While pediatric integrative medicine (PIM) emphasizes an “evidence-based practice using multiple therapeutic modalities”; paradoxically, literature reviews examining the prevalence and/or efficacy of such mind–body approaches often address PIM modalities separately. Such contributions are relevant, yet documentation of how to deliver combined complementary approaches in children and youth are scarce. Nevertheless, integrative practitioners in clinical practice routinely mix approaches to meet the individual needs of each patient. Best practices are flexible, and include blending and augmenting services within the same session, and/or connecting modalities sequentially for an incremental effect, and/or referring to outside resources for additional interventions. Resonating with integrative medicine’s definition, this article’s goal is to demonstrate paradigms that “bring together complementary approaches in a coordinated way within clinical practice” by linking clinical hypnosis, the trail-blazer modality in PIM’s history, with mindfulness, biofeedback, acupuncture, and yoga. Following the consideration of the overlap of guided imagery with hypnosis and an abridged literature report, this clinical perspective considers the selection of modalities within a collaborative relationship with the child/teen and parents, emphasizing goodness-of-fit with patients’ contexts, e.g., symptoms, resources, interests, goals, and developmental stage. Case vignettes illustrate practical strategies for mixing approaches. The cornerstone of pediatric mind–body approaches is clinical hypnosis—i.e., positive, mastery-oriented suggestions coupled with imagery to optimize individualized goals related to health, well-being, self-regulation, and resilience ,2—which Although pediatric integrative medicine (PIM) is one of the newest recognized academic subspecialties , the cliClinical hypnosis helped set the standard for the broad applications of pediatric integrative health. Groundbreaking publications addressed its efficacy in combination with or in lieu of conventional medical approaches for a remarkable range of pediatric health issues. These have included hypnosis for pediatric learning problems ,12,13, aCurrent reviews highlight further evidence- and empirically-based incorporation of hypnosis for children’s health care ,46,47,48One particularly exciting area of research is the work of Vlieger’s team in the Netherlands showing strong efficacy of pediatric hypnosis as the sole treatment for gut disorders. For example, in double-blind study gut-directed hypnotherapy (HT) was shown to be highly effective for pain frequency and intensity in pediatric patients (ages 8–18) with diagnoses of functional abdominal pain or irritable bowel syndrome compared to standard medical therapy (SMT), with continued efficacy at one year follow-up (85% for HT group compared to 25% for SMT group) . SubsequGoing forward, hypnosis’ cutting-edge research includes the work of Amir Raz, Ph.D., Canada Research Chair in the Cognitive Neuroscience of Attention at the Department of Psychiatry at McGill University. The thrust of his team’s and colleagues’ cognitive neuroscience and neuroimaging studies is to expand the understanding of hypnosis’ underlying mechanisms related to attention, self-regulation, expectation, and consciousness .Definitive conclusions about the value of pediatric guided imagery (GI) are obscured by a muddle of inaccurate and contradictory differentiations from clinical hypnosis ,70, the While there is some evidence for the efficacy of GI scripts , the litIt is important to clarify the mistaken assumption of some authors that hypnosis does not include imagery. Experts from the 1800s to recent times note “the importance of imagery and its integral role in hypnosis, particularly in children” (p. 21) . In a 19www.NPHTI.org) offers the only recurring pediatric-specific clinical hypnosis skills training workshops in North America. NPHTI provides extensive, supervised experiential learning practice of skills as well as to become adept with careful monitoring of each patient’s psychophysiological phenomena and responses; checking in as needed and adjusting the pacing, content, delivery, and prosody  of the thoughtfully planned, goal-related suggestions, rich imagery, and metaphoric stories.One clear disparity between hypnosis and GI is the required intensive training in pediatric hypnosis for licensed clinicians with advanced degrees to design tailor-made, individualized sessions vs. the abundant, ready-made GI scripts available to clinicians and lay people. The non-profit National Pediatric Hypnosis Training Institute  in this demonstration of a cost-effective intervention for a large group of children. Because it is our opinion that a personalized approach optimizes the potential for a meaningful therapeutic outcome, hopefully, future studies will contrast the individually designed intervention of pediatric hypnosis with these two different modes of script delivery.By contrast, the author of GI scripts imposes his/her own imagery onto the child/teen which could be inferred incorrectly that children prefer that sensory modality and type of imagery. Such scripts written for “every patient” are read-aloud by the clinician or lay people who must look at their paper rather than attending to the content’s impact on their patient. A recent study found that the use of a home-based CD-script vs. a therapist-read script (followed by the same home-based CD) for students with IBS, FAP, or FAPS had comparably very favorable results . Based oOther pediatric mind–body approaches also share some elements with hypnosis: mindfulness, biofeedback, yoga (and perhaps to a lesser degree) acupuncture also utilize the child/teen’s unfolding curiosity for novelty and learning; overall motivation for mastery; capacity for focused, narrowed attention; openness to positive suggestions and expanding internal resources; and willingness to practice emerging skills. Breath is often incorporated and patients learn the easily accessible value of slowed, diaphragmatic (‘belly’) breathing to activate the parasympathetic nervous system . It may be safe to say that the over-arching intent of mind–body modalities is to offer these “gifts” to maximize one’s own health, well-being, self-regulation, self-confidence, and self-efficacy.how to interlink hypnosis with four distinct complementary mind–body approaches . The additional case vignettes illustrate ways to blend PIM approaches, highlighting the importance of context for goodness-of-fit as well as practical points and considerations when personalizing PIM treatment.Following a brief synopsis of the literature, the following sections offer clinical perspectives from clinicians on A specific form of meditative practice called “mindfulness” was popularized by Jon Kabat-Zinn ,84 who dMindfulness continues to gain popularity, with an increasing presence in school curricula, workplace wellbeing initiatives, and health care settings. In clinics and hospitals, mindfulness-based stress reduction is prototypical of such practices in health care, first developed as a program to relieve suffering among adults with chronic conditions . SimilarExperience-based practice with formal meditative approaches  and informal meditation during everyday activities (such as eating) are called “guided mindfulness meditations” because they use in-person or recorded instructions. Collectively, these guided experiences and self-directed practices are called mindfulness-based practices (MBPs) . Some MBMindfulness and Hypnosis: The Power of Suggestion to Transform Experience [Guided mindfulness and other MBPs differ from clinical hypnosis in that the former is rooted within a contemplative philosophy with historical roots that did not include therapeutic goals. The hallmark of hypnosis is the use of specific therapeutic suggestions oriented towards one or more health-related goals. However, as therapist Michael Yapko, Ph.D. points out in his seminal book, perience , mindfulFocus your attention on being present, in this very moment… now THIS very moment… now THIS very moment…Amplify this moment-to-moment awareness by focusing on your five senses: be aware of what you hear NOW, what you see NOW, what you feel NOW, what you smell NOW, and what you taste NOW… and integrate that to being just present in this very moment…NOW, the final of the three steps: Create a feeling of deep Appreciation… it could be for your pet, your friend or another wonderful person, the shower, your favorite food, the sunset, your bed, or anything else that you really truly are grateful for.In fact, therapeutic goals are now a common component of mindfulness and simple MBPs as part of an integrative approach for children with psychological and mind–body issues, including those with chronic worries; rumination or being too ‘in their heads’; many ‘what-ifs’ who seek frequent reassurance; frequent over-estimation of the potential for negatives such as risk, threat, or danger; generalized anxiety disorder; major depression; and/or sleep-onset or sleep-maintenance insomnia. This modality is perfect to help these children and youth quiet their minds and be more fully present in the current moment (instead of being ‘stuck’ in the imagined negative future). This can be practiced and summarized with children and adolescents briefly with these simple steps developed by the first author (P.K.):Pediatric well-being can be improved through guided mindfulness and other MBPs in other contexts. A recent meta-analysis of MBPs in children and adolescents showed positive effects on academic achievement, school functioning, negative emotionality, subjective distress, internalizing symptoms, and a number of physical health indicators . For exaOther elements now thought to be important to such mindfulness-based programs that strikingly overlap with the inherent phenomena, process, and purposes of hypnosis include (a) dissociating from, and letting go of reactive or distressing thoughts and feelings and (b) cultivating absorbed attention, intention, and evoking curiosity to foster emotional-behavioral self-regulation . FurtherOngoing research aims to better specify the ways in which mindfulness and hypnosis work, including the extent to which they affect the central nervous system ,96. One In a similar way, “jettison” techniques  blend miTo further underline the commonalities between pediatric clinical hypnosis and MBPs, children and adolescents who learn self-hypnosis in clinical settings will frequently and spontaneously refer to their home practice as ‘meditation’. Indeed, when invited to demonstrate their self-hypnosis to the clinician or parent, some young people will adopt a stereotypical meditative posture such as the index fingers touching the thumbs while the dorsum of each hand rests upon each knee .Regardless of whether it is called mindfulness, meditation, hypnosis, or something else made up like “that thing the doctor showed me how to do”, such child-generated language is to be encouraged and built upon, not only as hypnotic ego-strengthening and utilization of a child’s individual strengths and talents, but also as post-hypnotic suggestions that empower children to apply therapeutic strategies across contexts. Because of the powerful self-regulation that can result from mindfulness-based hypnotic approaches as summarized above, clinical applications can include decreasing ruminative cognitions among vulnerable children , and preBest practices for mindfulness-based hypnosis  in pediaM. was first referred to the developmental-behavioral pediatrician at age 10 by his psychiatrist for recurrent abdominal pain. The psychiatrist had previously diagnosed M. with attention-deficit/hyperactivity disorder, inattentive type, co-occurring with generalized anxiety disorder, each treated with appropriate medications that had somewhat improved his ability to manage the symptoms of these conditions. These medications did not seem to affect his abdominal pain for better or worse, and a thorough medical evaluation by his primary care physician had confirmed the diagnosis of recurrent abdominal pain. His mother said that at home he would often cry in the morning due to the pain, and many nights he would “work himself up” worrying about the pain recurring the next day. His mother also indicated in private that he had experienced high levels of family dysfunction and maltreatment in early childhood. He presented as a thin, somewhat disheveled-appearing boy who was distracted, inattentive, and behaviorally inhibited. He spoke tentatively and with much elaboration about the characteristics of the pain, saying only “it hurts a lot sometimes” in the periumbilical region and could be “dull”, occurring most often before school.The first visit’s goals were to establish therapeutic resonance and to help M develop new ways of discriminating various levels of comfort. To do so, after acknowledging the reality of M.’s physical pain, the clinician reframed it as “discomfort” and affirming his “strength… shown so well already… because that’s what it means to get to school every morning even if we’re feeling uncomfortable”. The clinician ‘wondered’ with M. about “what else (he) might notice between today and the next visit about how the body feels or what the brain is thinking right before, or during, or even after, the discomfort shows up” to evoke M.’s curiosity and enlist his ability to be mindful, i.e., “pay attention on purpose”, of his experiences. At the following visit, M. said he had noticed that his “heart beat differently, like not faster but weird” right before an episode of abdominal discomfort. The clinician affirmed this new awareness, then began to teach M. about mindfulness: being aware of bodily sensations and perceptions when “the heart started to beat differently, and if the breathing changed or the chest changed in other ways, and when that abdomen began to feel any change in its level of comfort, and when any other parts had other differences in how they felt” .The clinician then got out his stethoscope and offered to teach M. how to use it, and M. responded with interest. As M. began to listen to his heartbeat, the clinician suggested that he “just notice the little or big differences” in his heart rate when inhaling vs. exhaling vs. holding his breath vs. hyperventilating. As he did so, he became very attentionally absorbed, and gradually began to smile. When he took off the stethoscope, the clinician asked him what else he noticed physically at that moment, and he responded that his entire body felt “relaxed” and that his abdominal area felt “calm and cool”. He was instructed to become more and more aware of sensory changes, in the tradition of a mindful body scan, i.e., “just take a few moments, or a few minutes, one or two or more times every day for the next two week, to check in with your body and notice how every part is feeling… like changes in temperature, or changes in how heavy or light a part feels, or tingly, or bigger or smaller, or differences between one side or area and another, or even colors that might look different on the skin if any part needs calming or cooling or comfort, then you can make that happen, because you discovered how to do that just now.” He was instructed to do this practice in the manner of alert hypnosis  although no specific name was given to him for this practice.Several visits later, M. reported that he had been regularly practicing his “noticing” (his word for the body scan) and his abdominal pain had completely abated. Over the next five years, his abdominal pain remained in full remission. He had transient, intermittent episodes of milder somatic complaints as well as mood difficulties, usually during times of life transition such as starting at a new school. Over time, with the clinician’s guidance, he discussed the traumatic events and adversity he had faced earlier in his childhood and connected these experiences to “stress… and stress makes me have more (aches and pains) and be crabby”.At this time  the clinician invited him to learn self-hypnosis to address the long-term goal of handling stress more effectively, and he said he was motivated to do so. To begin, he was simply asked to do the “noticing” body scan that he had previously found helpful; as he did so, he spontaneously closed his eyes and the clinician suggested he talk aloud to himself as he noticed each part of his body felt. The clinician then suggested he could “change any of those (sensations) now if they’re not yet comfortable, or just allow them to be how they are until they change themselves to be more comfortable”. Suggestions for self-paced stress reduction were then permissively offered, included metaphoric imagery such as letting go of one or more balloons filled with stress and watching them slowly rise, the stress getting smaller and smaller as the balloons went higher and higher into the sky, as well as imagery for strength such as pulling a heavy load of stress and watching it get smaller and eventually fade away to nothing as he got stronger and pulled it further. It was further suggested that by pulling that heavy load so far, he had become so strong that most stressors would bounce off of him and the few that did not bounce off would be easy for him to move around or transform into something harmless. He was then offered post-hypnotic suggestions, i.e., suggestions given during the hypnotic experience to be recalled and used with automaticity within the context of the patient’s everyday life, for a “power word” of M’s choosing, that he could use every time he would be practicing self-hypnosis at home which would then allow him to quickly and easily engage this “inner-strength stress-relief system” during times of distress or recovery from stressors. M. continues to do this self-hypnosis practice several times per week and uses his “power word” to deal effectively with life’s ups and downs, including interpersonal relationships, family transitions, and school.In the case of M., the session with the stethoscope integrated a mindfulness-based approach , unpleasant physical sensations) to promote M. orienting towards (instead of avoiding) his somatic experiences in a neutral manner, and as a hypnotic and post-hypnotic suggestion for self-regulation of neurophysiology . His subsequent use of these strategies on his own demonstrates the enduring value of mindfulness-oriented self-hypnotic approaches that empower young people who have faced chronic ‘toxic’ stress.Similar to hypnosis—and hypnosis with children ,102,103—www.heartmath.com); or EMG (electromyography) and peripheral skin temperature for migraine headaches [It is common, appropriate, and effective to invite children to consider and learn computerized biofeedback by presenting it as a “video game for your body”. With the everyday, even constant availability and prevalence of videogames, high tech formats are relevant and syntonic with popular culture, so much so that ‘apps’ on smart-phones and ‘smart watches’ and other portable devices now can and do provide multiple biofeedback options to children and adults alike, not to mention comparable resources on social media. Indeed, they are even promoted as therapeutic devices  therapeutic outcomes. In clinical as well as research studies, reference to, or identification of, the hypnotic elements are barely mentioned in passing if at all. For example, in most scientific paper describing biofeedback research, several paragraphs are often devoted to a description of the electronic monitoring equipment and the nature of the electrodes and operating systems, before a one- or two-line statement almost blithely states something like “and the child was instructed to relax and imagine a favorite activity”. This obvious hypnotic invitation/suggestion is rarely characterized as such though it seems it is integral to the clinical experience and, we believe, to the success of the therapeutic intervention. To our knowledge, no one has sought to discriminate the differential influence of the biofeedback process vs. the hypnotic suggestions per se.As the biofeedback experience proceeds, and particularly as the clinician observes the ‘results’ of improving physiologic regulation, the clinician commonly offers ‘ego-strengthening’ suggestions including compliments and verbal feedback that the subject is ‘doing well’, doing it ‘right’, and ‘the more you do it the better you get’. These reinforcing hypnotic suggestions are often used to provide future-oriented  suggestions for continued practice/rehearsal of the hypnotic-biofeedback strategy at home as a self-empowerment approach. Because anxious children typically experience exaggerated psychophysiological stress reactivity, they benefit from learning relaxation skills and self-regulation strategies to reduce over-arousal . ExampleWe have come to understand that biofeedback is a form of self-hypnosis and self-hypnosis is the ultimate form of biofeedback . More thHypnosis and biofeedback are strategies directed at evoking innate experiential resources to alter psycho-physiologic responses which have become maladaptive. Hypnosis relies on the resonance and rapport of a therapeutic relationship and the language of positive expectancy to (help the child to) cultivate the imagination. Biofeedback provides an external somatic focus as a proxy for internal psycho-physiological change. BOTH involve narrowly focused, intensified attention and heightened responsiveness to new ideas and associations. This ‘trance’ state can be reinforced by the clinician’s therapeutic language AND by the nature of the electronic/computerized information being received in the feedback. (p. 287)Writing in the first textbook on Integrative Pediatrics in the chapter “A Pediatric Perspective on Mind–body Medicine” Kohen wrote about the hypnosis/biofeedback interface:A 12-year-old boy, F., was referred to the developmental-behavioral pediatrician by his primary care pediatrician for the presenting complaint of school phobia. Though his school refusal had begun soon after the beginning of his first semester in 6th grade in his first year at the Junior High School, most of his elementary school peers were in the same school and as a good student he did not find the classes difficult or the teachers challenging, intimidating, or otherwise problematic. In fact, as is often the case, academic or peer-related anxiety was not the concern.He reportedly had “difficulty falling asleep” though this too was a function of underlying separation anxiety and not insomnia or other sleep disorder. He spoke of being afraid of the dark, not liking it, and being upset that his parents and siblings were asleep before he was, i.e., that he was the one awake and, “What if something happens?!” His mother noted that even when he told his parents he was “feeling fine now” and would “baby-sit” his younger six-year-old sister when the parents were going out for dinner for 2 h before dark, as soon as they would begin to back the car down the driveway, he would run after the moving car, crying and not wanting to be left alone. On occasion when they would go out and he and his sister stayed with a “baby-sitter” he frequently called his parents every 5–10 min at the restaurant to find out when they would come home.After developing rapport during the initial visit, F. was willing to acknowledge that he had a lot of “worry” and “nervousness”; and that this made him afraid to go to school, to be away from his parents, and to do stuff. When he thought about this he said he said he thought it was “dumb” and that he wished it would go away. He was especially embarrassed about having hyperventilation and crying “so easily, like a baby” when he was anxious.He was intrigued by the idea that with self-hypnosis he could learn to use his mind to be “the boss of his body”. He quickly learned the self-hypnotic technique of “three and six” , focusinThough F.’s anxiety improved, and he was able to more easily make it to school, he continued to call his mother frequently from school, with varying complaints that he “didn’t feel well” or “needed to come home”, and frequent visits to the nurse’s office. Despite his mother’s effectiveness in being sensitive in listening to F., she followed guidance to not pick him up early from school, and the School Nurse was equally collaborative in offering comfort and reassurance while dispatching F. back to class. As this continued, and in the context of knowing that F. also found comfort in successfully immersing himself in video games he could WIN, it was decided to introduce him to biofeedback by offering to show him “a computer-game for your body”. He was immediately intrigued by the graphics and the easy-to-understand process of the Emwave PRO computerized biofeedback . As children commonly do, as he became focused and absorbed in attending to the images on the computer screen (monitoring and measuring his heart rate variability), he spontaneously moved into a hypnotic state, evidenced by his body stillness in his chair, fixed gaze stare at the computer screen (with infrequent blinking), and spontaneous slowing of respirations, along with slowing of heart rate, without any verbal hypnotic suggestion to do any of those behaviors.He quickly became proficient at ‘winning’ the various games available in this program through control of his heart rate variability (HRV); and his pride and confidence in his growing competence were natural by-products of the process. As he enjoyed these biofeedback sessions, hypnotic suggestions were brief and focused upon suggestions directed at strengthening inner resources such as self-confidence (such as “you’re doing this exactly right!” or “wonderful!”) and post-hypnotic suggestions to foster competence and control over target symptoms . After two biofeedback sessions he and his family were encouraged to consider obtaining a personalized, portable version of the Emwave program, the Emwave PSR , which monitors and gives visual and auditory feedback of pacing and slowing of breathing, signaling when HRV is in a positive ‘coherence’ state.F. continued to improve. One day he came in for an appointment after school and was eager to report, “You won’t believe what happened today!” He said that at lunchtime he was on the playground and three older boys began bullying him. He said he did not know why, but they were pushing him around and he was getting sad and nervous and he began to cry and ran away. Luckily, they did not follow him. He ran to his locker, planning to get his Emwave PSR from his backpack and find a private place he could practice his Emwave and calm himself . He got his backpack, found a place in a corner where he could be in private. All set to practice his Emwave he discovered that it was not in his backpack! Hearing this, the clinician said “Oh, no! What did you DO to SOLVE this?” (Note the suggestions of the clinician regarding their confidence to help himself). F. said “Well, I decided all that I could do was “just pretend and imagine that I did have the Emwave, so I pretended to attach it (the HRV monitoring electrode) to my earlobe, and then I imagined I was holding it in my hand, and I closed my eyes and was doing the imagination and my breathing got slower and I was fine and didn’t feel like crying any more. I realized then that actually I am the Emwave, and the Emwave is me!” Beyond complimenting F., the clinician asked if it was okay to tell that story to other students, of course without mentioning his name… and he too was thrilled that his experience could be of help to others in that way.It was clearly a combination of self-hypnosis and biofeedback that allowed F. to develop mastery over his symptoms, and to cope with parental separation and stressful situations at school.In the foregoing, it was critical to identify a biofeedback system and modalities within that system that would be concordant with the abilities, interests, and maturation and cognitive developmental style of the child, 12-year-old F. Rapport with F. and knowledge of his facility and interest in videogames were identified as key resources that made this easy to accomplish, in part because the HRV biofeedback system selected has games that appeal to various ages and interests in childhood and adolescence. Just as we emphasize the importance of tailoring hypnotic approaches to the developmental level and capacity of the young ,102, so positive expectations for therapeutic outcomes;absorption/concentration/focused, narrowed attention;spontaneous relaxation in association with vigilant attention;concurrent psychophysiological changes .As reflected in the described case of F, hypnosis and biofeedback share similar  characteristics, including:Acupuncture is a form of eastern medicine that originated in China over 2000 years ago. The traditional concept of acupuncture is that Qi, the basic life force, travels along channels, i.e., meridians, which can be accessed by fine instruments  to balance and remove obstructions to its flow in order to treat mental and physical ailments and improve health. Acupuncture is one of the most popular complementary medicine modalities in the US  accordinThe unity between mind and body, i.e., an interactive relationship between the two, is an important component of Eastern medicine. As a result of this interaction, hypnosis and acupuncture may be uniquely suited to complement each other as therapies . NumerouAcupuncture is well tolerated in patients from infancy to adulthood . The manJ. is a 14-year-old adolescent with sickle cell disease who was referred to an outpatient integrative medicine clinic by her hematologist for assistance with pain management. J.’s sickle cell symptoms had been relatively well controlled until about a year ago when she began to present with painful crises requiring hospitalization every two months. She was receiving a number of medications for pain as needed including: acetaminophen, ibuprofen, gabapentin, and oxycodone. The hematologist had recommended hydroxyurea. The family was considering the addition of hydroxyurea but had some concerns about side effects.The initial integrative medicine visit was 90 min. Considerable time was spent listening to J’s story and how her sickle cell disease affected her life including her relationships and interactions with friends and family. We also discussed her goals for this session and for management of her pain in general, including the potential benefits of adding hydroxyurea as recommended by her hematologist. After development of rapport, J. was able to recognize that her fear of the pain, or of pain coming, was interfering with the enjoyment of her daily life. J.’s main goal was to be able to fully participate in the activities that she enjoyed with her friends. Her parents were concerned that she was beginning to isolate herself and hoped that when her pain was controlled that she would be able to continue to participate in the afterschool activities that she used to enjoy. Though she did continue to attend school despite the pain, she was worried about being too active—that doing so would cause the pain to return and that she would need to go back to the hospital for pain management. J. and her parents were very interested in acupuncture for pain management, but J. said that she was afraid of needles and too scared to have acupuncture.The clinician and J. discussed using her imagination to help her relax and explained that when she was in a more relaxed state she might be surprised to find that she does not mind having acupuncture at all and that she may find the experience to be pleasant and helpful . It was explained that some people also call this way of using your imagination hypnosis and that hypnosis is about using the mind and imagination to give her the power to be able to do the things that she wants such as having acupuncture and spending time with her friends without worry. She was curious about the process and agreed to proceed with reassurance that she was in control and could stop whenever she liked. This provided the safe space to allow her to more fully experience the trance state.The clinician proceeded with hypnosis using favorite place imagery for calming and relaxation during the acupuncture session. The clinician began with a conversational induction, speaking to J. in a calm and soothing voice about what we were planning to do. Reassurance was provided that she would remain in control and the discussion centered around ‘wondering’ what this experience would be like for her. It was also suggested that she would be able to speak and interact while maintaining a calm and relaxed state. Her gaze became fixed and her breath elongated as she began to deepen into trance, she then was invited her to close her eyes. Her eyelids closed. A few moments later rapid movement of her eyes beneath her closed lids was noted. Then, she was invited to imagine a door beyond which was her favorite place with all of her senses. As she explored her favorite place, she was able to report that her favorite place was her grandmother’s house. She was encouraged her to fully imagine being there, including paying particular attention to the look, the feel, sounds, and the smells. As she explored her favorite place, she became comfortable enough to accept the acupuncture needles. Encouragement and praise were provided for her continuing to fully experience her favorite place during acupuncture. She was able to share that in her favorite place she felt, “warm”, “safe”, and “loved”. It was suggested that she could continue to maintain those feelings.At that time, it was asked if she was ready to proceed with the treatment. She nodded that she was. With her permission, a needle was placed in GV-20 for deeper relaxation and then auricular acupuncture was performed using the battlefield technique for pain management . J. did Acupuncture and hypnosis are useful tools on their own, but when used in combination can work synergistically. In the case presented above, hypnosis allowed for relaxed state that provided an opening for the acceptance of the acupuncture needles. Acupuncture to GV-20 likely assisted with deepening which may have augmented the hypnotic state and experience.The practice of yoga, an ancient mind–body, “moving meditation” modality originating from India, traditionally involved a set of beliefs and rituals with an over-arching goal of a person’s union with Supreme Reality or the Universal Self . VariousMoving beyond the one-on-one tradition, group instruction became the norm. In recent years a plethora of yoga programs for children and teens has propagated across the U.S. In 2012, 3.1% of U.S. children (1.7 million) used some form of yoga . ParentsOf note, YogaKids describes that future teachers of YogaKids learn how to combine yoga with other activities involving music, books, games, art, reading, writing, and science for a group of children. Thus, perhaps not surprisingly, yoga has found its way into the classroom . On the Yoga Calm is another child- and family-oriented yoga program that incorporates “mindfulness” and “relaxation and reflection activities” with a goal of “self-regulation” and “social-emotional learning” . ParentsEarly reviews of yoga focusing on the physical and mental health for children and teens expressed caution in making conclusions, citing only preliminary benefits due to methodological limitations ,138,139.While PIM research has progressed remarkably, to date, research reviews of yoga focusing on outcomes of physical and mental health for children/teens have not yet examined differences based on many variables that complicate the comparison and contrast of findings and obscure conclusions about efficacy. As this area of study continues to unfold, investigators surely will begin to examine such variables as content ; format ; context  vs. home); age range; home practice expectations and adherence; teacher’s expertise; and long-term outcomes.Exciting, fresh lines of research about the neuroscience underpinnings of therapeutic yoga are very promising and adds credibility to this PIM modality. Similarly, sound exploration of theoretical models for potential self-regulatory mechanisms of yoga for psychological and physical health is expanding. An article by researchers from Harvard and other institutions  provide A complementary article by a group of University of California researchers offers a comprehensive, scholarly literature review, including a unique, methodical deconstruction of yoga’s main components, i.e., “posture or movement sequences, conscious regulation of the breath, and techniques to improve attentional focus” . Cogent Information about combining traditional yoga with hypnosis is scarce. Dalal and Barber’s 2008 chapter (a modestly revised version of a 1969 paper) on this topic is the notable exception with its discussion and challenge of the purported similarities, i.e., an altered state of consciousness (trance states) with associated unusual phenomena . Like soS. is a 14-year-old female referred for integrative therapies to help her manage physical symptoms of headache and body aches, difficulty with sleep onset, and a history of generalized anxiety disorder. S.’s anxiety problems began at eight years of age with separation anxiety and specific phobia symptoms. On the first day of ninth grade, she had a panic episode with multiple symptoms including racing heartbeat, shaking, sweating, cold extremities, and fear of “losing it”. Subsequently, she developed recurrent headaches due to clenching her teeth and general increased muscle tension of her neck, shoulders and back. In addition to being an excellent student, she was also an accomplished dancer but had become unable to participate in recitals due to performance anxiety.At her first appointment, considerable time was spent developing rapport by listening closely to her story, learning about her family, her interests, and her goals for this intervention. She specifically said she wished to learn skills to avoid taking more “anti-anxiety pills”, feel more comfortable in the classroom, and be able to dance in recitals with her friends. The clinician discussed with S. how she might learn to help herself achieve these goals by learning about the brain/body connections, combining yoga and hypnosis.Yoga was defined for S. as “uniting the mind, body and spirit.” It includes using the breath (‘pranayama’), physical poses (‘asanas’), and conscious awareness to create balance. She had done a little of this in a physical education class. She was more unsure of hypnosis, so the clinician talked about how it is “using your imagination on purpose”, which she already knew how to do since she practiced her dance routines in her mind. S. also described how she occasionally reminds herself (to reframe worries) that she “can do it!” The clinician suggested she might reframe her worries and fears to experiencing herself as strong, competent and successful. Hypnosis was further defined as beginning with focused attention on the breath, the body, or an image and may be intensified with greater sensory, or imagery awareness. The process then shifts to using specific goal-oriented suggestions to change one’s symptoms, perceptions, or behavior. The clinician emphasized that it is important to be certain that the use of hypnosis is appropriate for the desired outcome. S. and the clinician collaboratively planned for S. to spend time before the next visit simply noticing how she felt physically and emotionally when she was doing something she really enjoyed.At the second visit, S. could more easily describe how her heart raced, her muscles tightened, her hands got sweaty and she forgot what she wanted to say when anxious, in contrast to how she felt when she was calm. The clinician again reviewed the possibilities of S. learning to help herself by using interventions such as yoga and hypnosis to help her become more aware of her ability to be in control in healthy, positive ways. The clinician invited S. to begin with heart/belly breathing because all these modalities use breathing as a means of inducing calmness, relaxation, increasing body awareness, and being in the present moment. The clinician then gently put one hand over her own heart and the other hand over her own abdomen. The clinician further suggested that S focus her attention on her breath as it moved through her body and simply say to herself, “I breathe in (in breath) and I breathe out (out breath)”. As she did this she naturally elongated the exhalation and commented on feeling relaxed. After this invitation of narrowed attention to induce the hypnotic experience, the clinician then suggested that S. continue breathing in this easy and natural way while she imagined herself in her favorite place—laying in a hammock in her back yard. Utilizing this classic imagery technique to intensify the hypnotic experience, she visualized her mother’s colorful flower garden, felt the warm sun on her arms and legs and the gentle sway of the hammock. The clinician suggested that S allow herself to be absorbed inside her mind by these images and sensations and say to herself, “I am safe and calm” while doing so. Her assignment following this visit was to practice her self-hypnosis  daily for approximately 10 min as well as any time she began to feel anxious.At the next visit she wanted to learn more about yoga. The clinician invited her to stand in “mountain pose” with her feet about hip width apart, imagining her feet reaching deep into the roots of the earth. During this heightened focus on her body’s position and posture, S. was then offered hypnotic suggestions of self-efficacy and self-regulation, to repeat phrases in her mind, such as “I am strong” and “I can do this”. She then brought her hands to her heart and energetically pushed her hands and arms above her head—like an exploding volcano releasing worries, fears, negative self-talk, and anything that she no longer needed. This hypnotic metaphor, imagery, and suggestions were combined with the “releasing” process (movement and pose) in yoga that needs to occur before someone can calm down. Using her love of dance, she then created a routine that included using her breath to calmly sustain her while she gracefully moved her body—stretching forward/backward, and side to side releasing tension while imagining strength and courage to move further out into her world with confidence and success.After this introduction to combining hypnosis with yoga, S. found a class in her community where she could practice yoga with the support of others. She continued to interweave the practice the hypnotic phenomena of intentional breathing, focused attention, and absorption in mental imagery of favorite activities and rehearsal of future successes (as post-hypnotic suggestions).This case illustrates that hypnosis and yoga can work well together to manage physical symptoms, anxious thoughts and negative self-perceptions and are readily accepted by children and teens as a means of improving self-care and resilience. They can easily build on patients’ knowledge and experiences.PIM touts a growing array of approaches that initially were considered to be solely adjunctive interventions. For several years now, diligent efforts have preliminarily documented the efficacy and safety of separate integrative strategies that improve quality of care in order to recognize PIM as credible and viable by mainstream pediatrics. In spite of the epic history and groundwork of hypnosis as a common root of mind–body PIM, hypnosis may be overlooked as an integrative approach. There is confusion in the PIM literature where hypnosis ‘belongs’, as it has variably been considered a conventional , complemA related question concerns guided imagery (GI): despite both its heritage and oft-revealed overlapping ingredients with hypnosis as discussed above in this article, might this more neutral name (guided imagery) and its scripts similarly be preferred by some institutions, journals, and clinicians? It is our reasoning that GI bypasses the investment of time, effort, and cost needed to acquire skills that characterize the uniquely therapeutic communication of hypnosis.Beyond these two thorny questions, we have highlighted three key themes throughout this paper: (1) common components shared by pediatric hypnosis with GI as well as other mind–body techniques form the core of PIM, i.e., mindfulness, biofeedback, acupuncture, and yoga; and (2) permutations of combined PIM modalities reveal that individual PIM modalities are actually evolving by ‘borrowing’ elements from one another. Just like the ‘blending trend’ of integrative approaches with CBT, e.g., “cognitive hypnotherapy” ,153 and sequential use of integrative approaches, future research may find that a more refined delivery model [A third key theme of this paper is the value and importance of designing personalized treatments in PIM. Health professionals new to PIM modalities quickly discover the range of responses among children/teens, driven by underlying developmental, learning, experiential, and other individual differences. While some clinicians choose to deliver the same ‘procedure’ to every patient, others are embracing the critical importance of establishing rapport and solidifying trust and attunement in order to maximize each patient’s receptivity, cooperation, and adherence to acquiring new skills. As clinicians become more seasoned and secure in their use of PIM modalities, they invite and incorporate the child/teen’s own specific goals while contemplating goodness-of-fit between each patient and the potpourri of PIM approaches. The case vignettes we chose for this paper illustrated the additive value of incorporating hypnosis as well as numerous practical strategies and clinical acumen as guidelines for integrating PIM modalities to achieve this goal of individualized care. Honing one’s sensitivity to and flexibility in the selection, timing, and presentation of integrative approaches completes the criteria toward a new PIM benchmark for designing personalized treatment with each patient. Beyond the ry model , of ‘minAcquiring expertise in such a practice model takes time, mentoring, and ongoing training. PIM approaches vary widely in terms of effort, time, and cost to achieve competence or mastery, and differ in terms of complex skill development  vs. knowledge attainment . Obviously, such variations differentially lend themselves to hands-on learning, intensive supervised practice, and ongoing mentoring  vs. onliWhile the current integrative medicine board-certification exam in the US includes hypnosis as an area of core content , more wo


To help address a long-standing gap in research and knowledge, this paper explores the issue of what service providers need to be aware of to best meet the needs of ethnic minority children and families who have come to the attention of child protection authorities and have substantiated reports of domestic violence.The results are written in narrative form, combining informed insider perspectives with a small subset of data drawn from a larger rigorous mixed methods study in Australia, that involved an exhaustive literature review, review of 120 randomly selected case files, and in-depth qualitative interviews with 29 ethnic minority families involved in the child protection system and 17 child protection caseworkers.family name, which is greatly valued, leading to a preference for child maltreatment and family violence to remain private, and for compliance with Apprehended Violence Orders (AVOs) and service uptake/engagement to be low, (ii) family cohesion is also highly valued, so family violence victims may sacrifice their own personal safety to protect the family unity and cultural safety of their children, and (iii) family violence interacts with cultural factors for ethnic minorities but does occur in all families; attributing it to race or culture would be racism. Several implications for practice are identified, falling under a broad umbrella approach that asks for child protection authorities and family violence agencies to work collaboratively. A call for empirically rigorous future research is also made to ensure practice is evidence-based.Three issues for ethnic minorities relating to the nexus of child protection and domestic violence are identified: (i) being in the child protection system tarnishes  Little is known about the complex and niche nexus of child protection and domestic violence issues among ethnic minority communities in Western countries like Australia. This reflects a broader historical trend of low research attention being paid to ethnic minorities in Western child protection systems –7. To heThe aim of this paper is to report on the findings from that study that relate to domestic violence (DV) among ethnic minority families in the CPS. The main research question is: what do child protection and family violence service providers need to be aware of to best meet the needs of CALD children and families who have come to the attention of child protection authorities and have substantiated reports of DV? While the results are based in the state of NSW in Australia, they do have some transferability to other comparable Western countries such as the US, UK, Canada, and New Zealand. Thus, this is a significant contribution to the literature because it helps progress the field with identification of key themes, as well as summary points translated for practice.CALD groups are differentiated from Indigenous Australians  because they have a migration history and so are not First People. They are also differentiated from Anglo Australians (Saxon and/or Celtic) because they are non-mainstream in any of the four main dimensions of ethnicity — race, culture, language, and religion . Thus, CAccording to the seminal work of Hofstede (2001), the US, Australia, and UK have the highest ratings on ‘Individualism’ (IDV) of 91, 90, and 89, respectively; Western European countries rank next highest ; East European countries rank thereafter ; and South American, Asian, African, and Middle Eastern countries rank lowest on IDV .Hofstede (2001) has also identified the ratings of countries on the ‘Power Distance Index’ (PDI), which he defines as measuring “the extent to which less powerful members of organisations and institutions (e.g. the family) accept and expect that power is distributed unequally, so it represents inequality and suggests that a society’s level of inequality is endorsed by the followers as much as by the leaders”. It is therefore not wholly a measure of traditional gender roles but does include them, and the data shows that there is an observable trend between PDI and collectivism. For example, scores on PDI for the US = 40, Australia = 36, UK = 35, Netherlands = 38, Denmark = 18, France = 68, Switzerland = 34, Czech Republic = 57, Hungary = 46, India = 77, Japan = 54, Brazil = 69, Iraq = 80, Saudi Arabia = 80, Philippines = 94, Kenya = 64, China = 80, Singapore = 74, El Salvador = 66, Pakistan = 55, and Ecuador = 78.Since the term ‘CALD’ only draws attention to two of the four main dimensions of ethnicity (culture and language), it is not sufficient for naming all the barriers along which this group of people might face . Thus, ‘continual management of the need to adapt to the new culture against a competing need to preserve the one of origin ; Lebanese [LEB]; Pacific Islander—Samoan and Tongan [PAC]; Vietnamese [VIE]; Aboriginal [ABR]; and Anglo [ANG]. The sample was representative of gender as 62/120 (51.7%) cases were male, and the age range was 1–19 years .Case files were exhaustively scoped for: reported types of abuse and neglect; reported risk factors of abuse and neglect; reported strengths of children and families; reported issues with the CPS by families; reported assistance provided to families; examples of culturally appropriate and inappropriate practice; and examples of personal, organisational, or institutional barriers to culturally appropriate practice.Of the 29 CALD family participants in Stage 3, which involved semi-structured interviews: 10 were male (34.5%); they varied in age from 22–67 years (mean = 42.2 years); and they came from a diverse range of ethnic backgrounds . Of the 17 CP caseworker participants in Stage 3: only two were male (12%), however this is consistent with the typically female-dominated social-work-force; they ranged in age from 23–59 years (mean = 33.9 years); the 13 NESB caseworkers originated from Afghanistan, Egypt, Lebanon, Burma, Laos, Philippines, Vietnam, India, Uruguay, and Ghana ; and four interviewees were Anglo caseworkers all born in Australia.  of University of New South Wales .Interviews explored: norms, traditions, beliefs and practices that influence the way ethnic minority children are raised and family issues are addressed; reasons underpinning the entry of ethnic minorities into the CPS; services provided to ethnic minorities; perceived commonalities and differences in working with ethnic minority, Aboriginal, and Anglo children and families; how caseworkers take into account different cultural contexts for children, while adhering to one Australian child protection law; whether, and why, ethnic minorities and caseworkers prefer an ethnic-match; examples of effective and ineffective practice with interpreters; examples of culturally appropriate and inappropriate practice; the extent to which caseworkers perceive personal, organisational, and/or institutional barriers impeding culturally appropriate service delivery for ethnic minorities; the extent to which the CPS is perceived to sufficiently address the cultural needs of ethnic minorities; and suggestions for overcoming barriers to, and improving, the cultural appropriateness of child protection service delivery for ethnic minorities. Thus, interviews were in-depth and exhausted all themes relevant to the Fellowship.populations explored. Having said that, the qualitative interviews (Stage 3) did reach thematic saturation, and triangulating three different sources of data , add to the methodological strengths of this study. That is, a mixed methods approach to theory, data collection, and data analysis all help improve the representativeness of a study’s findings. Thus, the results overall are representative of ethnic minorities and child protection staff who work with them.While a total sample of 120 case files is large and robust for identifying relevant themes, the sample size of 20 per cultural group is not sufficient for conducting statistical analyses to test for cross-cultural differences. Thus, caution should be exercised when making inferences about each of the six Only data relating to domestic violence has been reported on here to address the research question , but asThus, these limitations mean that further research in the area is essential. At this nascent stage of knowledge-building in a critically under-developed area, this paper does not claim to offer evidence-based principles of best practice but rather only ‘issues to consider’ and ‘suggestions for practice’. The paper takes a narrative form that draws on twenty years of research on ethnic minority affairs in relation to the issues of racism, sexism, culture, migration, mental health, domestic violence, and child protection, as well as the insider perspective of an ethnic minority person thereby additionally valuing emic methodologies. Overall, suggestions offer a starting place about what might constitute as good practice, but studies with more empirically rigorous methodologies are required in the future to test them.“Children exposed to ongoing and extensive DV. Witnessing NF  continual threats to kill NM  and children” [ANG_case file].Children who enter the CPS due to substantiated reports of maltreatment—physical abuse, sexual abuse, emotional abuse, inadequate supervision, and/or chronic neglect—may also have reports of DV, which has been acting as a risk factor to child maltreatment. Thus, multiple child safety issues might need to be addressed. When CP workers refer these families to DV (counselling and refuge) services, the service is likely to receive families with complex needs; compromises to child safety in the form of emotional abuse due to witnessing DV may be but one issue in need of address. As one example of such emotional abuse, a case file report said: Indeed, one key finding from Stage 2 was that not including financial issues/poverty, DV was the most common risk factor of child maltreatment  in all six  cultural groups in Australia  can’t say anything” [CHN_case file]. Of course, they are not independent goals, but differences in the focal point mean that a mutually beneficial exchange between agencies is in the best interests of the child and family.However, the core business of CP workers is child safety, whereas the core business of DV service workers is family safety which includes victimised adults—mostly female, but no more qualitatively (as opposed to quantitatively) important to protect. As one reported example of DV among men: “Importantly, DV is a generalist issue; the physical, emotional, and sexual violence ‘looks the same’ and all families require equal attention in this regard. Having said that, DV interacts with cultural and other factors for ethnic minorities. The following section discusses these factors.National Plan to Reduce Violence against Women and their Children 2010–2022  was a private matter” [CHN_case file].While the numbers indicate that DV is an issue in all families, this does not mean that it is qualitatively experienced the same across cultural groups. Specifically, the trend toward keeping DV a private family matter is intensified in collectivist communities, which ethnic minorities tend to be, because of a definitive value for family and therefore family reputation. As one example of this, a case file report said: “Mother refused to provide a statement to police and get photos taken of her injuries” [LEB_case file], and “NM holds fears for her safety due to previous physical abuse by her husband that she was afraid to report as it would bring shame to the family” [LEB_case file].In other words, the family name must be protected at all costs, including the safety of adult and child victims, whose individual needs for safety are seen as second to those of the familial or collective group. Coming to the attention of police and CP authorities is perceived as a great shame because it tarnishes family name and community standing, and in turn, risks social rejection and isolation from their ethnic community. Community acceptance is particularly critical to protect for ethnic minorities because it provides cultural safety in addition to sense of belonging  order—mother allows father to have contact during dinner time with the children” [LEB_case file].As an example of ethnic minorities’ feelings of intrusion by authorities—whom ethnic minorities also tend to fear  — victimuntraditional.The need to protect family cohesion is a particular burden on ethnic minority mothers. Collectivist communities tend to have traditional gender roles, with overtly patriarchal social structures; daily life is lived with explicit understanding that males have more power than females . Several“AVO protecting mother and children from father, [but] mother not being protective, not enforcing AVO” [LEB_case file]; and “Mother not accepting any responsibility for keeping the children safe. She has indicated she will leave the father in the event of another domestic incident, however she has said this in the past and not followed through” [LEB_case file].Ethnic minority mothers who are victims of DV may be at odds with authorities in their construals of child safety. Authorities may perceive that an AVO offers child protection but mothers may perceive that children in a family unit that is not cohesive are subject to social rejection and isolation from their ethnic community and are therefore not protected. These mothers may sacrifice their own on-going ‘personal safety’ to protect the ‘cultural safety’ of their children; perceived as more important . One way“NM getting calls from mother and father-in-law saying ‘we’ll fix it between us’. NM said ‘no it’s too late, I’m protecting my daughter’. NM saw the counsellor who made her realise that she needs to protect her children” [LEB_case file]. Full and genuine empathy may also help counteract any fears the mother is having that the caseworker has come with ‘Western beliefs’ about choice and freedom and independence that she may not have . As an example, Adames and Campbell (2005) say, “the acculturative process and new economic demands may involve shifts in (standard) gender roles and power relations … Reluctant to accept these, (Latino men in the US may) resort to other means of asserting themselves such as IPV. Thus, exposure to mainstream U.S. culture and more egalitarian values and attitudes … could be more harmful than liberating” (p. 1342–1343)  the police, because it’s a shame for the woman [to] bring the police for the husband” [CALD family interviewee].Fear of the perpetrating spouse for disclosing abuse to authorities may also prevent victims of DV from seeking professional help. As Giglio 1997) says, “in cultures where men are considered superior to women, they may fear reprimand if they tell of abuse at home” (p. 5) . Arguabl97 says, NF indicating he wants to keep his family together. After some discussion, NF agreed to supports/referrals, originally hesitant due to shame/embarrassment. NF: ‘Can we keep confidential, can spark more problems. Wouldn’t want matter exposed’” [CHN_case file].It is reported in the literature that social service uptake and engagement tend to be lower from ethnic minority communities . This isHowever, there are also system failures that compound this trend. For example, interpreters may not be provided to families low in English proficiency, who then remain unaware of the full implications of the involvement of CP agencies in their families . AlternaMore significantly, ethnic minority communities may not engage with authorities or the service sector because of fears of racism. As Kanuha (1994) puts it , “becausThere are real grounds for these feelings. For example, DV refuges may not provide culturally sensitive services, which victims fear  or expecAdditionally, some ethnic minority families and communities in Australia may perceive the removal of their children as a repeat of the ‘Stolen Generations’ and the Northern Territory [NT] ‘intervention’; that the need for child safety is assumed to be greater in non-mainstream communities and therefore becomes racially targeted. In specific cases, such a response may be a defensive one to deflect from the violence occurring in their family, but unfortunately it does not negate the validity of the threat, and perception of threat, that cultural safety is at risk.overtly traditional gender roles. Ahmad et al. (2009) say, “there is a strong need to improve women’s social status in the South Asian community (in Canada). It is imperative to educate the community about gender inequality and its harmful linkages to domestic stress and partner abuse with serious consequences not limited to the victims. To trigger critical self-reflections for a positive change, an emphasis on the trans-generational consequences of abuse could be particularly beneficial due to its collectivistic and familial cultural values” (p. 619) [In this regard, Weston-Scheuber’s (2007) article is seen as a ‘must read’ for practitioners in the field . She dis(p. 619) . While tEvidently, much is happening in the space that occupies the nexus of child protection, domestic violence, and ethnic minority children, families, and communities. Informing practitioners of how best to navigate this space is in the best interests of children and adults unsafe from harm. To this end, this article offers the following suggestions for knowledge and practice. It is intended that should staff from CP agencies and DV services be aware of these issues, it can aid in their exchange because knowledge is not siloed off between agencies. However, CP and DV staff would still need to take carriage for how each suggestion would be implemented and cross-checked within their organisational practices and policies.All staff should:Appreciate that ethnic minority DV victims share personal/psychological barriers to leaving the harmful situation with Anglo and Indigenous DV victims, thereby paying attention to cross-cultural similarities.utmost value for family name/reputation, thereby paying attention to cross-cultural differences.Appreciate that the pressure to keep DV private in ethnic minority/collectivist communities is driven by an Appreciate that protecting the family name avoids social isolation and exclusion from their ethnic community, which may be seen as more important to protect than their child’s personal safety; empathy for this dilemma may help improve the DV victim’s accuracy of risk perception.Ensure that referrals for all types of presenting child maltreatment issues have been made/considered .Ensure that referrals with culturally appropriate DV refuges are made.Migration Act 1958.Ensure that victims receive legal advice regarding the ‘family violence exception’ of the Use a feminist framework when engaging with women victims of DV, so that gendered power inequality at the systemic/societal level is not omitted from service engagement with individual clients.Use a feminist framework appropriately when engaging with men victims of DV .Appreciate that their presence in an ethnic minority family is likely to be met with conflicting feelings of being both welcome and unwelcome by child and adult victims of maltreatment and violence.Be aware that in ethnic minority families, compliance with AVOs may only be partial because it threatens family cohesion, which is seen to be more important in the long-term to protect than personal safety.only belonging to ethnic minority communities.Acknowledge that traditional gender roles occur in all groups in Australia — Anglo, Indigenous, and ethnic minority — but that they are overtly accepted in ethnic minority communities. This helps see the role of patriarchy in ethnic minority communities and the burden it imposes on women victims of DV, but it also avoids the risk of seeing it as Be aware that service uptake may be low because DV victims fear reprimand from the perpetrator. This is true of all families regardless of their cultural background, but may be intensified in ethnic minority groups. To help address this, confidentiality must be repeatedly assured to ethnic minority families, who also fear tarnishing the family name should it be known that service support was being accessed. This way, staff can assure families there is no reason to fear the community finding out about the abuse and therefore no justifiable reason for them to ‘suffer in silence’. It may also help to remind the DV victim that its occurrence is high in all cultures, which is why extensive supports in the local community are available, and which may help decrease any isolation or loneliness.Be aware that DV service uptake may be low because ethnic minority/collectivist communities typically rely on intra-familial rather than external support. However, services should also reflect on whether they are culturally competent to ensure low service uptake is not due to policies and practices that are not client-centred.Provide an interpreter if English proficiency is low, but not see this as sufficient for meeting the needs of ethnic minority families.Be aware that violence in non-mainstream families is at risk of being labelled a ‘cultural issue’, unlike in Anglo families, because of stereotyping. Qualitative differences in the experience of family violence across cultures should be understood as part of cultural awareness, knowledge, and sensitivity, not as evidence for racist attributions.Three inter-related issues for consideration with ethnic minority children and families in Australia are: (i) family name, (ii) family cohesion, and (iii) racism. These make the ‘cultural’ subjective experience of CP and DV unique for ethnic minority families, however the violence itself is cross-cultural. That is, DV is a generalist risk factor of child maltreatment in all groups. Thus, cross-cultural similarities must not be over- or under-emphasised, but rather given equal consideration to cross-cultural differences. The main implication of these three issues is that cultural and racial factors are not addressed when only an interpreter is provided; the needs of ethnic minority groups are more than just linguistic.The suggestions for practice offered here should be evaluated for whether and how they translate to effective exchange between statutory and non-statutory agencies to best keep ethnic minority children and families safe from harm. This is particularly critical given that the prevalence of DV is high in all groups, but its true extent is higher than what the statistics reveal. Developing a solid and rigorous research body can aid in reducing the threshold of silence and permissiveness that currently surrounds DV in all groups.


The first metatheory conceives of truth in terms of coherence : a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other’s terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London,  Apart from indirect, this knowledge is also fallible, and hence our diagnoses are always more or less uncertain: the world in which we live is characterized by “irreducible uncertainty”  is true in the sense: correct. The consequences of this approach are twofold: first, it enables us to hold different versions of truth, as a consequence of using different criteria, while refraining from philosophical speculation. Second, it enables us to develop a new view of judging diagnostic competence, and we will try to demonstrate that if we can judge diagnostic competence, we can also improve it through education or experience.If we hold a belief about a patient’s diagnosis, make a judgment of a patient’s state, or decide on a treatment, how do we know that this belief, judgment, or decision is “true” or “correct”? Or, even more fundamental: What do we mean by “true” when we say, “the true diagnosis was…”? Some philosophers, most notably post-structuralists, will claim there is no such thing as a “true diagnosis.” However, we believe this view to be rather unconstructive and will adopt a more pragmatic stance, i.e., that diseases are entities that exist in the empirical word (“out there”) and that we all—doctors, students, patients, teachers, anyone—can obtain at least  Hammond . Rather correspondence theory of truth  offers tangible indicators of its intangible aspects, such as diseases . Full inconsistencies cannot be solved this way; if two claims are inconsistent, they contradict each other, and hence at least one must be false . Unfortunately, coherence is much harder to define than consistency , defensible , and leads to credible conclusions even in the absence of knowledge about their actual empirical accuracy  clinical reasoning will inevitably result in correct  diagnosis. For example, according to McGuire , “(…) thTo begin with, and maybe most importantly, clinical teachers should be aware that medicine is an example of a hybrid ecology Mosier , p. 161;hear this murmur in an actual patient. Teachers should always be aware they are training students to deal with descriptions of patients, rather than with real patients. Though teachers may test students’ coherence competence by asking hypothetical questions, e.g., “What would your primary diagnosis be if the test results were negative?,” it is not common, in this format, that students are encouraged to challenge the findings in a case per se. Finally, to foster analytical clinical reasoning, it is important the supervisor is not informed about the actual diagnosis of the patient—ideally, there is no “actual” diagnosis, for the case is “unauthentic”, i.e., constructed, or at least adapted; for students, this may be disappointing: they may want to know whether they “got it right” (in the correspondence sense). However, the risk of using an actual case with a known diagnosis is that clinical reasoning becomes a reconstruction of a remembered process, rather than unbiased diagnostic reasoning on basis of the givens in the case.Coherence diagnostic competence can best be trained in small-group sessions, under little or no time pressure, using paper cases (or simulations), with an emphasis on constructing a differential diagnosis, and providing process feedback: do the students identify the important information in the case, do they appropriately use their knowledge, can they defend and elaborate on the structure of their differential diagnoses? Custers et al.  describehow it works: in the clinic, it often requires an “intuitive jump” from the findings to the diagnosis. A large intuitive jump is subjectively experienced as a hunch , a small intuitive jump as plain pattern recognition. The smaller the jump, the lesser the diagnostician will be inclined to question the outcome. In case of pattern recognition, there is no diagnostic process that can be retraced and investigated in retrospect for possible errors; there is only an outcome. Correspondence outcomes may be improved by the use of electronic diagnostic devices, but their role in developing correspondence competence in students is not clear, in particular if their workings are opaque and their outcomes not infallible. For learning to occur, hunches and recognized patterns need to be confirmed or disconfirmed by immediate outcome feedback; if this feedback is delayed or absent, an incorrect association between the features and the response may be inadvertently reinforced. Thus, it will be good practice to prevent inexperienced students from jumping to conclusions, and early training of this form of competence will aim at encouraging students to describe as accurately as possible what they observe , rather than asking to come up with a diagnosis (or diagnostic suggestion) as quickly as possible. This is also important because studies have shown that after being informed about the correct diagnosis, students may ‘recognize’ symptoms or other features typical for this diagnosis they did not notice in advance  cues necessary to develop clinical acumen. The gold standard for an accurate diagnosis is usually the pathologist’s judgment or the outcome of one or more laboratory tests. Unlike coherence competence, correspondence competence does not assume that the clinician is consciously aware of


Epilepsy should be suspected in patients with Stiff‐person syndrome and new onset paroxysmal episodes. Musicogenic epilepsy may be a manifestation of anti‐GAD‐Ab spectrum, supporting an autoimmune workup in these patients. Appropriate treatment is not well established, and immunotherapy should be considered in patients with only partial response to antiepileptic drugs. Epilepsy should be suspected in patients with Stiff‐person syndrome and new onset paroxysmal episodes. Musicogenic epilepsy may be a manifestation of anti‐GAD‐Ab spectrum, supporting an autoimmune workup in these patients. Appropriate treatment is not well established, and immunotherapy should be considered in patients with only partial response to antiepileptic drugs. She had an anti‐GAD‐Ab titer of 800 nmol/L , with normal spine MRI, electromyogram, nerve conduction study, and muscle biopsy. She did well on symptomatic treatment (gabapentin and diazepam).Her seizures started in 2014 when her husband witnessed episodes of unresponsiveness and automatisms. Most of her seizures would occur at a weekly basis while singing or listening to choral music at church, triggering a religious emotion. According to her husband, she would stop singing, stare and exhibit mouth and hand automatisms lasting for few minutes, followed by a period of confusion lasting for 2‐3 minutes. The patient had no recollection of the events. Occasionally, she would experience spontaneous seizures, which were not triggered by music. She was admitted to the Epilepsy Monitoring Unit, and she had four seizures arising from the left TL characterized by apnea followed by loss of awareness and automatisms  an acute epilepsy associated with limbic encephalitis; (b) a chronic slowly evolving focal epilepsy, that can become pharmacoresistant.All three responded partially to AEDs. Two patients were treated with immunotherapy, one with no improvement.Epileptic seizures should be suspected in patients with SPS and new onset paroxysmal episodes. Autoimmune workup with anti‐GAD‐Ab determination should be performed in patients with MRS. Immunotherapy should be considered in epileptic patients with anti‐GAD‐Ab when they do not fully respond to AEDs.The authors have no conflicts of interest to declare.JJ‐R: involved in conception and design, analysis and interpretation of data, final approval of the version to be published, and agreed to be accountable for all aspects of the work. AB, MA, and MS: involved in acquisition of data, analysis and interpretation of data, drafting the manuscript, final approval of the version to be published and agreed to be accountable for all aspects of the work. GF‐BV and BK: involved in conception and design, revising the manuscript critically for important intellectual content, final approval of the version to be published, and agreed to be accountable for all aspects of the work.Subject has given her written informed consent to publish this case.


While the majority of attention and the literature has focused on transitional models out of the acute care setting, transitions from the post-acute setting—especially from the skilled nursing facility (SNF)—are not well understood. What are the ‘best practices’, or thoughtful considerations, for a successful transition back to home and the community? Facilitation of a smooth and seamless transition relies on the abilities of the SNF and primary care teams, as well as community agencies, to coordinate care in a patient-centered manner together. This article will focus on this specific transition within the healthcare continuum. Dr. James Lett, a former president of the American Medical Director Association, the Society for post-acute and long-term care medicine (AMDA-PALTC), and a former chair of the society’s transitions of care (TOC) committee, said at a 2015 TOC meeting, “the best transition is the one that never occurred”. What did Dr. Lett mean? Transitions occur constantly in healthcare; in fact, they are fundamental to care within the continuum: There are ‘micro’ transitions that occur between hospital providers’ teams or floors, or between primary care practitioners and specialists, and there are ‘macro’ transitions that occur between institutions, i.e., the hospital, the SNF, and home care and community services agencies. How can we fathom, then, that a transition might not occur in the care of our patients? Consider a transition—any transition—that was so seamless, so smooth, with such optimal communication and education between providers, nurses, facilities, case managers, support staff, patients, and families, that it ‘felt’ to everyone as if care was completely coordinated. To that patient and family, it might actually appear that (aside from geography) the logistics around care had not been interrupted or fragmented: that the semblance of a transition had ‘never occurred’. Can we get to this transition ‘Nirvana’ of patient-centered care? In 2018, the AMDA-PALTC TOC committee continues to contemplate the ‘never occurred’ transition state. What would be the ‘lowest hanging fruit’ in the transitions process from which we could take a leading practice ‘bite’ of improvement? This article will suggest that a good place to start is the SNF setting itself; and more specifically, at the transition point between the SNF and the community, a transition that has not been well-studied, but would embrace a stronger, more invested medical practitioner role, and an actionable, cohesive discharge plan (and summary) to potentiate ongoing care.While the essence of short-term rehabilitation in the SNF setting focuses on raising patient functional abilities to the highest practicable level via nursing monitoring and assessments, as well as nutritional, social work, and therapeutic interventions, the SNF is more than just a place for these aspects of ‘skilled care’. Another, perhaps even more substantial, function of the SNF remains poorly recognized: It is a unique setting within the continuum of care, in which each patient has the potential to be actively monitored and intervened upon, for up to weeks, in ‘real time’. In turn, the SNF patient can truly become the focal point around which families, ambulatory and hospital providers, and home care and community agencies together may participate as a team in communications, education, and outcomes. In this way, the SNF setting can be a ‘hallmark’ of ‘patient-centered care’. Furthermore, in recognition of this setting’s potential significance in post-acute patient transitions, and in accordance with the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), Medicare has become more intimately involved in trying to understand and improve the patient transition process. For example, it established a technical expert panel (TEP) panel, initiated in September of 2016, to determine ‘transition’ quality measures, in part, for when a patient was discharged from post-acute care to other providers and settings. In turn, as work groups such as the TEP were attempting to understand what distinguished quality in transitions, some higher-level, unanswered questions became evident: what were the natures of the SNF provider role, the discharge processes upon which a facility needed to focus, and the roles and responsibilities of the receiving provider(s) and community agency(ies).The potential of the SNF remains largely untapped because the actual role of the SNF provider, as described by the Medicare code of federal regulations (CFR), i.e., 42 CFR 483.40 (a) and (b), still remains subjective at best. When should a patient be initially seen? What is the best format for documentation? What is the relationship of the SNF provider to the SNF team? What is an impactful visit? Even with further clarification at the state-regulation level, the basic role of the physician is to provide “personal approval” of an admission recommendation, ‘supervise’ or ‘participate’ in resident care, supervise advanced practitioners, and generate visits that are intended to represent a more ‘active role’ in patient management. This description leaves significant room for variation in the approach to the provider–patient relationship and begs for the establishment of ‘best practices’. As the first step in taking full advantage of what the SNF setting has to offer—as the ‘therapeutic hiatus’ of care that it can be—attending physicians and advanced practitioners need to be the SNF multidisciplinary team leaders: they must become more invested in the overall care of their (assigned) patients and they must actively participate in the creation, enforcement, or modification of their patient’s plans of care. Furthermore, AMDA-PALTC, through its ‘core competencies’, wants to help invigorate this role of the SNF attending physician (and further develop that of the advanced practitioner) as a unique leader and specialist in post-acute care, through further, SNF-specific education and practices. In this regard, a SNF provider’s ability to implement ‘proactive’ plans of care can help to fortify a transition back to the community that is as impactful and long-lasting as possible. The AMDA-PALTC position statement regarding the role of the attending physician in the nursing home is perhaps more relevant today than at its introduction in 2003, and the provision of care is only augmented more with the evolving team role and responsibilities of the advanced practitioner . The posThis investment in patient-centered care by the provider and multidisciplinary team also makes the SNF an ideal environment for the opportunity to address the needs, goals, and wishes for all patients, but especially for ‘higher risk’ patients or those identified with life-determining illnesses. In Massachusetts, there is a code of regulations (CMR), 130 CMR 140.031, in the long-term care setting to identify such ‘appropriate’ patients and ‘at the minimum’ provide information for advance care planning (ACP) and palliative care or hospice services. In the short-term setting, with the increasing patient acuity on presentation from the hospital, a standardized process for all patients should be to initiate, document, and communicate ACP discussions in order to: (1) confirm advance directives ), (2) identify those patients for whom a palliative care consult would be beneficial, (3) understand patient (or verified surrogate) desires for resuscitation, rehospitalization, or advanced treatment options via a patient and provider-signed statement of ‘orders for life-sustaining treatments’ (for which some states refer to as a ‘MOLST’ or ‘POLST’), or (4) appreciate those patients for whom end-of-life discussions and hospice referrals might be the best plan of care for their successful transition back to the community. These ACP discussions also provide the opportunity to utilize the reimbursement codes that Medicare has established  to incentivize such discussions; but, regardless of regulation or financial benefit, advance care planning is one of the most valuable provider tools for enhancing transitional (and patient-centered) care from the SNF setting [Numerous models for transitions of care from the acute setting have been introduced over recent years , and in 2013, a Project RED (Re-Engineered Discharge)-based model was utilized to transition a unique set of patients from the post-acute setting to the community . HoweverThe successful transition to home also mandates the coordination of care with community agencies, such as visiting nursing/home care, and/or area agencies on aging (AAA)/aging services access points (ASAPs), as there is evidence that reduced thirty-day readmissions may be associated with a home health visit within a week of SNF discharge . AAA/ASACurrently, the vision of the seamless, coordinated pathway for patients from the SNF setting to home is far from that of Nirvana, but as one surpasses the many ‘needs’ discussed here for optimal transitional care, the pathway does become clearer. As long as disparities in the working relationships between providers, SNFs, and community teams continue, however, the ‘transition that never occurred’ will not become an actuality. Patient-centered care, at this transition point, demands more than what is ‘regulated’: it requires a true investment in advance care planning and the desire to utilize the SNF as a location—and as an opportunity—to elicit positive change through ongoing communication, education, and commitment to the multi- and interdisciplinary teams. These efforts will yield outcomes in quality that far outweigh those of ‘lengths of stay’ or ‘readmissions’—perhaps that will be this transition’s true ‘Nirvana’.


The EHA-Patient Joint Policy Symposium at EHA24  offered a day of stakeholder sessions on key policy and regulatory topics.While novel cell and gene therapies are very promising, their introduction raises the question how patients can benefit, given the complexity, budgetary burden and uncertainty about the long-term effectiveness of these treatments. Speakers in the morning sessions set out looking for answers, and did some expection management along the way.Not surprisingly, the panel members addressing the question at the heart of this session did not come up with a unified answer. Francesco Pignatti (EMA) reminded the audience that neither innovation nor excellence are requirements for market authorization, but that this is based on safety and efficacy. Decisions on medical benefit and prescription are up to doctors and patients; the role of EMA is to make sure they can make these decisions based on the best available information.The fact that a mandate has its inherent limitations was also evident in the two contributions on Health Technology Assessment (HTA). Patient advocate Zack Pemberton-Whiteley stressed that patient involvement in HTA must be combined with real influence on decision-making. EUnetHTA, represented by Anne Willemsen, considers input from patients essential, especially in the scoping phase. However, efforts to involve patients have so far had only limited success. Patient advocates in the audience mentioned several reasons for this, including lack of resources, COI issues and skepticism about the value of their contribution. Willemsen strongly defended the separation between joint clinical assessments, as piloted by EUnetHTA, and national-level appraisals, while Pemberton-Whiteley argued for reimbursement decisions to be made at the European level.Market access specialist João Carapinha discussed concepts of ‘value-based’ versus ‘fair’ pricing. A believer in value-based pricing (VBP) – in his opinion, prices should not be fixed but always negotiable – he nonetheless warned policy makers against implementing VBP models, for lack of resources. ‘Who pays?’ remains the inevitable question.Now that the importance of patient-reported outcomes (PRO) is broadly recognized, the four speakers in this session focused on their implementation. Patient advocate Giora Sharf discussed the use of PRO in clinical trials. The perception of the impact of PRO tends to differ between doctors and patients, but there is little doubt that they play a valuable role in stimulating discussion between the providers and the receivers of care. Tom Coats (King's College London) addressed the role of technology in hematology and cited “powerful studies” that suggest that PRO supports clinical decisions in cancer, with very good input even from computer-inexperienced patients.Mark Skinner from the Institute for Policy Advancement in Washington, DC, is equally convinced that “patients can influence the clinical pathway”, with the help of methodologically sound PRO tools, such as the one he presented, PROBE . Another insightful contribution was provided by Sarah Liptrott of the Hematology Nurses & Health Care Professionals group (HNHCP). Nurses play a prominent role in the interaction between physicians and patients, and are convinced that PRO are beneficial also for physicians as it positively affects their satisfaction levels, efficiency and time. Interestingly, HNHCP has developed disease-specific PRO measures, such as for sickle cell disease.In front of an overflowing room – as befitted a session dedicated to a hype – Hermann Einsele (University of Würzburg) and Natacha Bolaños  led a spirited discussion on CAR T-cell therapy.Ananda Plate of Myeloma Patients Europe agreed that CAR T-cell therapy is very promising, although in myeloma “it does not look like a miracle yet”. She called on all stakeholders to agree on a combined set of tools – communication, PRO/Quality of Life (QoL), health economics, protocol – that help achieve meaningful benefit for patients. Not knowing exactly what to expect from CAR T treatments causes uncertainty among both patients and nurses. As Mairead Ní Chonghaile of HNHCP asserted, “there is an awful lot of doubt and fear among healthcare professionals – all of them”.Jan van de Loo, cancer expert of the European Commission, views health inequalities across Europe and pricing as the main issues. The Commission acknowledges that Europe lags behind China and the US, but is faced with limited funding from Member States. It focuses its efforts on comprehensive uptake of CAR T-cell therapy in health systems, EU added value, partnerships, and fostering innovation. The last round of Horizon 2020 calls will offer “lots of opportunities for cell therapy”, on top of the two specific CAR T-cell topics in the most recent IMI2 call.Later in the day, speakers at the EHA-Patient Joint Policy Symposium highlighted the need for adaptation of regulatory processes to facilitate true patient-centered, personalized medicine.Leading the call for regulatory changes and flexibility was Ulrich Jäger from the Medical University of Vienna, member of EHA's European Affairs Committee. New regulations are needed to enable the tailored decision-making and personalization of trials that are necessitated by the combination of high-risk patients, treatment failures, rare diseases and novel target or drug discoveries. Adaptation is also required from pharmaceutical companies, in order to make multi-drug trials possible. An encouraging example is Roche experimenting with 10-drug trials. Challenges for companies include financial and legal risks, unwanted stimulus for off-label use, and, as Johannes Pleiner-Duxneuner of Roche Austria put it, “the need to turn real-world data into real-world evidence” which requires the combination of databases.Jan Geissler (CML Advocates Network) stressed the need to involve patients in all the difficult decisions on ethics, regulation and data protection. “If it is all for the patient, why are we not asked what an acceptable risk is?” He also pointed out that while new regulation may be necessary, much can be done with existing mechanisms such as the Clinical Trials Regulation, Adaptive Pathways and PRIME. Clinical assessor Olga Kholmanskikh Van Criekingen of Belgian medicines agency FAHMP agreed with fellow panel members that new trial designs could help increase the use of biomarkers and personalize treatments, that big data is crucial, and that patient input “along the continuum” is important. She signaled a number of risks, however, including increased operational complexity and challenges to safety oversight, data integrity and transparency. Widely diverging patient opinions on data sharing and usage are a complicating factor.There was agreement among the members of this panel addressing ‘personalized medicine trials’ that the data ownership question is crucial. Registries are seen as part of the solution, and hopes are that valuable lessons can be drawn from the HARMONY project .The most debated issue on this day was formulated, somewhat provocatively, by session chair Ton Hagenbeek (Amsterdam UMC/EHA European Affairs Committee): “EMA is bound by its mandate, but as a physician I say: there should be a real medical benefit before a medicine can be approved.” Raising the bar for drug approvals, by adding a ‘real added value for patients’ criterion to efficacy and safety, was not something that could, or should, be expected of EMA, as Francesco Pignatti explained. Not regulators, but doctors and patients should decide on medical benefit. “A paternalistic approach of raising the bar for all is not the answer.” And: “There is not a single bar we can all agree on”.Patient advocate Piarella Peralta (Inspire2Live) proposed refocusing the discussion to “raising the bar for patient care with quality of life”. This requires re-centering healthcare around the “magic combination of patients, clinicians and researchers”. Responding to Prof. Hagenbeek challenge that industry trials result in many ‘me-too’ drugs that are good for industry profits but of little added value to patients, Takeda's Kelly Page acknowledged industry can do better. She insisted, however, that “our responsibility as industry is to run the best studies we can”. Page expressed confidence that “patient involvement throughout the development continuum can help ensure value-added outcome”.There was consensus among panel and audience members on the need for meaningful involvement of patients in decisions on benefit, and for alignment of all stakeholders to determine patient-relevant endpoints. In a somewhat prickly exchange on the merits of ‘me-too’ drugs, however, patients in the room reminded everyone that patients are not a monolithic group with identical preferences. What is of negligible benefit to some, may be invaluable to others.