recertification. During this process, CAP will more fully assess clinical and implementation procedures and determine if more structured monitoring may be needed to identify areas of program drift and ensure that new materials are fully integrated.
Importantly, CAP can only maintain established institutional commitments and a strong network of trained psychologists by actively evolving the program. For example, in the five years since the program was first disseminated, best practices for neuroscience education, a key part of the program for adolescents and parents, has shifted. 41 With a stronger evidence base and consensus on key elements of education that are known to contribute to increased function, 42 CAP is currently revising the pain education module within the program. When this module is complete and reflects the current state of the art in this area, it will be reviewed by the peer and parent advisory boards, pilot tested at the local level, shared for comment across the network of CAP providers, and finally integrated into the program. New materials will replace existing content and will be shared with existing sites, and virtual training will be offered to promote implementation. In this way, CAP can produce a knowledge-to-action network and a knowledge dissemination highway reducing the individual clinical and research burden of each psychologist embedded within each institution. Furthermore, CAP remains a highly valued healthcare commodity, extending scarce resources while continuing to ensure that evidence-based intervention is widely accessible.

| Build network relationships
The creation of a solid professional network with available consultation opportunities is essential for collaborative research, content de-  44 an organization whose mission is to help medical institutions across the world identify gaps in pain medicine practice and implement evidence-based solutions. These key partnerships can greatly extend and enhance CAP's clinical reach, promoting knowledge mobilization at a macro level. These lines of implementation research will help to inform further programmatic developments and will increase the likelihood that all stakeholders can maximally benefit from CAP's evolving innovations and resources.

| CON CLUS ION
The Comfort Ability Program was developed in 2011 from the ground up to mobilize the psychology research evidence base for pediatric chronic pain, moving essential skills and strategies into accessible clinical practice. The goal was to maximize impact by aligning the clinical intervention with the strongest evidence in the field, carefully attending to patient-identified access barriers, and developing implementation procedures that could be systematically replicated. By adhering to an implementation science paradigm, such as the knowledge-to-action cycle, CAP has evolved into an intervention platform with a wide reach and growing capacity.
In addition to its evidence-based content and patient-informed

ACK N OWLED G M ENTS
The development of CAP is truly a collaborative team effort. We are extremely grateful to the 18 partner sites in the CAP network for thier ongoing clinical collaboration and for their essential contributions to the innovation and dissemination of CAP. For a complete list of current CAP partners, please visit our website: https://www.theco mfort abili ty.com/pages /find-a-workshop. We also gratefully acknowledge the vital contributions of our research participants and our peer and parent advisory board partners. We also wish to acknowledge the many psychologists, and post-doc-

CO N FLI C T O F I NTE R E S T S
There is no conflict of interest. CAP is a non-profit program licensed through Boston Children's Hospital. A portion of the licensing fees support the research laboratory and staff salary.