Development of the PROMIS Pediatric Physical Activity Item Banks

OBJECTIVE

The purpose of this study was to develop self-report and parent-proxy measures of children's physical activity for clinical research and practice and to demonstrate a valid and reliable instrument of children's lived experience of physical activity as reported by the children themselves or their parent proxies.

METHODS

This study involved qualitative development of item pools followed by 2 cross-sectional validity and reliability studies. The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) instrument development standards were applied to create child self-report and parent-proxy physical activity instruments from previously developed, content-valid pools of physical activity items. Each item used a 7-day recall period and had 5 response options. Item bank calibration was based on national samples totaling 3033 children aged 8 to 17 years and 2336 parents of children aged 5 to 17 years. Quantitative analyses included reliability assessments, factor analyses, item response theory calibration, differential item functioning, and construct validation.

RESULTS

The final item banks comprised 10 items each. The items were selected based on content and psychometric properties. The item banks appeared to be unidimensional and free from differential item functioning. They showed excellent reliability and a high degree of precision across the range of the latent variable. Child-report and parent-proxy 4- and 8-item fixed-length instruments were specified. The instruments showed moderate correlation with existing self-report measures of physical activity.

CONCLUSION

The PROMIS Pediatric Physical Activity instruments provide precise and valid measurement of children's lived experiences of physical activity.

IMPACT

The availability of the PROMIS Pediatric Physical Activity instruments will support advances in clinical practice and research that require measurement of pediatric physical activity by self- and parent-proxy report.

Development of patient-reported outcome measures of children's oral health aesthetics

OBJECTIVES

To develop and evaluate the psychometric properties of child- and parent-proxy measures of oral health aesthetics.

METHODS

Items that describe children's perceptions of their oral attractiveness and its impact on social, emotional, and behavioural functioning were developed based on a systematic review of existing measures, clinician feedback (n = 13) and child semi-structured interviews (n = 27). The tools' content validity was assessed in cognitive interviews with 21 children. Items were administered to socio-demographically diverse samples of 998 children aged 8-17 years and 626 parents of children aged 5-17 years. Psychometric methods were used to finalize and calibrate item banks, generate short questionnaire forms, and evaluate the tools' reliability, precision and validity.

RESULTS

The item banks and their short forms provide precise measurement across a wide range of oral health aesthetic states. They measure relevant and meaningful positive and negative experiences using terminology that most children as young as 8 years of age can understand. Known-group comparisons and convergence with existing measures of oral health-related quality of life, global health and body image provide evidence of construct validity. The scores are interpretable relative to the US general population.

CONCLUSIONS

The oral health aesthetic item banks and short forms provide precise and valid assessments of children's satisfaction with their oral appearance. They may be useful for targeting and evaluating paediatric dental and orthodontic care in clinical practice and research settings.

Assessing Children's Eudaimonic Well-Being: The PROMIS Pediatric Meaning and Purpose Item Banks

OBJECTIVE

To describe the development of the Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric Meaning and Purpose item banks, child-report and parent-proxy editions.

METHODS

Data were collected from two samples. The first comprised 1,895 children (8-17 years old) and 927 parents of children 5-17 years old recruited from an Internet panel, medical clinics, and schools. The second comprised a nationally representative sample of 990 children 8-17 years old and 1,292 parents of children 5-17 years old recruited from a different Internet panel. Item pool evaluation was done with Sample 1 and analyses were used to support decisions about item retention. The combined sample was used for item response theory (IRT) calibration of the item bank. Both samples were used in validation studies.

RESULTS

Eleven items were deleted from the item pool because of poor psychometric performance. The final versions of the scales showed excellent reliability (>0.90). Short form scales (4 or 8 items) had a high degree of precision across over 4 SD units of the latent variable. The item bank positively correlated with extant measures of positive psychological functioning, and negatively correlated with measures of emotional distress, pessimism, and pain. Lower meaning and purpose scores were associated with adolescence and presence of a special healthcare need.

CONCLUSION

The PROMIS Pediatric Meaning and Purpose item banks and their short forms are ready for use in clinical research and practice. They are measures of children's eudaimonic well-being and indicative of children's hopefulness, optimism, goal-directedness, and feelings that life is worth living.

Evaluation of the PROMIS pediatric global health scale (PGH-7) in children with asthma

OBJECTIVE

To evaluate the reliability and validity of the PROMIS Pediatric Global Health scale, a 7-item measure of perceived physical, mental, and social health, in children with asthma.

METHODS

From February 2014 to February 2015, convenience samples of 8-17 year-old children (n = 182) and parents of 5-17 year-old children (n = 328) visiting an emergency department for treatment of asthma were enrolled. The Asthma Control Test was used to characterize children as controlled versus not controlled, and the PROMIS Asthma Impact Scale was used to assess asthma symptoms' impact on functional status. We conducted longitudinal analyses among 92 children and 218 parents at 3 weeks, and 74 children and 171 parents at 8 weeks after enrollment.

RESULTS

The PGH-7 reliability ranged from 0.66 to 0.81 for child-report and 0.76 to 0.82 for parent-proxy. In cross-sectional analyses, children with controlled asthma had PGH-7 scores 0.40-0.95 standard deviation units higher than those who were uncontrolled. The PGH-7 was responsive to changes in overall general health between time points, with moderate effect sizes (0.5-0.6 standard deviation units). In longitudinal analyses, PGH-7 scores were no different between those who stayed uncontrolled versus became controlled at 3 weeks of follow-up; however, by 8 weeks of follow-up, the differences between these groups were 0.7-0.8 standard deviation units, indicative of large effects.

CONCLUSIONS

The PGH-7 is a reliable and valid patient-reported outcome for assessing general health among children with asthma. It is a useful complement to other asthma-specific outcome measures.

Development and Evaluation of the PROMIS® Pediatric Positive Affect Item Bank, Child-Report and Parent-Proxy Editions

OBJECTIVE

The purpose of this study is to describe the psychometric evaluation and item response theory calibration of the PROMIS Pediatric Positive Affect item bank, child-report and parent-proxy editions.

METHODS

The initial item pool comprising 53 items, previously developed using qualitative methods, was administered to 1,874 children 8-17 years old and 909 parents of children 5-17 years old. Analyses included descriptive statistics, reliability, factor analysis, differential item functioning, and construct validity. A total of 14 items were deleted, because of poor psychometric performance, and an 8-item short form constructed from the remaining 39 items was administered to a national sample of 1,004 children 8-17 years old, and 1,306 parents of children 5-17 years old. The combined sample was used in item response theory (IRT) calibration analyses.

RESULTS

The final item bank appeared unidimensional, the items appeared locally independent, and the items were free from differential item functioning. The scales showed excellent reliability and convergent and discriminant validity. Positive affect decreased with children's age and was lower for those with a special health care need. After IRT calibration, we found that 4 and 8 item short forms had a high degree of precision (reliability) across a wide range of the latent trait (>4 SD units).

CONCLUSION

The PROMIS Pediatric Positive Affect item bank and its short forms provide an efficient, precise, and valid assessment of positive affect in children and youth.

Development and psychometric evaluation of the PROMIS Pediatric Life Satisfaction item banks, child-report, and parent-proxy editions

PURPOSE

To describe the psychometric evaluation and item response theory calibration of the PROMIS Pediatric Life Satisfaction item banks, child-report, and parent-proxy editions.

METHODS

A pool of 55 life satisfaction items was administered to 1992 children 8-17 years old and 964 parents of children 5-17 years old. Analyses included descriptive statistics, reliability, factor analysis, differential item functioning, and assessment of construct validity. Thirteen items were deleted because of poor psychometric performance. An 8-item short form was administered to a national sample of 996 children 8-17 years old, and 1294 parents of children 5-17 years old. The combined sample (2988 children and 2258 parents) was used in item response theory (IRT) calibration analyses.

RESULTS

The final item banks were unidimensional, the items were locally independent, and the items were free from impactful differential item functioning. The 8-item and 4-item short form scales showed excellent reliability, convergent validity, and discriminant validity. Life satisfaction decreased with declining socio-economic status, presence of a special health care need, and increasing age for girls, but not boys. After IRT calibration, we found that 4- and 8-item short forms had a high degree of precision (reliability) across a wide range (>4 SD units) of the latent variable.

CONCLUSIONS

The PROMIS Pediatric Life Satisfaction item banks and their short forms provide efficient, precise, and valid assessments of life satisfaction in children and youth.

Children's family experiences: development of the PROMIS® pediatric family relationships measures

PURPOSE

To describe the development of pediatric family relationships measures, with versions for child self-report (8-17 years) and parent-report for children 5-17 years old. Measures were created for integration into the Patient Reported Outcomes Measurement Information System (PROMIS®).

METHODS

Semi-structured interviews with 10 experts, 24 children, and 8 parents were conducted to elicit and clarify essential elements of family relationships. A systematic literature review was conducted to identify item concepts representative of each element. The concepts were transformed into items that were iteratively revised based on cognitive interviews (n = 43 children) and item translatability review. Psychometric studies involving 2846 children and 2262 parents were conducted to further refine and validate the instruments.

RESULTS

Qualitative procedures supported the development of content valid Family Relationships item banks. Final child- and parent-report item banks each contain 47 items. Unidimensional item banks were calibrated using IRT-modeling to estimate item parameters representative of the US population and to enable computerized adaptive test administration. Four- and eight-item short forms were constructed for standard fixed format administration. All instruments have strong internal consistency, retest-reliability, and provide precise estimates of various levels of family relationship quality. Preliminary evidence of the instruments' validity was provided by known-group comparisons and convergence with legacy measures.

CONCLUSION

The PROMIS pediatric Family Relationships measures can be applied in research focused on determinants, outcomes, and the protective effects of children's subjective family relationship experiences.

Teachers' dispositional mindfulness and the quality of their relationships with children in Head Start classrooms

The quality of teachers' relationships with children is a key predictor of children's later social emotional competence and academic achievement. Interventions to increase mindfulness among teachers have focused primarily on the impacts on teachers' subjective well-being, but not on the quality of their relationships with children. Furthermore, none of these interventions have involved preschool teachers. To consider the potential of mindfulness-based interventions to improve the quality of teachers' relationships with preschool-aged children, we examined data from an online survey of 1001 classroom teachers in 37 Pennsylvania Head Start Programs. Using path analysis we investigated the association between teachers' dispositional mindfulness and the quality of their relationships with children (conflict and closeness). We further examined whether this association was mediated by teacher depressive symptoms and moderated by perceived workplace stress. Higher levels of dispositional mindfulness among teachers were associated with higher quality relationships with children (less conflict and greater closeness). The association between greater dispositional mindfulness and less conflict was partially mediated by lower depressive symptoms, and the conditional direct effect of mindfulness on conflict was stronger when perceived workplace stress was lower. These findings suggest that preschool teachers who have higher levels of dispositional mindfulness may experience higher quality relationships with children in their classrooms. Interventions to increase levels of dispositional mindfulness among early childhood educators may improve their well-being along with the quality of their relationships with children, potentially impacting children's educational outcomes. The potential impacts of such interventions may be even stronger if structural and systemic changes are also made to reduce workplace stress.

Patient-Reported Outcomes Measurement Information System Tools for Collecting Patient-Reported Outcomes in Children With Juvenile Arthritis

OBJECTIVE

To evaluate the precision and construct validity of pediatric Patient-Reported Outcomes Measurement Information System (PROMIS) instruments in a population of juvenile idiopathic arthritis (JIA) patients and parent proxies.

METHODS

A convenience sample of JIA patients and parents of JIA patients completed PROMIS instruments for 8 domains: anger, anxiety, depressive symptoms, fatigue, mobility, pain interference, peer relationships, and upper-extremity function. Short form and computerized adaptive test (CAT) scores were derived from item bank responses. Raw scores were translated to standardized T scores with corresponding SEs. Discrimination between inactive versus active disease was evaluated as an indicator of each measure's construct validity. SEs were plotted to evaluate each instrument's relative precision. Patient-parent concordance was assessed using intraclass correlations (ICCs).

RESULTS

A total of 228 patients and 223 parents participated, providing 71-78 responses per domain. Patient- and parent-reported anger, fatigue, mobility, and pain interference scores significantly differed between those with inactive and active disease. Anxiety, depressive symptoms, and peer relationships differed by disease activity levels for parent-report only. Short forms and CATs provided comparable reliability to the full item banks across the full range of each outcome. Patient-parent agreement ranged from ICC 0.3 to 0.8. CATs did not reduce the number of items for any domain compared to the short form.

CONCLUSION

Precision and discriminatory abilities of PROMIS instruments depend on health domain and report type (self-report versus parent proxy-report) for children with JIA. Varying levels of patient-parent concordance reinforces the importance of considering both perspectives in comprehensive health outcomes assessments.

Development and Evaluation of a Short Adverse Childhood Experiences Measure

INTRODUCTION

Clinicians require tools to rapidly identify individuals with significant childhood adversity as part of routine primary care. The goal of this study was to shorten the 11-item Behavioral Risk Factor Surveillance System Adverse Childhood Experiences (ACEs) measure and evaluate the feasibility and validity of this shortened measure as a screener to identify adults who have experienced significant childhood adversity.

METHODS

Statistical analysis was conducted in 2015. ACE item responses obtained from 2011-2012 Behavioral Risk Factor Surveillance System data were combined to form a sample of 71,413 adults aged ≥18 years. The 11-item Behavioral Risk Factor Surveillance System ACE measure was subsequently reduced to a two-item screener by maintaining the two dimensions of abuse and household stressors and selecting the most prevalent item within each dimension.

RESULTS

The screener included household alcohol and childhood emotional abuse items. Overall, 42% of respondents and at least 75% of the individuals with four or more ACEs endorsed one or both of these experiences. Using the 11-item ACE measure as the standard, a cut off of one or more ACEs yielded a sensitivity of 99%, but specificity was low (66%). Specificity improved to 94% when using a cut off of two ACEs, but sensitivity diminished (70%). There was no substantive difference between the 11-and two-item ACE measures in their strength of association with an array of health outcomes.

CONCLUSIONS

A two-item ACE screener appropriate for rapid identification of adults who have experienced significant childhood adversity was developed.

Adverse childhood experiences, dispositional mindfulness, and adult health

OBJECTIVE

To determine whether greater dispositional mindfulness is associated with better adult health across a range of exposures to adverse childhood experiences (ACEs).

METHODS

In 2012, a web-based survey of 2160 Pennsylvania Head Start staff was conducted. We assessed ACE score (count of eight categories of childhood adversity), dispositional mindfulness (Cognitive and Affective Mindfulness Scale-Revised), and the prevalence of three outcomes: multiple health conditions (≥ 3 of 7 conditions), poor health behavior (≥ 2 of 5 behaviors), and poor health-related quality of life (HRQOL) (≥ 2 of 5 indicators).

RESULTS

Respondents were 97% females, and 23% reported ≥ 3 ACEs. The prevalences of multiple health conditions, poor health behavior, and poor HRQOL were 29%, 21%, and 13%, respectively. At each level of ACE exposure, health outcomes were better in those with greater mindfulness. For example, among persons reporting ≥ 3 ACEs, those in the highest quartile of mindfulness had a prevalence of multiple health conditions two-thirds that of those in the lowest quartile (adjusted prevalence ratio (95% confidence interval)=0.66 (0.51, 0.86)); for those reporting no ACEs, the ratio was 0.62 (0.41, 0.94).

CONCLUSION

Across a range of exposures to ACEs, greater dispositional mindfulness was associated with fewer health conditions, better health behavior, and better HRQOL.

The physical and mental health of Head Start staff: the Pennsylvania Head Start staff wellness survey, 2012

INTRODUCTION

Despite attention to the health of low-income children in Head Start, little is known about the health of adults working for the program. The objective of our study was to compare the physical and mental health of women working in Pennsylvania Head Start programs with the health of US women who have similar sociodemographic characteristics.

METHODS

We used data from a web-based survey in 2012 in which 2,199 of 3,375 (65.2%) staff in 66 Pennsylvania Head Start programs participated. For the 2,122 female respondents, we determined the prevalence of fair or poor health status, frequent (≥14 d/mo) unhealthy days, frequent (≥10 d/y) work absences due to illness, diagnosed depression, and 3 or more of 6 physical health conditions. We compared these prevalences with those found in 2 national samples of employed women of similar age, education, race/ethnicity, and marital status.

RESULTS

Among Head Start staff, 85.7% were non-Hispanic white, 62.4% were married, and 60.3% had completed college. The prevalence (% [95% confidence interval]) of several health indicators was higher in Head Start staff than in the national samples: fair or poor health (14.6% [13.1%-16.1%] vs 5.1% [4.5%-5.6%]), frequent unhealthy days (28.3% [26.3%-30.2%] vs 14.5% [14.1%-14.9%]), diagnosed depression (23.5% [21.7%-25.3%] vs 17.6% [17.1%-18.0%]), and 3 or more physical health conditions (21.8% [20.0%-23.6%] vs 12.6% [11.7%-13.5%]).

CONCLUSION

Women working with children in Head Start programs have poorer physical and mental health than do US women who have similar sociodemographic characteristics.

Evidence of chemical stimulation of hepatic metabolism by an experimental acetanilide (FOE 5043) indirectly mediating reductions in circulating thyroid hormone levels in the male rat

N-(4-Fluorophenyl)-N-(1-methylethyl)-2-[[5-(trifluoromethyl)-1,3, 4-thiadiazol-2-yl]oxy]acetamide (FOE 5043) is a new acetanilide-type herbicide undergoing regulatory testing. Previous work in this laboratory suggested that FOE 5043-induced reductions in serum thyroxine (T4) levels were mediated via an extrathyroidal site of action. The possibility that the alterations in circulating T4 levels were due to chemical induction of hepatic thyroid hormone metabolism was investigated. Treatment with FOE 5043 at a rate of 1000 ppm as a dietary admixture was found to significantly increase the clearance of [125I]T4 from the serum, suggesting an enhanced excretion of the hormone. In the liver, the activity of hepatic uridine glucuronosyl transferase, a major pathway of thyroid hormone biotransformation in the rat, increased in a statistically significant and dose-dependent manner; conversely, hepatic 5'-monodeiodinase activity trended downward with dose. Bile flow as well as the hepatic uptake and biliary excretion of [125I]T4 were increased following exposure to FOE 5043. Thyroidal function, as measured by the discharge of iodide ion in response to perchlorate, and pituitary function, as measured by the capacity of the pituitary to secrete thyrotropin in response to an exogenous challenge by hypothalamic thyrotropin releasing hormone, were both unchanged from the controlled response. These data suggest that the functional status of the thyroid and pituitary glands has not been altered by treatment with FOE 5043 and that reductions in circulating levels of T4 are being mediated indirectly through an increase in the biotransformation and excretion of thyroid hormone in the liver.

Extrathyroidally mediated changes in circulating thyroid hormone concentrations in the male rat following administration of an experimental oxyacetamide (FOE 5043)

Evidence of increased hepatic metabolizing capacity coupled with reductions in serum thyroxine (T4) levels were noted in the rat during preliminary toxicity studies with FOE 5043, an oxyacetamide with herbicidal properties. These findings were consistent with reports in the literature suggesting that declines in T4 as a result of exposure to various classes of chemicals may be mediated extrathyroidally, such as through chemical induction of hepatic thyroid hormone metabolism. To examine this question with respect to FOE 5043, male rats were surgically thyroidectomized and provided thyroid hormone replacement therapy via implanted osmotic minipumps capable of maintaining a T4/triiodothyronine (T3) serum concentration for approximately 4 weeks at a level comparable to that of euthyroid controls. Seven days after minipump implantation, thyroidectomized + T4/T3 (TX + T4/T3) and nonthyroidectomized intact rats (NTX) were fed diets containing 0, 25, 1000, or 3000 ppm FOE 5043 for up to 3 weeks. Dose-related and equivalent declines in total and free serum T4 levels in both TX + T4/T3 and NTX rats were measured at Weeks 1, 2, and 3. Alterations in thyrotropin, total, free, and reverse serum T3 levels were also noted in both TX and NTX animals; however, a compound-related trend was difficult to discern and, when compared to the T4 response, the changes were markedly less consistent with respect to both time and dose. Additionally, dose-related increases in absolute and relative liver weights were measured in both TX + T4/T3 and NTX animals. As the only source of thyroid hormone in the TX + T4/T3 animals was that provided by the pump, these data suggest that FOE 5043-induced alterations in serum thyroid hormone levels, most notably T4, are being mediated indirectly, possibly as a result of increased hepatic metabolism, rather than through a direct effect on the thyroid gland.