Integrated Behavioral Health Prevention for Infants in Pediatric Primary Care: A Mixed-Methods Pilot Study

OBJECTIVE

Pediatric primary care is a promising setting in which to deliver preventive behavioral health services to young children and their families. Integrated behavioral health care models typically emphasize treatment rather than prevention. This pilot study examined the efficacy of an integrated behavioral health preventive (IBH-P) intervention delivered by psychologists and focused on supporting parenting in low-income mothers of infants as part of well-child visits in the first 6 months of life.

METHODS

Using a mixed-methods approach that included a pilot randomized clinical trial and post-intervention qualitative interviews, 137 mothers were randomly assigned to receive IBH-P or usual care. Self-report measures of parenting, child behavior, and stress were obtained at pre- and/or post-intervention. Direct observation of mother-infant interactions was conducted at post-intervention.

RESULTS

No differences between groups were found on maternal attunement, knowledge of child development, nurturing parenting, or infant behavior. A secondary analysis on a subsample with no prior exposure to IBH-P with older siblings found that mothers in IBH-P reported increased self-efficacy relative to controls. In the qualitative interviews, mothers stated that they valued IBH-P, learning about their baby, liked the integration in primary care, and felt respected and comfortable with their provider.

CONCLUSIONS

Findings are discussed in terms of the next steps in refining IBH-P approaches to prevention in primary care.

Behavior Problems in Low-Income Young Children Screened in Pediatric Primary Care

Importance

Screening of behavior problems in young children in pediatric primary care is essential to timely intervention and optimizing trajectories for social-emotional development. Identifying differential behavior problem trajectories provides guidance for tailoring prevention and treatment.

Objective

To identify trajectories of behavior problems in children 2 to 6 years of age screened in pediatric primary care.

Design, Setting, and Participants

This retrospective cohort study identified trajectories of behavior problems and demographic and clinical correlates. Data were collected as part of routine care in 3 pediatric primary care offices and 3 school-based health centers in Ohio serving a primarily low-income population. In total, 15 218 children aged 2 to 6 years with well-child visits between July 13, 2016, and January 31, 2022, were included.

Exposure

Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) at annual well-child visits.

Main Outcomes and Measures

Trajectory groups were identified using latent growth mixture modeling of SDQ total difficulties scores, and relative risk ratio (RRR) of various demographic (eg, race) and clinical (eg, depression in caregiver) variables were assessed by multinomial logistic regression analysis.

Results

Of 15 281 children (51.3% males), 10 410 (68.1%) were African American or Black, 299 (2.0%) were Asian, 13 (0.1%) were American Indian or Alaska Native, 876 (5.7%) were multiracial, 26 (0.2%) were Native Hawaiian and Other Pacific Islander, 2829 (18.5%) were White, and 39 (0.02%) were categorized as other. In addition, 944 (6.2%) identified as Hispanic and 14 246 (93.2%) as non-Hispanic. Four behavior problem trajectory groups reflecting severity were identified: low-stable (LS; 10 096 [66.1%]), moderate-decreasing (MD; 16.6%), low-increasing (LI; 13.1%), and high-increasing (HI; 4.3%). Relative to the LS group, patients in each elevated group were more likely to be male (HI RRR, 1.87 [95% CI, 1.55-2.26]; MD RRR, 1.55 [95% CI, 1.41-1.71]; and LI RRR, 1.94 [95% CI, 1.70-2.21]), White (HI RRR, 2.27 [95% CI, 1.83-2.81]; MD RRR, 1.28 [95% CI, 1.13-1.45]; and LI RRR, 1.54, [95% CI, 1.32-1.81]), publicly insured (HI RRR, 0.49 [95% CI, 0.28-0.84]; MD RRR, 0.56 [95% CI, 0.43-0.73]; and LI RRR, 0.50 [95% CI, 0.35-0.73]), have a social need (HI RRR, 3.07 [95% CI, 2.53-3.73]; MD RRR, 2.02 [95% CI, 1.82-2.25]; and LI RRR, 2.12 [95% CI, 1.84-2.44]), and have a caregiver with depression (HI RRR, 1.66 [95% CI, 1.38-2.00]; MD RRR, 1.44 [95% CI, 1.31-1.58]; and LI RRR, 1.39 [95% CI, 1.23-1.58]). Relative to the LI group, patients in the MD group were less likely to be male (RRR, 0.80; 95% CI, 0.68-0.93).

Conclusions

The substantial portion of young children with increased behavior problems observed in this cohort study underscores the need for screening in pediatric primary care. Caregivers with depression and family social needs warrant prioritization in early prevention and treatment to alter elevated trajectories.

A Randomized Clinical Trial Targeting Daily Living Skills in Autistic Adolescents Without an Intellectual Disability Before the Transition to Adulthood

OBJECTIVES

In the United States, more than 75,000 autistic adolescents graduate from high school each year, and many lack the skills to successfully transition to college, work, and independent living. Daily living skills (DLS) in autistic adolescents without an intellectual disability (ID) fall 6 to 8 years behind peers. Better DLS are linked to more positive adult outcomes for autistic individuals. Surviving and Thriving in the Real World (STRW) is the only known evidence-based intervention that targets age-appropriate DLS in autistic adolescents without ID. The study objective was to evaluate STRW's efficacy compared with an active comparator (Program for the Evaluation and Enrichment of Relational Skills [PEERS]).

METHOD

Autistic adolescents in their last 2 years of high school were randomized to STRW or PEERS. Outcome measures were the Vineland Adaptive Behavior Scales, Third Edition (VABS-3), DLS domain and subdomains (Personal, Domestic, Community), and DLS Goal Attainment Scaling (DLS-GAS) areas (Morning Routine, Cooking, Laundry, Money).

RESULTS

Adolescents were randomly assigned to STRW (n = 34) or PEERS (n = 30). Owing to COVID-19, 28.1% received in-person intervention and 71.9% received telehealth intervention. STRW youth made significant gains on the VABS-3 DLS domain ( p = 0.01) and Domestic subdomain ( p = 0.005) and DLS-GAS Total, Laundry, and Money areas (all p 's < 0.05) compared with PEERS.

CONCLUSION

STRW shows promise for acquiring age-appropriate DLS compared with PEERS. Adolescents in STRW progressed toward achieving DLS in the average range and closing the gap between chronological age and DLS. By improving DLS, STRW may facilitate more successful adult outcomes.

Provider Perspectives on an Integrated Behavioral Health Prevention Approach in Pediatric Primary Care

The purpose of this study was to use qualitative interviews to ascertain the perspective of pediatric primary care providers on the implementation of Integrated Behavioral Health (IBH) as provided by psychologists within an expanded HealthySteps™ model, and with a particular focus on prevention of behavioral health symptoms in the first five years. A semi-structured interview guide was used to assess medical providers' perceptions of behavioral health integration into their primary care clinics. A conventional qualitative content analysis approach was utilized to identify patterns of meaning across qualitative interviews. Four themes were identified: (1) practice prior to IBH and initial concerns about integration, (2) psychologist's role and perceived added value, (3) what integration looks like in practice, and (4) perceived families' response to and experiences with IBH. Despite initial concerns about potential disruptions to clinic flow, providers indicated that adoption of IBH was seamless. The distinct roles of the psychologist were clear, and both treatment and prevention services provided by IBH were valued. Multidisciplinary collaboration and real-time response to family needs was seen as especially important and primary care providers reported that families were accepting of and highly valued IBH.

A Pilot Randomized Trial of an Obesity Prevention Program for High-Risk Infants in Primary Care

OBJECTIVE

Rapid infant weight gain is associated with later obesity. Novel interventions to prevent rapid infant weight gain that are accessible to infants and families are needed, especially for those at the highest risk. Our aims were to examine: (a) feasibility and acceptability of a responsive parenting intervention delivered via Integrated Behavioral Health (IBH) in pediatric primary care and (b) preliminary effects on infant weight gain from birth to 6 (post-treatment) and 9 (follow-up) months.

METHODS

A parallel design, proof-of-concept randomized control trial was conducted with 65 mother-infant dyads (32 randomized to intervention, 33 randomized an IBH attention control focused on promoting healthy mental health), in which the majority identify as Black (80%) and low income (91% receiving Medicaid). Participants and assessors were masked to treatment condition. Outcomes included feasibility (enrollment), acceptability (retention and adherence), and conditional weight gain (CWG), an indicator of rapid weight gain.

RESULTS

The intervention was feasible (90% of eligible families enrolled) and acceptable (89% of families retained), with 81% receiving ≥3 of 4 treatment sessions. A medium effect was found on CWG (d = -0.54 post-treatment, d = -0.57 follow-up), with the infants in the treatment group showing significantly lower CWG (mean = -0.27, 95% CI, -0.63, 0.09) compared to the control group (mean = 0.29, 95% CI, -0.17, 0.76) at 9 months (p = .04).

CONCLUSIONS

This study demonstrates the feasibility of implementing a responsive parenting obesity prevention intervention within primary care. Delivery in pediatric primary care is advantageous for implementation and reaching at-risk populations. The preliminary effects on CWG are promising and support testing in a larger trial.

A Pilot Randomized Controlled Trial of a Daily Living Skills Intervention for Adolescents with Autism

Adolescents with autism spectrum disorder (ASD) without an intellectual disability have daily living skills (DLS) impairments. An initial feasibility pilot of Surviving and Thriving in the Real World (STRW), a group intervention that targets DLS, demonstrated significant improvements. A pilot RCT of STRW was conducted to extend these findings. Twelve adolescents with ASD were randomized to the treatment or waitlist groups. The treatment group had significant DLS improvements on the Vineland Adaptive Behavior Scales, 3rd Edition and the DLS goal attainment scale. Four adolescents from the waitlist crossed over and completed STRW. Entire sample analyses with 10 participants demonstrated large DLS gains. Results provide further evidence of the efficacy of STRW for closing the gap between DLS and chronological age.

Integrated Behavioral Health Increases Well-Child Visits and Immunizations in the First Year

OBJECTIVE

To assess whether integrated behavioral health (IBH) prevention encounters provided during well-child visits (WCVs) is associated with increased adherence to WCVs and timely immunizations in the first year.

METHODS

Data were collected in an urban pediatric primary care clinic serving a low-income population and using the HealthySteps model. Subjects were 813 children who attended a newborn well-child visit between January 13, 2016 and August 8, 2017. Data from the electronic health record was extracted on attendance at six well-child visits in the first year of life, IBH prevention encounters by the HealthySteps specialist, completion of immunizations at 5 and 14 months, and demographics and social and clinical risk factors.

RESULTS

After controlling for covariates, odds of attendance at 6, 9, and 12-month WCVs were significantly higher for those who had IBH prevention encounters at previous WCVs. Odds of immunization completion by 5 months was associated with number of IBH prevention encounters in the first 4 months (OR = 1.52, p = .001) but not immunization completion at 14 months (OR = 1.18, p = .059).

CONCLUSIONS

IBH prevention encounters were associated with increased adherence to WCVs in the first year and vaccine completion at 5 months of age. These findings are consistent with IBH having a broad positive effect on child health and health care through strong relational connections with families and providing value in addressing emotional and behavioral concerns in the context of WCVs.

Examining patterns of postnatal feeding in relation to infant's weight during the first year

BACKGROUND

There is mixed evidence regarding specific infant feeding behaviors and later risk for overweight and obesity. We sought to detect underlying patterns in duration of breastfeeding, introduction of solid foods and sweetened beverages, in order to understand the relation to later weight.

METHODS

Patterns of postnatal feeding were examined among infants enrolled in the Infant Feeding Practices Study II (N = 3033). At monthly intervals, mothers reported on the duration of any and exclusive breastfeeding, age of solid food and sweetened beverage introduction, and reported infant weight at ages 9- and 12-months. Latent profile analysis was used to empirically derive patterns of postnatal feeding and examine associations with weight z-scores at 9 and 12 months.

RESULTS

Two profiles emerged: (1) Short breastfeeding duration and early introduction to solid foods and sweetened beverages (Short BF/Early Introduction; 53%) and (2) longer breastfeeding duration and later introduction to solid foods and sweetened beverages (Longer BF/Later Introduction; 43%). Infants in the Shorter BF/Early Introduction profile had significantly greater weight z-scores at 9 (M = 0.18) and 12 months (M = 0.26), compared to those in the Longer BF/Later Introduction profile (M = -0.21; M = -0.17, respectively).

CONCLUSIONS

Overall, shorter BF duration and earlier food and sweetened beverage introduction is associated with higher weight z-scores at 9 and 12 months. Early intervention should aim to promote breastfeeding and later introduction of solids and discourage consumption of sweetened beverages. These postnatal patterns of feeding behaviors provides important context to inform targeted interventions aimed at reducing risk for later obesity.

Iterative Development of a Daily Living Skills Intervention for Adolescents with Autism Without an Intellectual Disability

Daily living skill deficits commonly co-occur in individuals with autism spectrum disorder (ASD). These deficits in adolescence are associated with poor outcomes, in both employment and independent living skills as adults. Currently, there are no interventions that directly target daily living skill acquisition in adolescents with ASD without an intellectual disability to facilitate a successful transition to adulthood. In this paper, we discuss the development, refinement, and initial efficacy studies of Surviving and Thriving in the Real World (STRW), a 14-session group treatment for both adolescents with ASD and their parent/caregiver that promotes attainment of critical daily living skills. We summarize initial feasibility studies that have been instrumental in the iterative development of STRW. The structure, core treatment elements, and content of STRW are described in detail. Lastly, we discuss the transition of the in-person STRW intervention to STRW-telehealth, which allows for adolescents with ASD to work on daily living skills in their own home with support from a therapist.

A novel behavioral health program for family caregivers of children admitted to a transitional chronic ventilator unit

BACKGROUND

The care of mechanically ventilated pediatric patients is complex and burdensome. It is essential to adequately support the family caregivers of these children to optimize outcomes; however, there is no literature describing interventions for caregivers in this population.

RESEARCH QUESTION

This study described a novel behavioral health program and examined its impact on family caregiver engagement and psychological distress on a pediatric inpatient chronic ventilator unit.

STUDY DESIGN AND METHODS

Electronic chart review was completed with retrospective and prospective participant enrollment for the purposes of longitudinal evaluation of caregiver engagement. For analytic purposes, participants were grouped into three categories: (1) preprogram, (2) postprogram, and (3) postprogram with completion of psychotherapy.

RESULTS

The behavioral health program was associated with increased caregiver participation in rounds, t = 7.76, p = < .001. Parents who completed a course of psychotherapy within the behavioral health program demonstrated reduced time to training completion (F = 5.89; p < .01), higher staff-rated caregiver engagement (F = 3.69; p < .05), and significantly reduced levels of caregiver distress (t = 2.09; p < .05).

Early-life determinants of excess weight in children born heavy

Infants born heavy are vulnerable to later obesity, but it is unknown whether obesity-related risk factors present between conception and delivery predict their postnatal weight trajectory. We modelled the weight trajectories of infants born high birth weight (HBW, greater than or equal to 4000 g) and/or large for gestational age (LGA, greater than 90th percentile) using data from the Infant Feeding Practices Study II (N = 371). A high percentage of infants were both HBW and LGA, but the trajectories were modelled separately. Weight of infants born heavy begins high, gradually decreases, and then levels off by 12 months. Delivery method was the only predictor of weight. Caesarean-delivered HBW infants were heavier than vaginally-delivered HBW infants although this effect disappeared by 12 months. Findings indicate that early-life influences are not necessarily deterministic of the postnatal weight trajectory of infants born heavy. Future research is needed to examine postnatal behaviours that may be implicated in the relationship between large size at birth and later obesity.

Sleep duration and bedtime in preschool-age children with obesity: Relation to BMI and diet following a weight management intervention

BACKGROUND

Sleep duration is associated with obesity in preschoolers. Weight-management interventions may be an opportunity to incorporate sleep health recommendations.

OBJECTIVES

To examine changes in sleep in preschool-age children with obesity following a family-based weight-management intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) compared with motivational interviewing and standard care conditions. Additionally, we examined associations between sleep with body mass index (BMI) z score (BMIz) and diet.

METHODS

One hundred fifty-one children (4.6 ± 0.93 y) completed baseline (pretreatment) and posttreatment (week 24) assessments, including anthropometrics, 24-hour dietary recalls, and a 7-day sleep diary. Analysis of variance (ANOVA) and chi-squared tests compared sleep variables between groups; linear regression models examined effects of sleep on BMIz and dietary intake at posttreatment, controlling for baseline values.

RESULTS

Bedtime and sleep duration were not significantly different between treatment groups from baseline to posttreatment. After adjusting for baseline sleep, earlier bedtime was associated with lower BMIz (95% CI, 0.00-0.04; .03), intake of added sugars (95% CI, 0.70-4.32; .007), and sweet/dessert food servings (95% CI, 0.00-0.19; .04) at posttreatment. Longer night-time sleep duration was associated with fewer added sugars at posttreatment, adjusting for baseline sleep (95% CI, -3.79 to -0.35; .02).

CONCLUSIONS

More comprehensive sleep intervention incorporated into weight-management intervention may be necessary to promote positive changes for preschoolers with obesity. A focus on earlier bedtime and longer sleep duration appears to be important given associations between sleep duration and bedtime with BMIz and dietary intake.

Maintenance Following a Randomized Trial of a Clinic and Home-based Behavioral Intervention of Obesity in Preschoolers

OBJECTIVE

To assess maintenance of improved weight outcomes in preschoolers with obesity 6 and 12 months following a randomized clinical trial comparing a home- and clinic-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) to motivational interviewing and standard care.

STUDY DESIGN

Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012, and June 8, 2015, were followed 6 and 12 months post-treatment. Child and caregiver weight, height, and caloric intake, child physical activity, and home environment were assessed. The primary outcome was maintenance of greater reduction of percent over the 50th percentile body mass index (BMI%50th) by LAUNCH compared with motivational interviewing and standard care at the 6- and 12-month follow-up.

RESULTS

Significantly lower child BMI%50th was maintained for LAUNCH compared with motivational interviewing at 12-month follow-up and to standard care at the 6-month follow-up; however, the effect sizes were maintained for comparison with standard care at 12-month follow-up. LAUNCH had significantly lower daily caloric intake compared with motivational interviewing and standard care at both follow-ups and maintained significantly fewer high-calorie foods in the home compared with standard care at 6 and 12 months and compared with motivational interviewing at 12 months. However, caloric intake increased by 12% from post-treatment. LAUNCH caregivers did not maintain improved BMI at follow-up.

CONCLUSIONS

LAUNCH showed success in reducing weight in preschoolers. However, maintaining treatment gains post-treatment is more difficult. Treatment may need to last longer than 6 months to achieve optimal results.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01546727.

Are Preschoolers Meeting the Mark? Comparing the Dietary, Activity, and Sleep Behaviors of Preschoolers With Obesity to National Recommendations

Objective

National health organizations and expert committees have issued recommendations for health behaviors related to obesity risk. Behavioral and family-based weight management interventions for preschoolers often target improving adherence to these recommendations, but it is unknown how the health behaviors of preschoolers with obesity enrolled in weight control treatments (WCTs) compare with these guidelines. In this study, the dietary intake, activity, and sleep behaviors of preschoolers with obesity enrolled in a family-based behavioral WCT are described and compared with national health behavior recommendations.

Methods

Health behaviors of 151 preschoolers with obesity (M age = 4.60, SD = 0.93) enrolled in a clinical trial of a weight management program were measured at baseline through caregiver-report questionnaires, three 24-hr dietary recalls, and accelerometers.

Results

In total, 70% of the sample exceeded daily caloric recommendations, only 10 and 5% met recommendations for fruit and vegetable intake, respectively, and only 30% met the recommendation of consuming no sugar-sweetened beverages. The majority of the sample met the daily recommendations for 60 min of moderate-to-vigorous activity (80%), < 2 hr of screen time (68%), and sleep duration (70%).

Conclusions

Behavioral weight management interventions for preschoolers with obesity should target the health behaviors where children are not meeting recommendations.

Psychological predictors of nutritional adherence in adolescents with cystic fibrosis

BACKGROUND & AIMS

The CF medical regimen is notoriously burdensome, comprised of respiratory treatments, oral medications, and nutritional demands. Adequate caloric intake has been identified as a challenge over the lifespan; however, we lack detailed information about nutritional adherence in teens, and the contextual drivers of these behaviors. Adolescence is a time of increased responsibility, reduced parental monitoring, and growing peer connections. There is no literature examining the impact of familial attitudes (e.g., privacy, disease disclosure) and the social milieu (e.g., friendships) on teen nutritional adherence behavior. We hypothesized that better teen nutritional adherence behaviors would be predicted by more favorable familial privacy attitudes, better relationship quality, and greater comfort in disease disclosure.

METHODS

Assessment included questionnaires of caregiver privacy attitudes, relationship quality, and disease disclosure. Teens tracked PERT adherence for 1 month and logged daily caloric intake for 2 weeks. This produced detailed information on daily enzyme adherence, caloric intake, and eating frequency.

RESULTS

Average PERT adherence, caloric intake, and eating frequency were suboptimal in this sample. More comfort in disease disclosure and less teen/mother discord predicted better PERT adherence. Higher caregiver privacy and lower teen closeness with friends predicted greater caloric intake and eating frequency.

CONCLUSIONS

Results suggest that comfort in disease disclosure supports consistent PERT adherence across environments. Adolescents with close friendships may have less time for self-management (e.g., eating). Future research should collect more detailed information about friendships of teens with CF. Results suggest that daily structure and positive, appropriately supportive relationships should be encouraged by care teams.

Changes in diet quality and home food environment in preschool children following weight management

Background

Family-based obesity treatment interventions can successfully reduce energy intake in preschoolers. An implicit goal of obesity treatment interventions is to improve diet quality, but diet quality has been less examined as a treatment outcome in studies of preschoolers. The purpose of this study was to conduct a secondary analysis comparing the change in diet quality and home food environment in preschoolers assigned to a behavioral family-based obesity intervention (LAUNCH), motivational interviewing (MI) condition, or standard care (STC) condition.

Methods

Three 24-h dietary recalls were completed at baseline and 6-months and were analyzed using NDS-R software; diet quality was assessed using the Healthy Eating Index-2010 (HEI-2010). Availability of foods and beverages in the home was assessed through direct observation using the Home Health Environment tool that classifies foods and beverages as ‘red’ or ‘green’ based upon fat and sugar content. Repeated measures linear mixed effects models were used to examine changes in diet quality and home food environment between conditions (LAUNCH, MI, STC).

Results

At 6-months, preschoolers in the LAUNCH condition had a higher HEI-2010 total score (62.8 ± 13.7) compared to preschoolers in the MI (54.7 ± 13.4, P = 0.022) and STC (55.8 ± 11.6, P = 0.046) conditions. Regarding the home food environment, families in LAUNCH had significantly less ‘red’ foods in their home at 6-months (12.5 ± 3.4 ‘red’ foods) compared to families in MI (14.0 ± 3.7 ‘red’ foods, P = 0.030), and STC (14.3 ± 3.4 ‘red’ foods, P = 0.006). There were no statistically significant differences across home food environments for number of ‘green’ foods.

Conclusion

Family-based obesity treatment interventions for preschoolers can improve overall diet quality and alter the home food environment through reductions in ‘red’ foods.

Trial registration

Clinicaltrials.gov, NCT01546727. Registered March 7, 2012.

Longer sleep duration during infancy and toddlerhood predicts weight normalization among high birth weight infants

Study Objectives

High birth weight (HBW; ≥ 4000 g) is strongly associated with later overweight, yet little is known about how to disrupt this trajectory. The current study examined sleep practices during infancy and toddlerhood among children born HBW or normal birth weight (NBW; 2500-3999 g).

Methods

Latent growth curve models were used to examine sleep during infancy and toddlerhood among 270 mother-child dyads enrolled in the Health Outcomes and Measures of the Environment Study. Total sleep duration in 24 hr, sleep maintenance, and restlessness/vocalizations were collected at 6 month intervals between ages 6 and 24 months. Height and weight were obtained at ages 24 or 36 months, and normal and overweight BMI were derived. Sleep was examined among children with a normal BMI during the preschool years who were either HBW (HBW-Normal, n = 36) or NBW (NBW-Normal, n = 184) compared with overweight preschoolers (Overweight, n = 50). It was predicted that the Overweight group would have poorer sleep across infancy and toddlerhood compared with HBW-Normal and NBW-Normal.

Results

HBW-Normal had the longest and Overweight had the shortest mean 24 hr sleep duration across all time points with NBW-Normal falling in-between the two groups. Compared with Overweight, HBW-Normal exhibited longer 24 hr sleep duration at age 6 months with this group difference maintained over infancy and toddlerhood. No group difference was found for NBW-Normal.

Conclusions

A longer sleep duration in the first several years of life is associated with development of normal BMI among HBW children. These findings suggest that longer sleep duration may protect HBW children from becoming overweight.

Greater Breastfeeding in Early Infancy Is Associated with Slower Weight Gain among High Birth Weight Infants

OBJECTIVE

To examine whether feeding patterns from birth to age 6 months modify the association between birth weight and weight at 7-12 months of age.

STUDY DESIGN

Longitudinal mixed models were used to examine feeding trajectories across categories of birth weight and weight at 7-12 months of age in 1799 mother-infant dyads enrolled in the Infant Feeding Practices Study II. The percentage of breast milk received and the average daily formula consumption were calculated from birth to 6 months of age. Birth weights were classified as high (≥4000 g) and normal (≥2500 g and <4000 g). Weights at 7-12 months of age were categorized as high (z score >1) or normal (z score ≤1). A secondary analysis was performed using categories defined by birth weight adjusted for gestational age percentiles (>90% and 10th-90th percentile).

RESULTS

High birth weight (HBW) infants with high weights at 7-12 months of age demonstrated a rapid decline in the percentage of breast milk feedings compared with HBW infants with normal weights at 7-12 months of age. Normal birth weight infants with high weights at 7-12 months of age received a lower percentage of breast milk and had greater absolute intakes of formula than those with normal weights at 7-12 months of age; these associations did not vary over time. Results were similar when infants were categorized by birth weight percentiles.

CONCLUSIONS

A lower proportion of breast milk feedings was associated with excess weight at 7-12 months of age in HBW infants. These findings suggest an initial target for obesity prevention programs focusing on the first 6 months after birth.

Clinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial

OBJECTIVE

To test the hypotheses that an innovative skills-based behavioral family clinic and home-based intervention (LAUNCH) would reduce body mass index z score (BMIz) compared with motivational interviewing and to standard care in preschool-aged children with obesity.

STUDY DESIGN

Randomized controlled trial with children between the ages of 2 and 5 years above the 95^th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012 and June 8, 2015. Children were randomized to LAUNCH (an 18-session clinic and home-based behavioral intervention), motivational interviewing (delivered at the same frequency as LAUNCH), or standard care (no formal intervention). Weight and height were measured by assessors blinded to participant assignment. The primary outcome, BMIz at month 6 after adjusting for baseline BMIz, was tested separately comparing LAUNCH with motivational interviewing and LAUNCH with standard care using regression-based analysis of covariance models.

RESULTS

A total of 151 of the 167 children randomized met intent-to-treat criteria and 92% completed the study. Children were 76% White and 57% female, with an average age of 55 months and BMI percentile of 98.57, with no demographic differences between the groups. LAUNCH participants demonstrated a significantly greater decrease in BMIz (mean = -0.32, SD = ±0.33) compared with motivational interviewing (mean = -0.05, SD = ±0.27), P < .001, ω² = 0.74 and compared with standard care (mean = -0.13, SD = ±0.31), P < .004, ω² = 0.75.

CONCLUSIONS

In preschool-age children, an intensive 6-month behavioral skills-based intervention is necessary to reduce obesity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01546727.

Preliminary efficacy of a daily living skills intervention for adolescents with high-functioning autism spectrum disorder

Daily living skills deficits are strongly associated with poor adult outcomes for individuals with high-functioning autism spectrum disorder, and yet, there are no group interventions targeting daily living skills. Seven adolescents with autism spectrum disorder and their parents participated in a feasibility pilot of a 12-week manualized group treatment targeting specific daily living skills (i.e. morning routine, cooking, laundry, and money management). Outcomes included the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) age equivalence scores and four goal attainment scaling scores. Adolescents demonstrated significant improvement on two Vineland-II subdomains and on all goal attainment scaling scores at post-treatment and 6-month follow-up. The intervention has promise for improving critical daily living skills' deficits that affect independent living and employment. Limitations and implications for future studies are discussed.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardian's motivation to make changes in diet and activity and providing tools to do so at the guardian's level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

A Preschool Obesity Treatment Clinical Trial: Reasons Primary Care Providers Declined Referrals

OBJECTIVE

To examine referral by primary care providers (PCPs) of preschool children with obesity (≥95th percentile for body mass index [BMI]) to a weight management intervention when offered through a randomized clinical trial (RCT), and identify reasons for not referring children.

STUDY DESIGN

In phase I, 3 experts in obesity, psychology, and nutrition completed an open card sort and classified PCPs' reasons for declining referral into groups based on similarity of reasons. Categories were then defined and labeled. In phase II, 2 independent sorters placed each decline into 1 of the categories defined in phase I.

RESULTS

PCPs referred 78% of eligible children to the RCT. Compared with children declined for referral, referred children had a significantly higher weight (48.4 lb vs 46.1 lb; P < .001) and BMI percentile (97.6 vs 97.0; P < .001). Eleven categories for decline were identified in phase I. In phase II, excellent reliability was obtained between each independent sorter and the phase I categories, and also between the 2 independent sorters (κ values, 0.72-1.0). The most common reason for declining was "family not a good fit" (23.6%), followed by "doesn't believe weight is a problem" (13.9%), "family would not be interested" (12%), and "doesn't believe measurement is accurate" (11.5%). Appropriately, exclusionary criteria of the RCT was a reason as well (11.8%).

CONCLUSION

The availability of weight management for preschoolers through RCTs appeared to overcome barriers of resources, time, and credible treatment cited in previous studies. However, concerns about the family's response or interest in a weight management program remained barriers, as did PCPs' perceptions about obesity in young children.

TRIAL REGISTRATION

ClinicalTrials.gov:NCT01546727.

A Review of the Structural Characteristics of Family Meals with Children in the United States

Family meals are associated with a range of positive outcomes among children and adolescents. There is inconsistency, however, in the way in which studies have defined and measured family meals. Therefore, a systematic review of the literature was conducted to determine how studies describe family meals with the use of structural characteristics. The current review focused on studies in the United States that included children ages 2-18 y. A total of 33 studies were identified that characterized family meals with the use of ≥1 of the following structural features: frequency or mean number of family meals per week, length of family meal, people present at meal, and where meals occurred. No study characterized family meals by using all 4 family meal features, whereas most studies (81%) characterized family meals by using frequency or mean number of meals per week. Findings not only provide an initial understanding of the structural features used to define family meals but also point to the importance of developing a more comprehensive, sensitive assessment that can accurately capture the complex and multidimensional nature of family meals.

Treating Obesity in Preschoolers: A Review and Recommendations for Addressing Critical Gaps

Developing interventions targeting obesity reduction in preschoolers is an emergent area. Although intensive, multicomponent interventions seem a promising approach to preschool obesity reduction, this review identifies and discusses approaches to 3 critical gaps (poor reach to families from low-income and minority backgrounds, lack of sufficient evidence to determine the most effective and efficient treatment components and approaches to treating obesity in early childhood, and lack of consensus on how best to discern intervention effectiveness) that need to be addressed to advance the preschool obesity literature.

The impact of a pilot cooking intervention for parent-child dyads on the consumption of foods prepared away from home

This pilot study investigated the impact of a parent-child dyad cooking intervention on reducing eating dinner away from home. Eating away from home often results in consumption of energy-dense, nutrient-poor foods that can contribute to excess energy consumption in children. A pre-post design to evaluate a 10-week cooking intervention on reducing eating dinner away from home, energy intake, and improving diet quality was implemented. The intervention was delivered at an instructional kitchen on a university campus and assessments were completed at a children's academic medical center. Subjects included six parent-child dyads whom reported eating dinner away from home ≥3 times/week and in which the parent was overweight based on their body mass index (BMI) of ≥25 kg/m(2). Parents were a mean age of 34.7 (SD = 3.9) years, and children were a mean age of 8.7 (SD = 2.0) years. Two-thirds of parents self-identified themselves and their children as White. Results showed the proportion of dinners consumed by parent-child dyads away from home significantly decreased (F (1,161) = 16.1, p < 0.05) from 56% at baseline to 25% at post-treatment. Dyad cholesterol intake at dinner also significantly decreased over time; however, changes in energy intake, total fat, saturated fat, and sodium at dinner were not significant. A large effect size was found for changes in parent ratings of enjoyment of cooking between baseline and post-treatment. A cooking intervention that involves parent-child dyads and incorporates behavior management strategies and nutrition education may be an innovative obesity prevention intervention.

Health-Related Quality of Life in a Community Sample of Preschool-Age Children with and without Obesity

While mothers seeking obesity treatment for preschoolers report poorer child health-related quality of life (HRQOL) than mothers of healthy-weight peers, little is known about this relationship in non-clinical preschoolers. Eighty-six mothers of 3-5-year-olds completed the parent-proxy PedsQL. HRQOL scores for children with obesity and without were compared. No significant differences were found between groups for any PedsQL subscales, nor did differences reach established Minimally Clinically Important Differences. Mothers of preschoolers with obesity from the community did not report poorer HRQOL. If parents do not view their child's HRQOL as impacted by weight status, they may be unlikely to seek treatments.

Web-Based Intervention for Nutritional Management in Cystic Fibrosis: Development, Usability, and Pilot Trial

OBJECTIVES

Usability and pilot testing of a web intervention (BeInCharge.org [BIC]) of behavior plus nutrition intervention for children with cystic fibrosis (CF) ages 4-9 years.

METHODS

Think Aloud methodology was used with five mothers to assess usability and refine the intervention. A pilot trial was then conducted with 10 mothers of children with CF ages 4-9 years randomized to the web-based BIC or a Standard Care Control (STC). Change in weight gain for each group was compared in a pre-to-post design.

RESULTS

Mothers rated the usability and clarity of BIC highly. The pilot trial showed children of mothers who received BIC had a significant change in weight pre-to-post-treatment (0.67 kg, p = .04). Change for the STC was not significant (0.41 kg, p = .10).

CONCLUSIONS

A web-based behavior plus nutrition intervention appears promising in increasing weight gain in children with CF.

Eating dinner away from home: Perspectives of middle-to high-income parents

This study sought to understand barriers and facilitators for preparing and eating dinner at home in families who report eating dinner away from home ≥3 times per week. Cross-sectional, mixed methods (focus groups, questionnaires) study. Twenty-seven parents with a child 3-10 years-old who reported eating dinner away from home ≥3 times per week from a pediatric medical center in the Midwest participated. The key concepts analytic framework guided focus group analysis. Descriptive statistics were used to characterize parent demographics, anthropometrics, attitudes and confidence toward cooking, perceptions of dinner costs and portions, and parent and child dinners. Parents reported confidence in cooking a home prepared meal, but that eating away from home was reinforcing because it provided quality family time and diminished barriers such as picky eating and perceived costs. Home cooking was also hindered by early school lunch and after-school sports as children were not hungry or home at the typical dinner hour and parents did not want to cook after 8pm. Parents estimated preparing and eating a meal at home took significantly more time than driving and eating out (80.7 min vs. 30.3 min, p < 0.001). Parents significantly (F (3, 104) = 8.80, p < 0.001) overestimated the cost of home-prepared meals compared to take-out and frozen meals. Portion size was also overestimated for a protein serving. Findings are limited to predominantly married, female parents whom are highly educated and working. To reduce eating out, interventions should address family factors (e.g., time management, quality time) and child behavior (e.g., picky eating). Innovative interventions that include experiential cooking opportunities that incorporate time management, address picky eating and enthusiasm for cooking with education on decreasing costs may be particularly beneficial for middle-to high-income families.

Quality of life in children with CF: Psychometrics and relations with stress and mealtime behaviors

BACKGROUND

The purpose of this study was to evaluate the utility of the Cystic Fibrosis Questionnaire-Revised (CFQ-R) with toddlers and preschool-aged children. Clinically relevant relations between health-related quality of life (HRQOL), stress, and mealtime behaviors have not been examined. It was hypothesized that problematic mealtime behaviors and increased stress would be negatively associated with HRQOL.

METHODS

Parents of 73 children (2-6 years) with CF completed questionnaires assessing their children's generic (PedsQL) and CF-specific HRQOL, parenting and CF-specific stress, and mealtime behaviors.

RESULTS

CFQ-R Physical, Eating, and Respiratory HRQOL subscales had acceptable to strong reliability (alphas = 0.73-0.86); other scales approached acceptable reliability. Lower CF-specific stress was associated with higher CFQ-R Eating HRQOL (B = -0.84; P < 0.05) scores. Fewer eating problems were associated with higher CFQ-R Eating (B = -1.17; P < 0.0001) and Weight HRQOL (B = -0.78; P < 0.01) scores.

CONCLUSIONS

As hypothesized, problematic eating and higher CF-specific stress was associated with lower CF-specific HRQOL. The CFQ-R has promise for use in young children with CF, but will need to be modified to exchange items not relevant to preschoolers with items that are more relevant to this age group.

Behavioral and nutritional treatment for preschool-aged children with cystic fibrosis: a randomized clinical trial

IMPORTANCE

Evidence-based treatments that achieve optimal energy intake and improve growth in preschool-aged children with cystic fibrosis (CF) are a critical need.

OBJECTIVE

To test whether behavioral and nutritional treatment (intervention) was superior to an education and attention control treatment in increasing energy intake, weight z (WAZ) score, and height z (HAZ) score.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 78 children aged 2 to 6 years (mean age, 3.8 years) with CF and pancreatic insufficiency (intervention, n = 36 and control, n = 42). The study was conducted at 7 CF centers between January 2006 and November 2012; all 78 participants who met intent-to-treat criteria completed through follow-up.

INTERVENTIONS

Behavioral intervention combined individualized nutritional counseling targeting increased energy intake and training in behavioral child management skills. The control arm provided education and served as a behavioral placebo controlling for attention and contact frequency. Both treatments were delivered in person or telehealth (via telephone). Sessions occurred weekly for 8 weeks then monthly for 4 months (6 months). Participants then returned to standard care for 1 year, with 12-month follow-up thereafter.

MAIN OUTCOMES AND MEASURES

Changes in energy intake and WAZ score were examined from pretreatment to posttreatment (6 months) and change in HAZ score was assessed pretreatment to follow-up (18 months). Covariates included sex, Pseudomonas aeruginosa status at baseline, and treatment modality (in person vs telehealth).

RESULTS

At baseline, mean (SD) energy intake was 1462 (329) kcals/d, WAZ score was -0.44 (0.81), and HAZ score was -0.55 (0.84). From pretreatment to posttreatment, the intervention increased daily energy intake by 485 calories vs 58 calories for the control group (adjusted difference, 431 calories; 95% CI, 282 to 581; P < .001) and increased the WAZ score by 0.12 units vs 0.06 for the control (adjusted difference, 0.09; 95% CI, -0.06 to 0.24; P = .25). From pretreatment to follow-up, the intervention increased the HAZ score by 0.09 units vs -0.02 for the control (adjusted difference, 0.14 units; 95% CI, 0.001 to 0.27; P = .049). Measured treatment integrity and credibility were high for both groups.

CONCLUSIONS AND RELEVANCE

Behavioral and nutritional intervention improved energy intake and HAZ score outcomes but not WAZ score outcomes. Our results provide evidence that behavioral and nutritional treatment may be efficacious as a nutritional intervention for preschoolers aged 2 to 6 years with CF and pancreatic insufficiency.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT00241969.

Changes in parent motivation predicts changes in body mass index z-score (zBMI) and dietary intake among preschoolers enrolled in a family-based obesity intervention

OBJECTIVES

To examine whether changes in parent motivation over the course of a pediatric obesity intervention are significantly associated with long-term changes in treatment outcomes. 

METHODS

 Study hypotheses were tested with a secondary data analysis of a randomized controlled trial (N = 42). Study analyses tested whether baseline to posttreatment change in total score for a self-report parent motivation measure (Parent Motivation Inventory [PMI]) was significantly associated with baseline to 6-month follow-up changes in body mass index z-score (zBMI), dietary variables, and physical activity. 

RESULTS

 Increases in PMI were significantly associated with decreased zBMI, decreased consumption of sugar-sweetened beverages and sweets, and increased consumption of artificially sweetened beverages. 

CONCLUSIONS

 Given that increases in parent motivation were associated with some treatment benefits, future research should evaluate the impact of directly assessing and targeting parent motivation on weight outcomes for preschoolers participating in a weight management program.

A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers

OBJECTIVE

Tested two family-based behavioral treatments for obesity in preschool children, one meeting the Expert Committee guidelines for Stage 3 obesity intervention criteria (LAUNCH-clinic) and one exceeding Stage 3 (LAUNCH with home visit [LAUNCH-HV]), compared with a Stage 1 intervention, pediatrician counseling (PC).

METHODS

In all, 42 children aged 2-5 years with a body mass index (BMI) percentile of ≥95th were randomized. A total of 33 met intent-to-treat criteria. Assessments were conducted at baseline, Month 6 (posttreatment), and Month 12 (6-month follow-up). 

RESULTS

 LAUNCH-HV demonstrated a significantly greater decrease on the primary outcome of change in BMI z-score (BMIz) pre- to posttreatment compared with PC (p = .007), whereas LAUNCH-clinic was not significantly different from PC (p = .08). Similar results were found for secondary outcomes. 

CONCLUSIONS

 LAUNCH-HV, but not LAUNCH-clinic, significantly reduced BMIz compared with PC by posttreatment, indicating the need for intensive behavioral intervention, including home visitation, to address weight management in obese preschool children.

Examination of the association between lifestyle behavior changes and weight outcomes in preschoolers receiving treatment for obesity

OBJECTIVE

Preschoolers (ages 2-5 years) have been significantly underrepresented in the obesity treatment outcome literature, despite estimates that 12.1% are already obese. As such, little is known about the most important intervention targets for weight management within this age group. The aims of this study were (a) to examine lifestyle behavior changes for 30 obese preschoolers participating in a weight-control intervention and (b) to explore which lifestyle behavior changes predicted changes in body mass index (BMI) z score.

METHOD

Preschooler height, weight, diet (three 24-hr recalls), physical activity (accelerometry), and television use (parent report) were measured at baseline and posttreatment (6 months). A linear regression was conducted to examine pre- to posttreatment changes in diet (i.e., intake of calories, sugar-sweetened beverages, fruits and vegetables, and sweet and salty snacks) and activity (i.e., moderate-to-vigorous activity and television use) behaviors on changes in BMI z score.

RESULTS

Despite significant reductions in sugar-sweetened beverage intake and television use, and increases in fruit and vegetable intake, only reductions in absolute caloric intake significantly predicted reductions in BMI z score.

CONCLUSION

Our findings suggest that attaining healthy caloric goals may be the most important component of weight-control interventions for preschoolers. Future research using innovative methodologies, such as the Multiphase Optimization Strategy, may be helpful to prospectively identifying the lifestyle behavior changes that are most effective in helping families to achieve healthy weight outcomes for preschoolers and thereby improve intervention efficiency and decrease treatment burden for families.

Differences in home food and activity environments between obese and healthy weight families of preschool children

OBJECTIVE

To develop and test a home food and activity instrument to discriminate between the home environments of obese and healthy weight preschool children.

DESIGN

A modified questionnaire about home environments was tested as an observation tool.

SETTING

Family homes.

PARTICIPANTS

A total of 35 obese children with at least 1 obese caregiver were compared with 47 healthy weight children with no obese caregivers.

MAIN OUTCOME MEASURES

Home observation assessments were conducted to evaluate the availability of devices supporting activity behaviors and foods based on availability, accessibility, and readiness to be eaten.

ANALYSIS

Agreement statistics were conducted to analyze psychometrics and MANOVAs were conducted to assess group differences, significance, P < .05.

RESULTS

Home observations showed acceptable agreement statistics between independent coders across food and activity items. Families of obese preschoolers were significantly less likely to have fresh vegetables available or accessible in the home, were more likely to have a television in the obese child's bedroom, and had fewer physical activity devices compared with healthy weight preschoolers.

CONCLUSIONS AND IMPLICATIONS

Families of young children live in home environments that were discriminatively characterized based on home observations. Future tool refinement will further clarify the impact of the home environment on early growth.

Impaired health-related quality of life in preschoolers with obesity

OBJECTIVES

To examine whether health-related quality of life (HRQOL) for treatment-seeking preschoolers with obesity (N = 60) differed from preschoolers in a nonclinical comparison sample (N = 457).

METHODS

Parents in both samples completed the parent-proxy form of the pediatric quality of life inventory (PedsQL). Between-group comparisons were conducted to examine differences for all scales and summary scores of the PedsQL.

RESULTS

Parent proxy-reported HRQOL was significantly lower for treatment-seeking preschoolers with obesity for all scales and summary scores except school functioning. Differences on the total scale score met the criterion for being a clinically important difference.

CONCLUSIONS

Our study suggests treatment-seeking families perceive worse HRQOL for children with obesity as early as the preschool years. Discussion of HRQOL may be a more effective strategy for health care professionals in broaching the topic of weight with parents and identifying families who may be more receptive to weight management suggestions for preschoolers.

Obesity in preschoolers: behavioral correlates and directions for treatment

Nearly 14% of American preschoolers (ages 2-5) are obese (BMI ≥ 95th percentile for age and gender), yet this group has received little attention in the obesity intervention literature. This review examines what is known about behavioral correlates of obesity in preschoolers and the developmental context for lifestyle modification in this age group. Information was used to critically evaluate existing weight management prevention and intervention programs for preschoolers and formulate suggestions for future intervention research development. A systematic search of the medical and psychological/behavioral literatures was conducted with no date restrictions, using PubMed, PsycInfo, and MEDLINE electronic databases and bibliographies of relevant manuscripts. Evidence suggests several modifiable behaviors, such as sugar sweetened beverage intake, television use, and inadequate sleep, may differentiate obese and healthy weight preschoolers. Developmental barriers, such as food neophobia, food preferences, and tantrums challenge caregiver efforts to modify preschoolers' diet and activity and parental feeding approaches, and family routines appear related to the negative eating and activity patterns observed in obese preschoolers. Prevention programs yield modest success in slowing weight gain, but their effect on already obese preschoolers is unclear. Multi-component, family-based, behavioral interventions show initial promise in positive weight management for already obese preschoolers. Given that obesity intervention research for preschoolers is in its infancy, and the multitude of modifiable behavioral correlates for obesity in this age group, we discuss the use of an innovative and efficient research paradigm (Multiphase Optimization Strategy; MOST) to develop an optimized intervention that includes only treatment components that are found to empirically reduce obesity in preschoolers.

Developmental and psychosocial issues in cystic fibrosis

Cystic fibrosis (CF) is a multisystemic life-limiting genetic disorder, primarily affecting respiratory functioning. Most patients with CF are diagnosed by 2 years of age, and the current median predicted survival rate is 37.4 years old, with 95% of patients dying from complications related to pulmonary infection. Given the chronic, progressive, and disabling nature of CF, multiple treatments are prescribed, most on a daily basis. Thus, this illness requires children, with the aid of their families, to adopt multiple health-related behaviors in addition to managing more typical developmental demands. The morbidity and mortality factors pose cognitive, emotional, and behavioral challenges for many children with CF and their families. This article applies a developmental perspective to describing the psychosocial factors affecting psychological adjustment and health-related behaviors relevant to infants, preschool and school-age children, and adolescents with CF. Topics particularly pertinent to developmental periods and medical milestones are noted, with clinical implications highlighted.

The effects of an intensive behavior and nutrition intervention compared to standard of care on weight outcomes in CF

Inadequate intake and suboptimal growth are common problems for patients with CF and a critical target for intervention. The purpose of this study was to compare the growth outcomes of children with CF who participated in a randomized clinical trial to improve energy intake and weight to children with CF receiving standard of care during the same time period. Our primary outcome was change in body mass index z-score (BMI z-score) over 2 years. An exploratory outcome was forced expiratory volume at 1-sec (FEV(1) ) over 2 years. Participants were children ages 4-12 with CF, who participated in a randomized clinical trial of behavior plus nutrition intervention versus nutrition education alone, and a matched Comparison Sample receiving standard of care drawn from the Cystic Fibrosis Foundation (CFF) Registry. Children in the Clinical Trial Group (N=67) participated in a 9-week, nutrition intervention and were followed at regular intervals (3, 6, 12, 18, and 24 months) for 2 years post-treatment to obtain anthropometric and pulmonary function data. For each child in the Comparison Sample (N=346), these measures were obtained from the CFF Registry at matching intervals for the 27-month period corresponding to the clinical trial. Over 27 months, children in the Clinical Trial Group (the combined sample of the behavior plus nutrition and the nutrition alone) demonstrated significantly less decline in BMI z-score, -0.05 (SD=0.68, CI= -0.23 to 0.13), as compared to children in the Comparison Sample, -0.21 (SD=0.67, CI= -0.31 to -0.11). No statistically significant differences were found for decline in FEV(1) between children in the Clinical Trial Group and the Comparison Sample. The key implication of these findings is that intensive behavioral and nutritional intervention is effective and needs to be adapted so that it can be broadly disseminated into clinical practice.

A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers

We evaluated the efficacy of a 6-month clinic and home-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health; LAUNCH) to reduce obesity in preschool children ≥95th BMI percentile compared to enhanced standard of care (Pediatrician Counseling; PC). LAUNCH was a family-based behavioral intervention that taught parents to use child behavior management strategies to increase healthy eating and activity for their children and themselves. PC presented the same diet and activity recommendations, but was delivered in a one-time PC session. Eighteen children aged 2-5 years (mean 4.71 ± 1.01) with an average BMI percentile of 98 (±1.60) and an overweight parent were randomized to LAUNCH or PC. Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post-treatment) BMI z (-0.59 ± 0.17), BMI percentile (-2.4 ± 1.0), and weight gain (-2.7 kg ± 1.2) than PC and this difference was maintained at follow-up (month 12). LAUNCH parents also had a significantly greater weight loss (-5.5 kg ± 0.9) at month 6 and 12 (-8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Efficacy of increasing physical activity to reduce children's visceral fat: a pilot randomized controlled trial

OBJECTIVE

To examine whether differentially targeting physical activity within the context of pilot family-based pediatric weight control treatment results in differential change in abdominal fat, particularly visceral fat.

METHOD

Twenty-nine overweight children (>85(th) body mass index [BMI] percentile) and at least one participating parent were randomly assigned to one of two family-based behavioral weight management conditions that either targeted 1) primarily dietary change (STANDARD; n = 15) or 2) dietary plus physical activity change (ADDED; n = 14). Differences at post-treatment in overall child weight status (e.g., BMI), whole-body composition (measured by dual x-ray absorptiometry), and abdominal fat (measured by waist circumference and magnetic resonance imaging) were assessed using intent-to-treat analyses, as were post-treatment parent BMI and waist circumference. Child and parent physical activity and dietary behavior changes were also evaluated. Results. At post-treatment, overall child weight status, whole-body composition, and child dietary measures did not differ by condition. Children in the ADDED condition tended to have higher physical activity and lower visceral abdominal fat at post-treatment relative to children in the STANDARD condition.

CONCLUSIONS

Increasing physical activity may be important to optimize reductions in abdominal fat, especially visceral fat, among overweight children provided with family-based behavioral weight management treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00359957.

Developmental and psychosocial issues in CF

Cystic fibrosis (CF) is a multisystemic life-limiting genetic disorder, primarily affecting respiratory functioning. Most patients with CF are diagnosed by 2 years of age, and the current median predicted survival rate is 37.4 years old, with 95% of patients dying from complications related to pulmonary infection. Given the chronic, progressive, and disabling nature of CF, multiple treatments are prescribed, most on a daily basis. Thus, this illness requires children, with the aid of their families, to adopt multiple health-related behaviors in addition to managing more typical developmental demands. The morbidity and mortality factors pose cognitive, emotional, and behavioral challenges for many children with CF and their families. This article applies a developmental perspective to describing the psychosocial factors affecting psychological adjustment and health-related behaviors relevant to infants, preschool and school-age children, and adolescents with CF. Topics particularly pertinent to developmental periods and medical milestones are noted, with clinical implications highlighted.

Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings

OBJECTIVE

To determine if children treated by community physicians who participated in an attention-deficit/hyperactivity disorder (ADHD) quality improvement intervention demonstrate symptom and impairment improvements comparable with those achieved in university-based clinical trials.

DESIGN

Case series.

SETTING

Rural, suburban, and urban practices, with 28% of the 47 practices serving primarily (>50% of patients) Medicaid-receiving populations.

PARTICIPANTS

A total of 785 children aged between 7 and 11 years were treated for ADHD by community physicians participating in the study. Intervention A total of 158 community physicians from 47 separate practices participated in a quality improvement intervention, the ADHD Collaborative, designed to improve physician adherence to evidence-based ADHD treatment guidelines. The intervention included mapping and redesign of practice office flow to facilitate adherence to American Academy of Pediatrics ADHD guidelines as well as didactic sessions related to diagnosis and treatment of ADHD. Medical record reviews were completed at the initial assessment and every 3 months for 1 year to evaluate treatment outcome.

OUTCOME MEASURES

Improvement in parent- and teacher-rated ADHD symptoms and functional impairment.

RESULTS

Children showed large improvements in parent- and teacher-rated ADHD symptoms, similar to some clinical trials, but made no significant improvements in functional impairment.

CONCLUSIONS

Large improvements in ADHD symptoms can be achieved in primary care settings when physicians provide evidence-based ADHD care using medication. Because many children with ADHD continued to have significant functional impairment despite symptom improvement, collaboration with other mental health or educational services in additional to medication appears warranted.