Relaxation Breathing Training for Children

After consent is signed, a baseline questionnaire will be given to the participant, including
demographics and baseline data followed by randomization into one of the following
groups:Relaxation breathing training alone or Technology-enhanced relaxation breathing.The
intervention will occur through the use of the StressEraser, Breathe2Relax and text
messaging.

1. The StressEraser is a handheld biofeedback device that measures heart rate variability
(HRV). Heart rate increases during inspiration and decreases during expiration. This
HRV, depicted on a miniature screen, essentially represents respirations. We have been
using this device in the pediatric outpatient department over the past two years (in a
non research entity) and it has been well accepted by children 6 years of age and above.
In our prior study, which took place in school, the device was also easily mastered and
acceptable to children above 6 years of age.

2. Breathe2Relax is a free mobile app, developed by the Dept. of Defense's National Center
for Telehealth and Technology to help veterans with PTSD and others use breathing
practice for stress management. This application guides users in relaxation breathing
and is available for both android and iOS phones. It is adapted for children 6 years and
up. The user downloads the app. and is walked through steps that easily explain the
purpose of the app (to guide relaxation breathing). The active part of the app shows a
tube that fills in during inspiration and empties during expiration. For children the
cycle lengths can be shortened which is explained to participating parents by the
research team. There is a selection of quiet music and the user can choose backgrounds
for personalization. The Breath2Relax app will be downloaded for the RT-enhanced group
at the time of the intervention for the RT-enhanced group, and the parent will be shown
how to modify the length of the breath cycle depending on their child's age.

3. Text messages: Weekly texts will be sent out to parents in the RT-enhanced group
regarding relaxation breathing and to remind parents to practice the daily relaxation
breathing with their child.

For the breathing training, the study research assistant (RA) will follow the standardized
protocol used in BMC pediatric clinic over the past two years. The child is taught firstand
learns how to use relaxation breathing and then the child teaches their parent how it works
with the support of the RA. This step assures that the child has learned the relaxation
breathing skills and also creates a moment when relaxation breathing is practiced together by
the dyad. The parent-child dyad are encouraged to practice relaxation breathing once
daily.Caregivers usually choose bedtime to practice breathing because the practice can be
done while the child is in bed.

The training is followed for the Technology-enhanced relaxation breathing group by
downloading the Breath2Relax app on the parent's smartphone. Parents will be prompted by the
RA to choose a specific time each day to practice the relaxation breathing with their child,
and for the Technology-enhanced relaxation breathing group using the Breath2Relax app.

Inclusion Criteria:

- child between 6 and 11 years of age and their parent

- primary language either English or Spanish

- parent has a working smartphone

Exclusion Criteria:

- a child who is in Department of Children and Families (DCF) custody whose caregiver is
a foster parent

- parent who does not speak or read English or Spanish