*3.3. Objective 2: Contents and Structure of the Intervention* 3.3.1. Attendance

Members from all six families completed the family sessions (100% family attendance), and all families were represented in the parent seminar. Due to illness, one parent neither completed the second half of the intervention nor the T2 assessment. However, the child and the other parent completed as planned. All four school meetings were conducted for all participants (100% school attendance), and four families participated in at least one

school meeting. The rest of the meetings that parents did not attend were forgotten by the parents. On average, the family sessions lasted 98 min including breaks. The children attended parts of all the sessions, according to what topic was being discussed and the child's concentration and willingness to participate. All families received extra telephone follow-ups related to their goals and strategies in addition to the procedures described in the manual (with a total duration of 20 to 150 min per family). For two families, telephone contact was also made to other collaborators: physiotherapist (20 min), school nurse (20 min) and the special educational service (45 min) for one family, and two phone calls to the child's assistant for the other family (40 min). Overall, the high attendance rates indicate that the intervention implementation was feasible.

#### 3.3.2. Evaluation of the SMART-Goal and GAS Approach

All families set SMART-goals that were related to some or all of the main problem areas they reported at baseline (Table 3). For two families, new areas to work on became evident during the intervention. Five families defined three goals and one family defined five, providing a total of 20 goals. Of these, six goals had their starting point at GAS 1, whereas the rest started at GAS 2. The most frequent topic was fatigue, which was the focus of at least one goal in five families. Increased independence in everyday life was a topic for two children, including leaving the house on his/her own in the morning, keeping track of appointments, taking the bus and starting to ride a bike again. Two worked on goals to reduce pain and two had goals regarding social functioning. Two families worked toward parental mental health goals, and two families had goals regarding family communication and learning how to talk about the injury with others. One family aimed to apply a problem-solving technique and one set a goal related to the child's study skills.

The children's participation in the goal-setting process varied according to their abilities and motivation. For instance, the youngest child (11 years) would participate in setting the goal and name already existing good strategies to obtain the goal (for instance, rest after school). The child would also participate in discussing new possible strategies to ensure ownership and collaboration (for instance, how the child would be comfortable resting at school). Due to short attention span, strategies related to the parents' actions would be discussed when the child took a break (for instance, encouraging the child to name the level of experienced fatigue three times a day on an "energy-scale" and taking notes of the different activities the child had endured that day). In contrast, one of the teenagers was cognitively able to participate in larger parts of the sessions, the goal-setting processes and discussions on strategies. During the family sessions, all children were encouraged to share their experiences in working with the strategies since the last session and to state their opinions on whether the strategies were helpful and feasible for them. The strategies were adapted and/or new strategies were established as needed. To a large extent, the strategies were external, which means adapting the environment or facilitating the establishment of new skills. One example is parents who trained their child to use a smart-watch by using principles of errorless learning [66], where the parents gradually offered less help as the child gained confidence and skills. Implementation of the strategies in everyday life was highlighted throughout the intervention by basing the strategies on the individual family's everyday life routines and resources and through encouraging daily use of the strategies.

The families attained all their goals but one (in family B). For 14 of the 20 goals, goal achievement was beyond the expected level on the GAS. Figure 4 shows goal attainment scaling per goal for each family. None of the goals showed negative GAS change.

### 3.3.3. Responses to the SMART-Goal Approach

Both parents and children perceived the SMART-goals as highly relevant, with all but one score ranging from 3 (agree) to 4 (completely agree) on the corresponding item on the Acceptability Scale. See Table 4 for the individual ratings. All children confirmed the importance of the goals and were pleased to achieve the skill, but some of them found working on the skills and spending time in meetings instead of being at school or with friends tiresome. The parents reported that the strategies to achieve the goals had helped their children, with four families responding with 4 (completely agree) on this item and two families scoring 3 (agree). Overall, the SMART-goal and GAS-methodology was deemed highly feasible.

**Figure 4.** Goal attainment scaling on each goal per family, measured by the GAS change from T1 to T2. A positive number means that the goal was achieved. For family B, one goal had no progress on the GAS and is not visible in the figure.


**Table 4.** Working alliance, usefulness and evaluation of SMART-goals and strategies, scale from 0 ("Completely disagree") to 4 ("Completely agree").

\* Indicates missing data. <sup>1</sup> Parent rated

3.3.4. The Use of Videoconferences in Treatment Delivery

Overall, the technical solutions worked very well. All families but one had excellent internet connection, and every family owned equipment suitable for videoconferences (PC or tablet). Support was provided to the family with slow internet connection, and solutions were found to enhance the quality of the videoconferences. External microphone speakers were sent to the families to optimize the sound. There were only a few incidents of needing to restart the equipment (less than one session per family) throughout all of the 40 videoconferences. According to the predefined criteria, the technical solutions were highly feasible.

The satisfaction with the use of videoconference in the intervention (see Table 4) was rated as high by both parents and children (median score 3 for both). The therapists rated the use of videoconferences in the intervention as good overall (median 3) and also experienced it as highly feasible to set goals and strategies and to implement the intervention with the family (median score 4). However, the therapists rated it as challenging to maintain good communication with the children through videoconference, with most ratings at the lower end of the scale on the question framed "communication was good with the child". The therapists' ratings varied from 0 to 4, with the lowest rating being in regard to a child with very severe cognitive deficit. Overall, the use of videoconference was evaluated as an acceptable approach for treatment delivery, but with a special focus on involving the children.
